Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

A Provider’s

Introduction to 

Substance Abuse 

Treatment for 

Lesbian, Gay, Bisexual, 

and Transgender 

Individuals

 

A Provider’s 

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 

1 Choke Cherry Road 

Rockville, MD 20857 
All material appearing in this volume may be reproduced or copied without permission from the 

Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) 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 copyright status of all such material or to secure permission of the copyright holders. 

This publication was developed by SAMHSA’s 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 CSAT’s Knowledge Application 

Program (KAP) under contract number 270-99-7072 with JBS International, Inc., and The CDM 

Group. Karl White, Ed.D., served as the CSAT KAP Government Project Officer. 

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

(HHS). 

This publication may be ordered from SAMHSA’s Publications Ordering Web page at http:// 

store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and 

Español). The document can be downloaded from the KAP Web site at http://kap.samhsa.gov. 

HHS Publication No. (SMA) 12–4104 

First printed 2001 

Revised 2003, 2009, and 2012 
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 .....................................................................................................xxiii
 

Conclusion.........................................................................................................................xxiii
 

SECTION I: OVERVIEW 

Chapter 1—An 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 2—Cultural Issues in Working With LGBT Individuals...............................................15
 

Introduction..........................................................................................................................15
 

iii 
iv Table of Contents

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 3—Legal Issues for Programs Treating LGBT Clients ...............................................29 

Protecting the Confidentiality of LGBT Individuals in

Do LGBT Individuals in Substance Abuse Treatment 

Introduction..........................................................................................................................29
 

Substance Abuse Treatment Programs ...........................................................................30
 

Discrimination Against LGBT Individuals ............................................................................35
 

Have Any Legal Protections?...........................................................................................39
 

Recommendations...............................................................................................................44
 

Resources............................................................................................................................45
 

Chapter 4—Overview 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: CLINICIAN’S GUIDE 

Chapter 5—The Coming Out Process for Lesbians and Gay Men...........................................63
 

Introduction..........................................................................................................................63
 

What the Coming Out Process Means for Counselors .......................................................63
 

Stage Models of Transforming an Identity ..........................................................................64
 

Stage One: Identity Confusion ............................................................................................65
 

Stage Two: Identity Comparison .........................................................................................65
 

Stage Three: Identity Tolerance ..........................................................................................66
 

Stage Four: Identity Acceptance .........................................................................................66
 

Stage Five: Identity Pride ....................................................................................................66
 

Stage Six: Identity Synthesis ..............................................................................................67
 

Recovery Issues for Lesbians and Gay Men ......................................................................67
 

Chapter 6—Families of Origin and Families of Choice .............................................................71
 

Introduction..........................................................................................................................71
 

Family of Origin ...................................................................................................................71
 

Family of Choice and Relationships....................................................................................73
 

Parenting Issues..................................................................................................................73
 
v 

Chapter 7—Clinical Issues With Lesbians..................................................................................75
 

Introduction..........................................................................................................................75
 

Destructive Myths and Stereotypes.....................................................................................76
 

Clinical Issues With Substance-Abusing Lesbians..............................................................77
 

Counselors’ Responsibilities................................................................................................77
 

Chapter 8—Clinical Issues With Gay Male Clients ....................................................................81
 

Introduction..........................................................................................................................81
 

Being Male and Being Gay..................................................................................................83
 

Gay Male Social Life ...........................................................................................................84
 

Alcohol and Drug Use and Sexual Activity..........................................................................85
 

Gay Male Life Cycles and Relationships.............................................................................86
 

HIV/AIDS: Loss and Grief....................................................................................................86
 

Chapter 9—Clinical Issues With Bisexuals ................................................................................89
 

Introduction..........................................................................................................................89
 

Myths ...................................................................................................................................90
 

Professional Biases Versus Research ................................................................................90
 

What Counselors Need To Know About Bisexual Clients...................................................90
 

Psychosocial Issues ............................................................................................................91
 

Counseling Strategies .........................................................................................................91
 

Chapter 10—Clinical Issues With Transgender Individuals .....................................................93 

Introduction..........................................................................................................................93
 

Definitions............................................................................................................................94
 

Research Into Substance Abuse and HIV Among Transgender Individuals.......................96
 

Clinical Issues in Substance Abuse Treatment With 

Transgender Individuals...................................................................................................97
 

Chapter 11—Clinical Issues With Youth...................................................................................101 

Introduction........................................................................................................................101
 

Alcohol and Drug Use in LGBT Youth...............................................................................102
 

Stigma, Identity, and Risk..................................................................................................102
 

Abuse and Homelessness.................................................................................................104
 

Assessment and Treatment...............................................................................................105
 

Chapter 12—Related Health Issues...........................................................................................107
 

Introduction........................................................................................................................107 

Gay and Bisexual Men ......................................................................................................108
 

Lesbian and Bisexual Women...........................................................................................108
 

Transgender Individuals ....................................................................................................109
 

Common Barriers to LGBT Individuals Receiving Adequate Health Care........................109
 

Common Mental Health Issues That LGBT Individuals May Face ...................................110
 

Interpersonal Violence in the LGBT Community ...............................................................110
 

Assessment .......................................................................................................................111
 

Interventions ......................................................................................................................112
 

Table of Contents
vi Table of Contents

Chapter 13—Counselor Competence in Treating LGBT Clients ............................................117 

Introduction........................................................................................................................117
 

Counselor’s Professional Responsibility............................................................................118
 

Helping Clients Heal From the Negative Effects of 

 Homophobia and Heterosexism.....................................................................................119 

Practical Suggestions for Providing Competent Treatment ..............................................120
 

Treating LGBT Clients in the Criminal Justice System .....................................................121
 

SECTION III: PROGRAM ADMINISTRATOR’S GUIDE 

Chapter 14—Policies and Procedures ......................................................................................127
 

Introduction........................................................................................................................127
 

Strategies and Recommendations ....................................................................................127 

Chapter 15—Training and Education ........................................................................................135
 

Introduction........................................................................................................................135
 

Issues To Consider............................................................................................................136
 

Strategies...........................................................................................................................136
 

Addressing the Six Components Effectively......................................................................137
 

A Training Model ...............................................................................................................140
 

Chapter 16—Quality Improvement and LGBT Clients.............................................................143
 

Introduction........................................................................................................................143
 

A Framework for Functionally Defining Quality .................................................................144
 

Collecting Baseline Data ...................................................................................................145
 

Monitoring Progress ..........................................................................................................146
 

Evaluating Outcomes ........................................................................................................149
 

Chapter 17—Using Alliances and Networks To Improve Treatment 

for Lesbian, Gay, Bisexual, and Transgender Clients.................................................151
 

Introduction........................................................................................................................151
 

Rationale for Alliance Building and First Steps .................................................................151
 

The Impact of Managed Care on Behavioral Health and LGBT Individuals .....................152
 

Concerns About Managed Care Organizations.................................................................157
 

Advocacy Efforts and Partnerships To Improve LGBT Care ............................................159
 

LGBT Provider Networks...................................................................................................160
 

Chapter 18—Recommendations ................................................................................................163
 

Introduction........................................................................................................................163 

Recommendations for Research.......................................................................................163
 

Recommendations for Clinicians.......................................................................................164
 

Recommendations for Training .........................................................................................165
 

Recommendations for Administrators ...............................................................................165
 
vii 

SECTION IV: APPENDIXES 

Appendix A—Glossary of Terms .......................................................................................169
 

Appendix B—References ..................................................................................................173
 

Appendix C—Acronyms ....................................................................................................193
 

Appendix D—Studies on LGBT Substance Abuse ...........................................................195
 

Table of Contents

ix 

Foreword 

The Center for Substance Abuse Treatment 

(CSAT) of the Substance Abuse and Mental 

Health Services Administration (SAMHSA) is 

pleased to present A Provider’s 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 (LGBT) 

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 

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 implementation—clinicians 

and administrators. Section I provides an 

introduction for both audiences and includes 

information on sexual orientation, legal issues, 

and treatment approaches and modalities from 

an LGBT standpoint. Section II is written for the 

practicing clinician. It offers further information 

on clinical issues of LGBT 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 cooperative 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 
x Foreword

regarding the availability of vaccines for This publication is the result of the 

hepatitis A and hepatitis B. Educating LGBT collaboration of many contributors, and CSAT 

people about these vaccines, the importance gratefully acknowledges the dedication, time, 

of vaccination, and strategies for preventing talent, and hard work that the writers and 

hepatitis C infection is a responsibility of all reviewers have brought to this publication. 

health care providers, not just substance 

abuse treatment professionals. 

Pamela S. Hyde, J.D. 

Administrator 

Substance Abuse and Mental Health Services Administration 

Peter J. Delany, Ph.D., LCSW-C 

Director 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services Administration 
 

 

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 Administrator’s Section 

were Ednita Wright, Ph.D., and Roxanne Kibben. 

The coordinator for the Clinician’s 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. 

José Martin Garcia Orduna 

Candace Shelton, M.S., CADAC 

Frank Y. Wong, Ph.D. 

Additional appreciation is extended to the 

following constituency organizations that participated in the development of this document: 

AIDS Action Boston 

AIDS Project of Los Angeles 

Gay and Lesbian Medical Association 

Gay Men’s 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 

Alcohol Abuse and Alcoholism 

xi 
xii 

 

 

 

Acknowledgments

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. D’Augelli, 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. 
 

 

 

Executive Summary 

This publication presents information to 

assist providers in improving substance abuse 

treatment for lesbian, gay, bisexual, and 

transgender (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 treating 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 heterosexual 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 (methylenedioxymethamphetamine) 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 segments 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 
xiv Executive Summary

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 orientation 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 one’s 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 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. A transgender person may be 

sexually attracted to males, females, or both. 

Sexual orientation and gender identity are 

independent variables in an individual’s 

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 classification 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 heterosexism 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 

persons. 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 
xv 

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 discrimination and are not a consequence of one’s 

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. 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 comprises 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 percent 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 

client’s ethnic background, counselors should 

keep in mind how the client’s 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 one’s 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 one’s sexual orientation can lead 

to employment problems or the denial of housing 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 Summary
xvi 

 

 

 

 

Executive Summary

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 client’s 

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 society’s 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 manner 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 

trained and culturally competent staff members, 
xvii 

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 client’s sexual identity. 

Often, LGBT couples are not treated with sensitivity, 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 client’s 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 services 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 client’s social 

support, living arrangements or environments, 

employment status, type of employment, and 

ongoing issues related to his or her sexual 

orientation or identity. Possible support systems include the client’s 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 partner 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 client’s comfort level 

with his or her feelings about his or her sexual 

identity 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 client’s 

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 client’s 

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 

multidimensional situations and come from 

Executive Summary
xviii Executive Summary

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 family’s 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 

choice—a legal spouse or unrelated individuals 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 understanding 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 treatment 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 client’s individual situation 

and experiences, they may miss important 

aspects of the client’s 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 limited LGBT people’s 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 internalized 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 alcohol 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 

include relying on women’s bars for socializing 
xix 

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 men’s 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 psychologically 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 transgender 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 transgender people can involve multiple patterns of 

abuse and multiple problems; treatment must 

be multimodal to correspond to a client’s 

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 selfesteem. Many transgender people have had 

negative experiences with providers of health 

care, and they may be distrustful of providers. 

Executive Summary
xx Executive Summary

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, 

especially 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 sensitive 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 client’s 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 invisible 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; RothermanBorus, 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 selfesteem 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 additional 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 selfidentification as lesbian or gay at ages 15 

to 16 (D’Augelli & 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 violence such as physical attacks, verbal and 

physical abuse, and harassment (D’Augelli & 

Dark, 1995; Dean, Wu & Martin, 1992). 

Youth of color and those who are openly or 

stereotypically gay are more likely to be 
xxi 

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 considering these factors, providers of substance abuse 

treatment for LGBT clients should, as with any 

client, screen for other health problems—for 

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 appropriate 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 transgender individuals, may be reluctant to use mainstream 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 

(O’Hanlan, 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 relationships as in heterosexual relationships (Island & 

Executive Summary
xxii Executive Summary

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 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 be nonjudgmental and respectfully accepting of the client’s 

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. Establishing the proper ethos of care for LGBT clients 

requires that counselors monitor themselves 

and be aware of and work through their feelings 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 reacting to a client because of their own unresolved 

personal conflicts (Corey, 1991). 

Administrative Issues 

A substance abuse treatment program’s 

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 program’s 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 information 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 sensitivity 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. 
xxiii 

Alliances and Networks 

A substance abuse treatment program seeking 

to improve care to LGBT individuals has many 

allies throughout both the health care community 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 treatment 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 Summary

SECTION I: 

OVERVIEW
 

1 

An Overview for Providers Chapter 1 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 

 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 

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 community. 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 
2 An Overview for Providers Treating LGBT Clients

 

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 mindaltering 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 Administration’s 

(SAMHSA’s) 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 immunodeficiency 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 heterosexuals (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 population. 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. 
3 An Overview for Providers Treating LGBT Clients

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 preparedness 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-tofemale (MTF) transgender individuals and, 

increasingly, among some groups of lesbians. 

What makes the current epidemic so disconcerting 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 communities. The so-called party drugs, such as MDMA 

(methylenedioxymethamphetamine) (also 

known as ecstasy or X-T-C),“Special K” or 
4 An Overview for Providers Treating LGBT Clients

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 seroprevalence 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 longings—erotic 
5 An Overview for Providers Treating LGBT Clients

and affectional—and 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 orientation 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 

sex—that 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 

individual’s 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. One’s 

gender identity is the sense of one’s self as 

male or female and does not refer to one’s 

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 preoperative—or who have undergone 

sexual reassignment surgery—called 

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 heterosexual, 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 

(DSM–IV) (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 

identity—that 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 
6 An Overview for Providers Treating LGBT Clients

 

 

 

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 predominately 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 populations, bisexuality—but not homosexuality—is 

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 percent 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, discrimination, and violence. Verbal attacks can range 

from denigratory language to pseudoscientific 

theories and findings, which serve as a foundation 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 
7 An Overview for Providers Treating LGBT Clients

 

 

 

 

 

 

 

 

 

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 

everyone—LGBT individuals as well as 

heterosexuals—because 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 men—are 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 treating 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 
8 An Overview for Providers Treating LGBT Clients

 

 

 

 

 

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 heterosexism 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 negative 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 one’s 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 homosexuality as a topic of special interest. Sigmund 

Freud believed a person’s sexual orientation, 

in and of itself, did not impair his or her judgment 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 
9 An Overview for Providers Treating LGBT Clients

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, effectively 

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 understanding 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, 
10 An Overview for Providers Treating LGBT Clients

and Weinrich and their colleagues (Bailey et 

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 males—based on 

the incidence of homosexuality—but are not 

more likely to have lesbian sisters than are heterosexual 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 homosexuality 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 

categories—homosexual, bisexual, or 

heterosexual—clearly 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 people’s behavior falls 

somewhere in between. Sexual orientation 

also follows the same continuum—from 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 

people’s sexual orientation may vary. Women’s 

orientation may be more changeable than 

men’s, possibly because of society’s homophobia 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. 
11 An Overview for Providers Treating LGBT Clients

Some types of therapies claim to be able to 

change a person’s 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 and—rather 

than helping an individual become comfortable 

with his or her inborn and natural sexual 

orientation—make 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 client’s 

feelings. Coleman (1987) devised a relatively 

simple assessment tool to help map out or 

identify the sexual orientation of clients 

(see exhibit 1–1). 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 understand 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 (D’Augelli, 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 relationships, 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 circumstances, 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 client’s partner, children, family of 

origin, and family of choice when providing care. 
12 An Overview for Providers Treating LGBT Clients

 

 

 

 

 

 

 

 Continued 

Exhibit 1–1: 

Coleman’s Assessment Tool
 

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 partner—Duration:______________________________________
 

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 

Source: Coleman, 1987 
13 An Overview for Providers Treating LGBT Clients

Exhibit 1–1: 

Coleman’s Assessment Tool (continued)
 

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 

Physical Identity 

 I was born a biological. . . 

 

Gender Identity 

 I think of myself as physically. . . 

 

 In my sexual fantasies, I imagine 

 myself as physically. . . 

Sex-Role Identity 

 My interests, attitudes, appearance, 

and behaviors would be considered 

female or male (as traditionally 

 defined). . . 

 Sexual Orientation Identity 

 My sexual activity has been with. . . 

 

 My sexual fantasies have been with. . .

 

 My emotional attachments (not 

 necessarily sexual) have been with. . .

 

FUTURE (IDEAL) 

Physical Identity

 Ideally, I wish I had been born 

as a biological. . . 

Gender Identity

 Ideally, I would like to think of 

myself as physically. . .

 In my sexual fantasies, I 

 imagine myself as physically. . . 

Sex-Role Identity

 I wish my interests, attitudes, 

 appearance, and behaviors would 

 be considered female or male 

 (as traditionally defined). . .

 Sexual Orientation Identity

 I wish my sexual activity would be 

with. . .

 I wish my sexual fantasies 

would be with. . .

 I wish my emotional attachments

 (not necessarily sexual) would be 

with. . . 
14 An Overview 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 attractiveness 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 arrangements 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 knowledgeable 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. 
15 

Cultural Issues in Working Chapter 2 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 

José Martin Garcia Orduna, Latina/o Lesbian, Gay, Bisexual & Transgender Organization 

(LLEGÓ), Washington, DC

Victor Martinez, Latina/o Lesbian, Gay, Bisexual & Transgender Organization (LLEGÓ) 

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 

 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 

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 diversity. 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 
16 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: 

• CSAT’s publication Cultural Issues in 

Substance Abuse Treatment, 1999b 

• CSAT’s 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 developing 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 client’s 

cultural context to develop a culturally appropriate assessment, identify problems, and choose 

appropriate treatment strategies for the client. 

A culturally competent model of treatment 

acknowledges the client’s 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 client’s 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 

organization’s 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 
17 Cultural Issues in Working With LGBT Individuals

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 person’s 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 environment 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. 
18 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 rules—often the 

strongest are the ones not spoken. Because 

cultural rules are usually reinforced by parents 

or special people in one’s 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 valued—a 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 client’s primary 

language is not enough. Materials or oral translations need to be adapted to be culturally 

appropriate for the intended audience. 

Historical factors such as discrimination and 

how a person interprets another’s 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, touching the person being addressed is a sign of 

attentiveness. It is important for counselors 

to be sensitive to a client’s 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 client’s sources 

of comfort, to understand the individual’s 

beliefs and customs around healing—what will 

make the client feel better—and to understand 

the person’s definitions of illness and health. 

The Western health care tradition tends to 

compartmentalize health issues and assumes 
19 Cultural Issues in Working With LGBT Individuals

that healing should be left to those who know 

best—medical 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, closemindedness, 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 individual’s own ethnic group. 

Little research has been done on the 

interactions among ethnic diversity, homosexuality, 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 culture—norms 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 community, 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 importance 

for counselors to be aware of how their own 

cultural values, biases, and attitudes influence 

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 

populations 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. 
20 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 

people’s 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 on—parents, 

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 heroes—public 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 entertainment, 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 
21 Cultural Issues in Working With LGBT Individuals

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 homosexuality 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 

lesbians 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 provider’s 

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 questions 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 center, 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 client’s real personality when, 

in fact, the client is on alert and hiding it from 

the provider. It is important for providers to signal respect, openmindedness, and acceptance 

by using appropriate gestures and vocabulary. 
22 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 roleplays may be more appropriate, and peers with 

similar experiences are likely to have influence. 

Any materials used in treatment that acknowledge the LGBT experience will be more effective 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 person’s feelings about his or her sexual 

orientation or gender identity, his or her ability 

to express that identity, and how other members 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 

person’s 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, middleclass 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 bisexuality 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 community 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 “twospirited” 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 
23 Cultural Issues in Working With LGBT Individuals

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, 

language, and religion of American Indian and 

Alaska Native people were oppressed by the 

majority culture. Christian missionaries used 

their influence in converting many traditional rituals 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 traditional respect for two-spirited people also was 

diminished. 

While American Indian and Alaska Native 

clients are in treatment, it is important to determine 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 one’s family is a measure of 

health and connectedness. If the family has difficulty accepting the client’s 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 one’s sexual orientation 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, allegiance to one’s 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 symbolism, animism, subtle humor, and metaphors 

is important. Direct questioning is not as important. 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, nonverbal 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 

rooted 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 
24 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 AfricanAmerican 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 AfricanAmerican LGBT community. Identifying oneself 

as an LGBT individual publicly may put an 

African American at risk for losing his or 

her most important support system—the 

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 publication’s 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 considered an extended self, and this group orientation 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 client’s lead. 
25 Cultural Issues in Working With LGBT Individuals

Learning styles. Learning styles tend to be 

relational rather than analytical. Oral communication 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 characteristics 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 

one’s 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 group—family, 

community, or other groups. Varying from one’s 

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 uncommon 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. 
26 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 common 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 immigrants, 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 client’s 

cultural background (Mexican, Colombian, 

Puerto Rican, etc.) is recommended. The use 

of Latino, Chicano, or Hispanic differs among 

groups and communities. An interpreter may be 
27 Cultural Issues in Working With LGBT Individuals

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 behavioralchange processes. 

Summary 

The information in this chapter is only a 

skeletal framework to introduce providers to the 

complex issues of cultural competency, ethnicity, 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. 

29 

Chapter 3 Legal Issues for Programs Treating 

LGBT Clients 

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

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 

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 discrimina

tion. 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 individual’s being fired or 

being denied access to housing and social 

services—all 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 individu

als have sometimes been denied protection. 

Little wonder that LGBT individuals regard 

protecting information about their sexual 

orientation and substance abuse histories as 

­

­
30 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 

http://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 themselves. 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 individual 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 

Administration’s (SAMHSA’s) Publications 

Ordering Web page at: http://store.samhsa.gov. 

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 client’s 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.) 
31 Legal Issues for Programs Treating LGBT Clients

 

 

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 3–1.) 

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 

client’s 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 information 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 client’s 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 

client’s signed consent, it is not required to try 
32 Legal Issues for Programs Treating LGBT Clients

_______________________________________________________________________________ 

 

 

_______________________________________________________________________________ 

_______________________________________________________________________________

 

 _____________________________

 

_______________________________________________________________________________ 

_______________________________________________________________________________ 

_______________________________________________________________________________ 

 

_______________________________________________________________________________ 

Exhibit 3–1:
 

Consent for the Release of Confidential Information
 

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. 

(Client’s 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) 
33 Legal Issues for Programs Treating LGBT Clients

 

 

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 

adolescent’s 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 minor’s 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 

minor’s consent for disclosures and cannot rely 

on the parent’s 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 3–1). 

•		 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). 
34 Legal Issues for Programs Treating LGBT Clients

 

 

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 client’s signed consent is up to 

the program, unless State law requires or 

prohibits a particular disclosure once consent is 

given. The program’s 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 client’s 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 client’s 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 client’s 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 3–1 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 client’s 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.” 
35 Legal Issues for Programs Treating LGBT Clients

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 employer’s 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 

client’s 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 client’s 

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 

client’s care with a mental health provider. It 

would not be appropriate to disclose this information to a client’s 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 client’s 

consent in writing (as well as parental consent 

in States requiring it). 

Unless the client has consented, the program 

should not disclose the client’s 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 protection they offer. All allow for disclosure of HIVrelated 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
36Legal 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 

State’s 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 spouse’s 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 “cu’ed.” (It remains unclear 

whether other States will recognize such 

unions between individuals who travel to 

Vermont for the purpose of being cu’ed.)

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 citizens than the Federal equal protection clause. 

The advantage of the court’s 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 court’s reasoning.

For up-to-date information on the laws regarding discrimination against LGBT individuals, 

see http://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 
37 Legal Issues for Programs Treating LGBT Clients

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 HIVrelated 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 history) 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 attorney. Depending on Barbara’s relationships with 

her spouse and the children’s 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.” 
38 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 inheritance. 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 

http://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 procedures 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 consequences. The minor’s 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. 
39 Legal Issues for Programs Treating LGBT Clients

 

 

 

 

 

 

 

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 display 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 implementing 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 discussion 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 at SAMHSA’s Publications 

Ordering Web page. Many States also have 

laws protecting people with HIV/AIDS from discrimination. 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. 
40 Legal Issues for Programs Treating LGBT Clients

 

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 employees 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.) 

Case History #1 

Bill is a 41-year-old African-American man who has applied for admission to an inpatient alcohol treatment 

facility. Bill’s 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. Bill’s 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. Bill’s late wife’s 

parents have never accepted him and have always blamed Bill for their daughter’s 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 district’s 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 district’s EAP. 

What legal issues does this case present? 

1) Disclosures of treatment information to the district’s EAP: Bill should sign a consent form that complies 

with 42 CFR Part 2 so that the facility can release information to the district’s EAP about his progress in 

treatment. The consent form should be limited to disclosure of general assessments of Bill’s 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 Bill’s 

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 Bill’s 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 3–1). 

Continued 
41 Legal Issues for Programs Treating LGBT Clients

 

 

2) Disclosures of treatment information to the district’s HMO: The HMO will require information about Bill’s 

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 personnel or HMO records, result in his losing his job. The Federal rules prohibit HMOs from redisclosing information 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 Bill’s 

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 3–1). 

3) Disclosure of information about Bill’s sexual orientation to his in-laws: Disclosure could spark an attempt 

to challenge Bill’s custody of his children. In many States, the combination of Bill’s sexual orientation and 

his history of alcohol abuse could be used by relatives to try to wrest custody from him. If Bill’s in-laws 

do file a court case seeking custody and their attorney issues a subpoena for Bill’s treatment records, 

the program can, working with Bill’s attorney, ask the court to issue an order restricting the scope of the 

information 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 SAMHSA at 1-877-726-4727. 

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. 

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. Denise’s parents are working professionals 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 
42 Legal Issues for Programs Treating LGBT Clients

 

 

 

 

 

 

What legal issues does this case present? 

1) Does the facility have to tell Denise’s parents about her sexual attraction to other girls? No. Denise has 

consented to communications with her parents about her substance abuse treatment. Denise’s fears 

about her parents’ reaction may be entirely realistic. Disclosure of this information to Denise’s 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 Denise’s counselor knows Denise’s 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 3–1). 

2) Can Denise’s 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 information in connection with their treatment responsibilities. 

3) Should Denise’s 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 girl’s 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. 
43 Legal Issues for Programs Treating LGBT Clients

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 city’s HMO plan. 

After intake, Frankie is settled in a room with another male patient. On Frankie’s first night at the facility, a 

nurse observes that Frankie has female genitals. Frankie’s 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 Frankie’s care? Since Frankie and Janice are not legally married, and 

cannot be, Janice is not responsible for the cost of Frankie’s 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 Frankie’s 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 kin”—Janice? or Frankie’s child? Since Frankie’s and Janice’s relationship 

is not State sanctioned, Frankie’s 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 program’s 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 Frankie’s consent, the program should conduct a sensitivity session to educate clients about 

transgendered individuals as well as those who are lesbian, gay, or bisexual. 
44 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. 
45 Legal Issues for Programs Treating LGBT Clients

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 at http://store.samhsa.gov.) 

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: 800–223–4044 

http://www.LAC.org 
46 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: 202–347–5700, Fax: 202–347–2263 

http://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 

http://www.amplifyyourvoice.org/youthresource 

(for LGBT youth). 

American Civil Liberties Union (ACLU) 

132 West 43rd Street 

New York, NY 10036 

Ph: 212–944–9800 

http://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: 212–549–2627 

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: 202–638–4160, Fax 202–347–5323 

http://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 
47 Legal Issues for Programs Treating LGBT Clients

 

• 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 10005–3904 

Ph: 212–809–8585, Fax: 212–809–0055 

http://www.lambdalegal.org 

Lambda is the Nation’s 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: 415–392–6257, Fax: 415–392–8442 

http://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 20009–2624 

Ph: 202–332–6483, Fax: 202–332–0207 

TTY: 202–332–6219 

National Gay and Lesbian Task Force (Policy 

Institute) 

121 West 27th Avenue, Suite 501 

New York, NY 10001 

Ph: 212–604–9830, Fax: 212–604–9831 

http://thetaskforce.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 20035–5301 

Ph: 202–328–3244, Fax: 202–797–1635 

http://www.sldn.org 

On July 19, 1993, the Clinton administration 

announced a new policy regarding gays in the 

military. Dubbed “Don’t ask, don’t tell, don’t 

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 members. 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. 

Gender Education & Advocacy 

http://www.gender.org/ 

Gender Education & Advocacy is a civil rights 

group seeking to secure and safeguard the 

rights of all transgender individuals. 

Queer Resources Directory 

http://www.qrd.org 

Queer Legal Resources 

http://www.qrd.org/qrd/www/legal 

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: 
48 Legal Issues for Programs Treating LGBT Clients

 

 

 

 

 

 

• 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: 617–988–2605 

Fax: 617–988–2629 

http://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 Project’s 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. 
49 

Overview of Treatment Approaches, 

Chapter 4 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 

 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 

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 programs 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. 
50 Overview of Treatment Approaches, Modalities, and Issues of Accessibility in the Continuum of Care

Even if the LGBT individual is open about his 

or her identity, it is virtually impossible to deny 

the effects of society’s 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 person’s 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. 
51 Overview of Treatment Approaches, Modalities, and Issues of Accessibility in the Continuum of Care

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 

person’s sexual orientation/gender identity 

caused his or her alcohol and drug use. One’s 

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 experiences. Be sensitive to the LGBT individual’s 

experience and facilitate these issues within a 

therapeutic context. 

Often negative feelings or attitudes are based 

on real experiences and should be acknowledged 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-genderspecific toilet and shower facility for some LGBT 

clients, particularly in residential treatment settings. 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 treatment settings should be the same for LGBT 

persons as for heterosexual individuals. 
52 Overview of Treatment Approaches, Modalities, and Issues of Accessibility in the Continuum of Care

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 LGBTaffirming. Exhibit 4–1, 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 

heterosexual—unaware 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 one’s 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 affirmative—that 

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 acknowledge 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 

one’s 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. 
53 Overview of Treatment Approaches, Modalities, and Issues of Accessibility in the Continuum of Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exhibit 4–1: 

LGBT Sensitivity Model
 

Anti-LGBT 

Treatment

 Traditional 

Treatment

LGBT-Naive 

Treatment 

LGBTTolerant 

Treatment 

LGBTSensitive

Treatment

 LGBTAffirming

 Treatment 

No LGBT 

sensitivity 

No LGBT 

sensitivity

No LGBT 

sensitivity 

Minimal LGBT 

sensitivity 

Moderate 

level of LGBT 

sensitivity 

Highest level 

of LGBT 

sensitivity 

Antagonistic 

toward LGBT 

individuals 

No realization 

that there are 

LGBT clients 

Realization 

that there are 

LGBT clients 

Recognition 

that there are 

LGBT clients 

Several clients 

and/or staff are 

open with their 

LGBT identity 

Program 

primarily 

targets LGBT 

population 

Treatment 

focuses 

exclusively on 

heterosexuals 

and excludes 

LGBT clients 

No acknowledgment 

or discussion

of LGBT 

issues; it is 

assumed 

everyone is 

heterosexual 

As an agency, 

has not yet 

 begun to 

address the 

special issues 

of the LGBT 

population 

Some staff 

may verbalize 

that it is okay 

to be an LGBT 

individual; 

however, such 

discussions 

are limited to 

individual 

sessions 

Several 

workshops 

and/or groups 

focus on 

LGBT issues; 

they may have 

LGBT groups 

or a “track” for 

LGBT issues; 

groups are 

generally mixed 

All workshops 

specifically for 

LGBT clients; 

workshops 

and groups 

affirm the 

LGBT 

individual, 

have LGBTspecific 

materials, 

etc.; groups 

and workshops are not 

mixed with 

heterosexuals 

No specific 

LGBT 

treatment 

components 

No specific

LGBT 

treatment

components 

 No specific 

LGBT 

 treatment 

components 

No specific 

LGBT

treatment

components 

Some specific 

 LGBT 

 treatment 

components 

All treatment 

components 

are LGBT 

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 4–2 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. 
54 Overview of Treatment Approaches, Modalities, and Issues of Accessibility in the Continuum of Care

Exhibit 4–2: 

Principles 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 individual’s 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 client’s needs. 

Be consistent with each client’s cultural needs and expectations

Programs may need to employ multilingual and multicultural staff as well as individuals representing LGBT populations. 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 individual’s 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 

communities—or 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. 
55 Overview of Treatment Approaches, Modalities, and Issues of Accessibility in the Continuum of Care

 

 

 

 

 

 

 

 

 

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 assessment forms may need to be modified or 

redeveloped for the LGBT populations to 

include more inclusive language (refer to 

Coleman’s 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 individuals with a substance abuse problem, some 

additional factors may need to be assessed. 

Following are a sample. 

• Determine the individual’s comfort with being 

an LGBT person. Evaluate the person’s 

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 individual’s 

support and social network, including 

whether there are any current relationships 

or past relationships and the individual’s 

relationship with his or her family of origin. 

• Determine whether there are any health 

factors of concern, including the individual’s 

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 colleagues? 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 choice—the 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? 
56 Overview of Treatment Approaches, Modalities, and Issues of Accessibility in the Continuum of Care

 

 

 

 

 

 

• 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 alcohol 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 concerns. 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 homophobia 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, professionals, 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 LGBTor 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 client’s 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-toone services may decrease the difficulty of 

mixing heterosexual and LGBT clients in 

treatment groups and decrease the likelihood 
57 Overview of Treatment Approaches, Modalities, and Issues of Accessibility in the Continuum of Care

that heterosexism/homophobia will become an 

issue. LGBT individuals will be able to discuss 

issues revolving around their sexual orientation/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 individuals 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 LGBTsensitive counselors or programs in the client’s 

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 homosexuality. 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 
58 Overview of Treatment Approaches, Modalities, and Issues of Accessibility in the Continuum of Care

“roundups”—large, 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 emotionally 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 relationships, and the adjustment to recovery couples 

must make that will heal the client and avoid the 

negative impact of codependent relationships. 
59 Overview 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 Ruth’s mother to keep Ruth away 

from the church until she “recovered her senses.” Ruth’s 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 relationship, 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 couple’s 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.
 
60 Overview 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 Ruth’s 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 client’s 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 LGBTsensitive, 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 lover’s case, couples therapy would probably not have been helpful. The therapist was very 

aware of the need to recognize this fact and used the couple’s 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 Ruth’s life and recovery, she should play a role in the early 

recovery process. Ruth’s inpatient treatment counselor will need to include her just as she would 

the significant other of a non-LGBT person. 
SECTION II: 

CLINICIAN’S GUIDE 

63 

The Coming Out Process Chapter 5 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 noteworthy, 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 others) and working through their internalized 

homophobia to feel good about themselves. 
64 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, counselors 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, transgender, 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 internalized racist cultural values and attitudes and 

developed a positive identity. Similarly, Cass 

(1979) proposed a model for the process by 
65 The Coming Out Process for Lesbians and Gay Men

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, HanleyHackenbruck’s (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 themselves as lesbians, and how their alcohol 

abuse and recovery interacted with the stages 

of developing a sexual identity. It is also noteworthy that these stage models resemble 

Prochaska, Norcross, and DiClemente’s (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 one’s 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 rehabilitation 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. 
66 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 

counselor 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 lesbian”—an 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 lesbian 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 characterized 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 opportunity 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 

medicate 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 women’s 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 society’s 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. 
67 The Coming Out Process for Lesbians and Gay Men

“Collette’s” 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 

anything—no 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’ meaning 

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 discovered 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 I’m 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 endpoints—even 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 themselves 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. 
68 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. Lee’s 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 can’t talk about anything. She says she is too afraid. She doesn’t want to lose her family. 

She can’t 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 she’s not sure; she was having blackouts at the time. She doesn’t know what to 

do. She doesn’t feel attracted to her husband and thinks this must mean she’s a lesbian, but she 

doesn’t 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.
 
69 The Coming Out Process for Lesbians and Gay Men

Suggested Interventions 

What stage a person is in should determine which interventions are appropriate for and sensitive 

to the patient’s 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 Lee’s 

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 client’s 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 client’s 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. 

71 

Chapter 6 Families of Origin and Families of Choice

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

 What providers will learn 

from this chapter: 

• What a counselor needs to 

know about relationships 

and families when counseling LGBT clients 

• The difference between 

families of origin and 

families of choice 

• How a counselor can 

identify unresolved issues 

with a client’s family of 

origin that could trigger 

a relapse 

• How a counselor can be 

sensitive to an LGBT 

client’s family of choice 

in treatment 

Introduction 

This chapter addresses the family dynamics 

that are important in working with lesbian, 

gay, bisexual, and transgender (LGBT) individuals 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 comprehensive, 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 client’s early 

development. Taking a family history and 

reviewing the dynamics of the family of 

origin should be part of a thorough biopsychosocial assessment. Counselors should 

exercise great care in asking sensitive 

questions, particularly about members of the 

family of origin. The client’s cultural norms 

will be particularly important during this 
72 Families of Origin and Families of Choice

 

 

 

 

 

questioning and should be respected for an 

assessment to be effective. 

LGBT clients often will have unresolved issues 

about their family of origin, particularly regarding sexual orientation or gender identity. As 

they do with all clients, counselors need to 

review the client’s 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 family’s 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 origin’s response to one’s 

disclosure of an LGBT identity can have a 

long-lasting and—if it is negative and 

unaccepting—often 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 identify 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 numerous others who acknowledge the importance 

of resolving these conflicts from our childhood 

and our family of origin. 
73 Families of Origin and Families of Choice

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 individuals 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 definition, it includes those who, by their support, 

nurturing, and understanding, have earned a 

significant place in the LGBT individual’s life. 

Substance abuse counselors and treatment 

centers need to create a safe place for healing. 

This safety needs to include respect, understanding, 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 counselor needs to be sensitive to the individual’s 

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 who—as 

a result of their affections—find 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 one’s 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 selfacceptance 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 
74 Families of Origin and Families of Choice

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. 
75 

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 client—that 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 
76 Clinical Issues With Lesbians

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 tolerates 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 heterosexual 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 monogamous. 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 generation’s 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 only—or predominantly—about 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 heterosexuals. 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 
77 Clinical Issues With Lesbians

 

 

 

 

 

 

 

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 assumptions—that 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, certain risk factors are noted repeatedly, such as: 

• The reliance of many lesbians upon women’s 

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 

one’s 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 one’s 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 sexually 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 negative effects of homophobia and heterosexism. 

Finally, there may be other traumas, such as 

being African American or Latina in a prejudiced 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 chapters 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 
78 Clinical Issues With Lesbians

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 client’s treatment and 

recovery. 

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 seeking treatment for “problems I’m having because of my drinking.” She will lose her 7-year position in her 

company if she doesn’t 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 (“They’re not very friendly. Maybe because I’m 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 description, 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 Rita’s 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 counselor 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 counselor’s 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 extremely homophobic. Restraint is also crucial because it creates the safety essential to engendering the patient’s 

willingness to participate in her treatment and recovery. 
79 Clinical Issues With Lesbians

 

 

 

Example #2: Andrea, 23, has been drinking alcohol since she was 12. She also became addicted to her 

mother’s 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 she’s achieved sobriety, she doesn’t know how to meet women who want to date her. She has become 

shy and uncertain—she 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 she’s clean and 

sober, and that she will need to learn the tasks of adolescence that she missed learning. 

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 don’t 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 client—this 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 client’s position, whatever that may be (“I’m not a lesbian”; “I’m confused”; “I’m 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. 

81 

Chapter 8 Clinical Issues With Gay Male Clients

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

 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 

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 substances, 

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 change—a 

description that can be said to apply in the 

case of lesbian, gay, bisexual, and transgen

der (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 discrimi

nation, 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 models for many young gay 

­

­

­
82 Clinical Issues With Gay Male Clients

people just coming 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 moodaltering 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 identity may be intimately involved with substance 

use. Swiss psychoanalyst Alice Miller (1981) 

sheds light on the link between the psychodynamic 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 

children’s 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 Miller’s 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 youth—such as 

depression, suicidal thoughts (or attempts), 

and running away from home, as well as drug 

use—even 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. 
83 Clinical Issues With Gay Male Clients

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 feelings 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-didn’t-know-what-I-didlast-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 similar—the “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, 

hopelessness, 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 recognize or successfully treat their substance 

abuse. Providers need to know that self-acceptance of one’s 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 one’s sexual orientation, 

add social and personal pressures. These 

cultural expectations—basically gender role 

expectations—vary 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 stereotype—or who do not wish to act 

like this stereotype—may 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 cultures, stigmatize any man who is like a woman. 

Some have speculated that this may be one 
84 Clinical Issues With Gay Male Clients

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 “effeminate”—that 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 heterosexual. 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 boys—which, 

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 contribute to their using alcohol and drugs to try to 

cope. 

Some gay men may feel pressure—even or 

especially by other gay men—to 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-yearold 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 partying. 

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 
85 Clinical Issues With Gay Male Clients

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 media—to 

be young, thin, well-built, usually Caucasian, 

and sexually focused—and 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 racism—from 

heterosexuals as well as other gay people. In 

addition, they may have specific cultural or ethnic issues about homosexuality or ways of having sex with which to contend (as may many 

Caucasian gay men). For example, many cultures 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 identifiable elements of gay social life. 

An activity that seems unique to gay people— 

mostly men, though some lesbians take 

part—is 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 use—to enhance the 

dancing (like at a “rave”) and sexual activity. 

The “designer” drugs—ecstasy, gamma 

hydroxybuturate (GHB), Special-K, and 

others—as 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 

media’s 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 activity and alcohol and drug use that add to the risk 

of gay men developing substance abuse problems 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 amphetamines—transient 
86 Clinical Issues With Gay Male Clients

impotence. Sexual desire is still greatly 

enhanced—for up to 14 hours—thus 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 selfaccepting—just 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 children—by marriage or a relationship with a woman, by adoption, or by a 

coparenting relationship with a lesbian friend, 

for example—and 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 man’s 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 men—all LGBT people in general—also 

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. Behaviors—risky sex or sharing needles, 

for example—are the risk factors, not the 

orientation. Still, gay men are at greater risk, 

since so many gay men are HIV-infected, and 
87 Clinical Issues With Gay Male Clients

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 Treatment’s 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 HIVinfection 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 precautions 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. 

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 weekend—“more 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 don’t 

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. 
88 Clinical Issues With Gay Male Clients

 

 

Suggested Interventions 

This case points out many of the issues discussed in this chapter—the 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 Greg’s 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 selfacceptance 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. Greg’s 

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 counselor’s 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). 
89 

Chapter 9 Clinical Issues With Bisexuals 

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

What providers will learn 

from this chapter: 

• The myths and misconceptions about bisexuals 

that might interfere with 

their treatment 

• What substance abuse 

counselors need to know 

about bisexual women 

and men (including transgender women and men 

who identify themselves 

as bisexuals) in treatment 

• Psychosocial issues unique 

to bisexuals in treatment 

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 psycho

social 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 homosexuality. 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 

­

­

­

­
90 Clinical Issues With Bisexuals

 

 

look back at their coming out process and 

recall a time in their lives when they selfidentified as bisexual, this does not negate 

the fact that some individuals clearly are 

bisexual and that bisexuality can be understood 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 individuals, 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 women—transitionally, sequentially, 

or concurrently—as psychologically or emotionally damaged, as developmentally immature, or 

as having a personality disorder. Individuals 

classified under the last category are generally 

labeled as having a borderline personality disorder, with changing sexual behavior manifesting 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 maladjustment 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 phenomenon. 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 one’s 

life and remain intact across the lifespan. This 

is known as continuous bisexuality. 
91 Clinical Issues With Bisexuals

 

 

 

 

 

 

 

 

 

 

 

• Desire may be experienced by bisexuals as 

sexual attractions to same-sex or oppositesex 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, socioeconomic status, and modes of sexual 

expression and desire. 

Counseling Strategies 

Recovery from substance abuse and addiction 

for bisexuals will be facilitated by empathetic, 
92 Clinical Issues With Bisexuals

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. 
93 

Clinical Issues With Chapter 10 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 

 What providers will learn 

from this chapter: 

• The definition of 

transgender 

• The different theoretical 

models used to describe 

the development of gender identity in transgender 

women and men 

• Transgender-specific 

clinical issues 

• Treatment “do’s” and 

“don’ts” in dealing with 

issues related to transgender men and women 

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 

­
94 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 differences 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) (DSM–IV). 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 individuals) 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 individuals 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. 

One’s 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 biologically 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 one’s identity is a matter distinct 

from sexual orientation. 

One’s 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. 
95 Clinical Issues With Transgender Individuals

 

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 gender 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 transsexuals 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 sometimes 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 transgender 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 

men’s 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. 
96 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 

people’s HIV risk behavior. Treatment can help 

reduce transgender individuals’ risk of HIV 

infection if they remain in treatment; however, 

discrimination and prejudice against transgender individuals can make access to service 

agencies and health care resources problematic (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 
97 Clinical Issues With Transgender Individuals

 

 

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 discrimination 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, discrimination, 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 recommendations. 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 relevant 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 client’s 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 client’s 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, internalized 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 medical 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 
98 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 prescribed hormonal treatment under proper medical 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 men’s 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. 
99 Clinical Issues With Transgender Individuals

 

 

 

 

 

 

 

 

 

 

 

 

 

DO’S
 

• 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. 

DON’TS 

• Don’t call someone who identifies himself as a female he or him or call someone who 

identifies herself as male she or her. 

• Don’t 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. 

• Don’t make the transgender client educate the staff. 

• Don’t assume transgender women or men are gay. 

• Don’t 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. 
100 Clinical Issues With Transgender Individuals

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 “doesn’t 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. 

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 counseling issues, in individual counseling. Staff and client education about transgender and transsexual issues 

will help alleviate some of these concerns. 
101 

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 

 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 

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, O’Malley & 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 
102 Clinical Issues With Youth

use crack cocaine, in particular, are at high risk 

for HIV infection. A study of HIV-positive adolescents 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 development. 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 multiethnic 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 selfesteem 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 (D’Augelli & 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 
103 Clinical Issues With Youth

self-identifying as lesbian or gay is much shorter 

than in previous generations (see exhibit 11–1). 

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 11–1: 

Sexual Identity: Age of Onset 

Behavior/ 

Identity 

Gender Earlier Studies* 

Average Age 

(Years) Event 

Occurs 

More Recent 

Studies** 

Average Age 

(Years) Event 

Occurs 

First awareness 

of same-sex 

attraction 

Males 13 9 

First awareness 

of same-sex 

attraction 

Females 14–16 10 

First same-sex 

experience 

Males 15 13–14 

First same-sex 

experience 

Females 20 14–15 

First selfidentified as 

lesbian or gay 

Males 19–21 14–16 

First selfidentified as 

lesbian or gay 

Females 21–23 15–16 

*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 communities—including 

their ethnic or cultural community, LGBT 

communities, and mainstream culture—none 

of which provide support for all aspects of their 

multiple identities. Having to manage more 

than one stigmatized identity increases the 

adolescent’s 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). 
104 Clinical Issues With Youth

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 person’s 

ability to cope. Hetrick and Martin (1987) have 

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 various 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 exploitation. 

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 (D’Augelli & 

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 adolescent’s 

feelings of vulnerability, often intensify a young 

person’s 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 (D’Augelli, Hershberger & 

Pilkington, 1998). 
105 Clinical Issues With Youth

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. 

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 he’s 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 David’s 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. 

David’s 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 David’s 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. 

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, appropriate 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. 

107 

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 

 What providers will learn 

from this chapter: 

•Thehealthconcernsof

substance-abusingLGBT

individuals

•Someofthementalhealth

issuesthatsubstanceabusingLGBTindividuals

face

•Whatiscurrentlyknown

aboutinterpersonal

violenceandsubstance

abuseintheLGBT

community

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 
108 Related Health Issues

health problems—for 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 

intercourse—often without birth control or 

protection against STDs—they are at risk for 

both pregnancy and STDs (O’Hanlan, 1995). 

Research information is limited, but some 

STDs, such as the human papilloma virus, 

bacterial vaginosis, and Trichomonas, can be 

transmitted among women, although femaleto-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. 
109 

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 (O’Hanlan, 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 Association’s Task Force on the 

Status of Lesbian and Gay Psychologists and 

the American Psychiatric Association’s 

Committee on Gay, Lesbian, and Bisexual 

Issues. Although these changes have been 

important steps in establishing ethical guidelines 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 

Related Health Issues
110 Related Health Issues

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 inappropriate 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 substance 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; 
111 

 

 

 

 

 

Leonard & Jacob, 1987; Faller, 1988), and 

women who abuse alcohol and other substances 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 partner’s 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. 

Related Health Issues
112 Related Health Issues

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 client’s 

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 thirdperson example so as not to personalize the 

question, thereby making the client defensive. 

For example, “Some people think that under 

the right circumstances, it’s 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. 
113 

 

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 individual’s 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 client’s sexual orientation. 

A practitioner is likely to encounter the same 

defensive strategies (e.g., denial, defensiveness, 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 practitioner’s 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. 

Related Health Issues
114 

 

 

 

 

 

 

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 Ron’s 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 women’s 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. 
115 

 

 

 

 

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. 

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. 

Related Health Issues

117

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

What providers will learn 

from this chapter:

 • How counselors can 

become more aware of 

their homophobia and 

heterosexism, how these 

biases can lead to mistreatment, 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 LGBTsensitive treatment

 • What counselors should

consider in treating LGBT 

criminal justice clients

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 
118 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 client’s 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. 

Counselor’s 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. Countertransference 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 counseling. 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: 
119 

 

 

 

 

 

 

 

 

 

 

• 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 counselors 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 differently 

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 heterosexism 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 one’s 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 client’s 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
120 

 

 

 

 

 

 

 

 

 

 

 

Counselor Competence in Treating LGBT Clients

sexual abuse—recognizing 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 individuals—a 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 client’s “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 “do’s and 

don’ts,” 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. 

Do’s 

• 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 person’s 

relationship to the client. 
121 

 

 

 

 

 

 

 

• 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. 

Don’ts 

• Don’t 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. 

• Don’t pressure clients to come out. Respect 

their sense of where they are in this process 

and their need to feel safe. 

• Don’t ignore significant others and family 

members. Don’t assume because people are 

not related by blood or marriage that they 

are not extremely important to the client. 

• Don’t interpret on behalf of the client by 

saying “It must be hard being a lesbian,” or 

“You must be angry because your parents 

don’t accept your being a person of 

transgender experience.” Follow the client’s 

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 

offender’s 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
122 Counselor Competence in Treating LGBT Clients

clients may have trouble bonding with other 

LGBT offenders. These clients usually present 

with profound feelings of isolation, fear, depression, 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 LGBTspecific 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. 

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 experience, both by the direct homophobia of her fellow clients and by the staff’s 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, John’s 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 John’s 

alcohol abuse and because he was still in the closet. John’s 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. 
123 

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 John’s 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

SECTION III: 

PROGRAM 

ADMINISTRATOR’S GUIDE 

127 

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 

What providers will learn 

from this chapter: 

•Administrativepoliciesand

proceduresforserving

LGBTclientsinthe

followingareas:

–Organizationalmission

–Outreachandpromotionalmaterials

–Advertisingandpublic

relations

–Communityrelations

–Administrative

–Personnel

–Stafftraining

–Programdesignand

implementation

 –Aftercare

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 bias—from 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 agency’s mission, 

treatment programming, promotional 
128 

 

 

 

 

 

 

 

 

 

 

Policies and Procedures

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 

organization’s 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. 
129 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• 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 

women’s 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 discrimination 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 heterosexual. 

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
130 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policies and Procedures

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 community 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 agency’s LGBTsupportive 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 nonthreatening 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 
131 

 

 

 

 

 

 

 

 

 

 

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 transportation 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 discharged 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 communities, coming out to their family of origin if 

they decide to do so, and dealing with 

homophobia, 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 specific 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
132 Policies and Procedures

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 House’s 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 city’s 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 agency’s 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 House’s 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. 
133 

Dr. Brian Greenberg can be reached for further 

information at 

Walden House 

http://www.hafe-wh.org 

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/assessment 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-Care’s efforts resulted in a 

fivefold increase in LGBT clients. 

Policies and Procedures

135 

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 

 What providers will learn 

from this chapter: 

•Training andeducational

issuesrelatedtoserving

LGBTclients

•Strategies andactionsteps

forimplementingtraining

•EssentialLGBT-specific

educationalexperiences

forimprovingcompetenciesofprofessionalsand

supportstaff

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, 
136 Training and Education

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 information 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 heterosexuality, 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 selfidentified 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 orientation and may have difficulty with their families 

of origin, complications related to other addictive behaviors, and issues related to HIV/AIDS, 

such as grief and loss or medication compliance. 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 
137 

 

 

 

 

 

 

 

 

 

 

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 LGBTappropriate 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 audience’s 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
138 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Training and Education

• 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 schedule—an 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 professional 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. 
139 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• 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 administrative, 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
140 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 competency. The curriculum includes information 

on the need to raise consciousness about 

LGBT clients, stereotyping, myths, homophobia, and terminology. An example of the 

resources included in it is shown in exhibit 

15–1, the Cass Model of Lesbian and Gay 

Identity Development. This model can be 

especially 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 development tools that address diversity in the 

workplace and homophobia/heterosexism 

assessment surveys. 

To receive this curriculum see: 

http://www.oasas.ny.gov/workforce/training/ 

manuals.cfm 
141 

 

 

Exhibit 15–1: 

Cass Model of Lesbian and Gay Identity Development
 

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 one’s 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; selfactualization as a gay man or lesbian 

Feelings: Excitement, happiness 

Defenses: Minimal 

Recovery: Maintenance (end stage) 

Adapted from Cass, 1979 

Training and Education

143 

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 

What providers will learn 

from this chapter: 

•Howleadersdetermine

whetherqualityassurance

effortsareneeded

•Specific questionsthat

helpdefinequalityin

providingtreatmentto

LGBTclients

•Howleadersmonitorand

assesseffortstoimprove

quality

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 agency’s quality improvement program. 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. 
144 

 

 

 

 

 

 

 

 

 

 

 

Quality Improvement and LGBT Clients

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 organizations. 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 support 

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? 
145 

 

 

 

 

 

 

 

 

• 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 

one’s 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 one’s 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 people’s 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 communities 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). Selfadministered 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 Coleman’s 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
146 

 

 

 

Quality Improvement and LGBT Clients

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 identifying 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 16–1). 

Another tool that might prove useful is the 

guest client—a 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 staff’s 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 staff’s comfort with LGBT issues. 

This can be their last opportunity to communicate 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. 
147 

 

 

Exhibit 16–1: 

Client Satisfaction Survey
 

Today’s 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 

Quality Improvement and LGBT Clients
148 

 

 

 

 

 

 

 

 

 

 

 

Quality Improvement and LGBT Clients

Exhibit 16–1:
 

Client Satisfaction Survey (continued)
 

• 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 
149 

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 agency’s quality improvement strategies. Again, assistance from LGBT 

advocacy groups and other LGBT treatment 

programs will be valuable in addressing specific issues. As with any quality improvement 

effort, continuous reassessment of the available data or information is essential to maintaining 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 agency’s 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 

agency’s 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 

agency’s outcomes can be compared with 

outcomes of organizations that have wellestablished programs for LGBT clients. This 

last comparison may be useful in establishing 

realistic, yet appropriately ambitious, benchmarks 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
150 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 city’s 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. 
151 

Using Alliances and Networks To 

Chapter 17 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 rationaleforalliance

buildingamongLGBT

communities

•Theessentialelementsof

alliancebuilding

•How managedcare

affectscareforLGBT

individuals

•Howalliancesand

networkscanbeusedto

helpwiththefinancing

anddeliveryoftreatment

servicesforLGBT

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, components 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 organizations—the 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 
152 Using Alliances and Networks To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender Clients

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 development (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 care’s 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 essentials of forming effective formal alliances and 

making them work is presented in exhibit 17–1. 

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 
153 

 Continued 

Exhibit 17–1: 

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. 

Don’t 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 recommendations 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. 

Using Alliances and Networks To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender Clients 
154 Using Alliances and Networks To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender Clients

Exhibit 17-1:

 Forming Effective Alliances and Making Them Work (continued)
 

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 group’s 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 sympathetic, 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 alliance’s 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. 
155 

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 discrimination 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 RCD’s message. The Alliance’s membership legitimizes the issue, and the 

public now perceives broad-based community support, effectively weakening RCD’s opponents’ ability to 

label RCD’s efforts as those of “special interests.” 

RCD’s alliance-building process involves both LGBT and non-LGBT community groups. They include 

representatives from the faith community (Cathedral of Hope—Metropolitan Community Church; Potter’s 

House—Transformation 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., Johnnie’s Manor), drug intervention programs (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 Affairs—North 

Texas Health Care System), and non-LGBT community groups (Parents, Families and Friends of Lesbians 

and Gays, PFLAG Dallas). 

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 mental 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 

Using Alliances and Networks To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender Clients 
156 Using Alliances and Networks To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender Clients

so for those targeting LGBT individuals, 

because LGBT concerns are not well 

understood by—or even visible to—the 

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 system nor communicating honestly with health 

care providers—all 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 concerns 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 predisposing 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 person’s 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 

position—self-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 

company’s panel of providers and also satisfy 

the cultural and ethnic competency standards 
157 

 

 

 

 

 

 

articulated in some States’ Behavioral Health 

Request for Proposal (RFP) (e.g., Iowa 

Substance Abuse RFP, pp. 30–17). 

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-forservice 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 orientation. 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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Using Alliances and Networks To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender Clients

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 practice 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 supports 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 consumer rights issues within managed care. 

The Gay and Lesbian Medical Association’s 

(GLMA’s) 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 competence in LGBT health so that optimal patient 

care can be rendered to LGBT people.” 
159 

 

 

 

 

 

 

 

 

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 LGBTfocused 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 provided 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 Center’s 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 LGBTsensitivity 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 

Women’s Health Initiative, and the District of 

Columbia’s Medicaid program to incorporate 

training programs in the District’s 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 

Using Alliances and Networks To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender Clients 
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Using Alliances and Networks To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender Clients

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 created 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 psychotherapist 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. 
161 

 

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 

project’s 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 

• Client’s 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 http://www.glbthealth.org.) 

Using Alliances and Networks To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender Clients 
162 Using Alliances and Networks To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender Clients

Advocates for LGBT-Specific Health Care Services 

Gay and Lesbian Association of Retiring Persons 

Gay and Lesbian Medical Association (GLMA) 

Gay, Lesbian, Bisexual Employees of the Federal Government 

Human Rights Campaign 

National Association of Lesbian & Gay Addiction Professionals (NALGAP) 

National Lesbian & Gay Nurses Association 

Parents, Families and Friends of Lesbians and Gays 
163 

Chapter 18 Recommendations

 This chapter provides 

recommendations for: 

•Additionalresearchneeds

•Cliniciansonimproving

treatmentforLGBTclients

•Improvingtrainingabout

LGBTissues

•Administratorson

improvingtreatmentfor

theLGBTcommunity

•Managedcare,program

planning,andquality

assurance

Introduction 

Lesbian, gay, bisexual, and transgender 

(LGBT) individuals are entitled to services 

provided in a safe and appropriate environment 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, administrators, 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 
164 

 

 

 

 

Recommendations

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 orientation, 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 client’s 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 
165 

 

 

 

 

 

 

 

 

 

 

 

is connected to sexual identity formation, 

coming out, and self-acceptance processes 

for many LGBT persons. 

• Treatment providers should work at the 

individual client’s comfort level related to his 

or her sexual orientation issues and consider 

how the client’s feelings about his or her sexual orientation affect the client’s recovery. 

• All staff and clients should not assume that 

stereotypes and myths about LGBT individuals are true. Each LGBT individual is unique. 

Recommendations for Training 

A limited number of facilities offer LGBTsensitive 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 populations. 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 homophobic 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 confidentiality 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 organizations 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
166 

 

 

 

 

 

 

 

 

Recommendations

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 LGBTspecific 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. 
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. 

Acculturation—Accommodation to the rules 

and expectations of the majority culture without 

giving up cultural identity entirely. 

Ageism—Discriminatory behavior relating to 

age. 

Assimilation—Adaptation to a new culture by 

taking on a new identity and abandoning the 

old cultural identity. 

Biphobia—Irrational fear and dislike of bisexuals. 

Bisexual—Man and woman with a sexual and 

affectional orientation toward people of both 

genders. 

Circuit Party—Weekend 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 Out—Individual and personal process 

by which a person accepts his or her homosexual 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. 

Confidentiality—Restriction against disclosure 

to certain persons or institutions of medical or 

personal information about a client without his 

or her consent. 

Co-occurring Disorders—Condition in which 

a person has more than one disorder or 

disease. 

Countertransference—Process of counselors 

seeing themselves in their clients, overidentifying with their clients, meeting their own 

personal needs through clients, or reacting to a 

client because of unresolved personal conflicts. 

Cultural Competence—Broad-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. 

Denigrate—To cast aspersions on, to defame, 

or to deny the importance or validity of 

something or someone. 

Dysphoria—State of feeling unwell or unhappy. 

Epidemiology—Incidence, distribution, and 

control of disease in a population. 

Family of Choice—Persons 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. 

169 
170 Appendix A–Glossary of Terms

Family of Origin—Birth or biological family or 

any family system instrumental or significant in 

an individual’s early development. 

Gender Identity—Sense of oneself as male 

or female. As a comparison, a person may be 

born biologically male yet have a female 

gender identity. 

Hermaphrodite—A person born with both 

male and female reproductive organs. 

Heterosexism—Value 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. 

Heterosexuals—Term 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. 

Holistic—Consideration of the entire individual 

(physical, intellectual, emotional, spiritual, and 

environmental). 

Homophobia—Irrational fear or dislike of 

homosexuals. This includes the discomfort and 

dislike that some heterosexuals have toward 

lesbian, gay, bisexual, and transgender 

individuals. 

Homosexual—Term 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 Homophobia—Accepting 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 Cycle—Stages of development (infancy, 

childhood, adolescence, young adult, adult, 

elder). 

Lookism—Prejudice that some people harbor 

based on a limited and narrow definition of 

what physical traits are desirable. 

Methamphetamine—Powerful 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. Methamphetamine 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 drug—a drug with little 

medical use and a high potential for abuse. 

Next of Kin—Person or persons designated in 

case of emergency. Traditionally this 

designation has been used only for immediate 

family of origin or married partners. 

Nonoperative—The status of a transsexual 

individual who will not undergo sex 

reassignment surgery. Also called non-op. 

Out or Out of the Closet—Refers to varying 

degrees of being open about one’s 

homosexual or bisexual orientation. 

Passive Partner—Term frequently used in 

reference to male-to-male sexual behavior, 

specifically the receptive partner during sexual 

intercourse. 

Postoperative Person—Transsexual who has 

completed gender reassignment surgery. 

Power of Attorney—Legal document in which 

one person authorizes another person to act 

on the former’s behalf. 
171 

Preoperative Person—Transsexual who is 

contemplating gender reassignment surgery. 

Quality Improvement Program—A systematic 

effort undertaken by an organization to analyze 

processes and procedures and identify and 

implement changes in order to achieve more 

desirable outcomes. 

Rave—Type of dance party at which many of 

the patrons are involved in substance use and 

abuse. 

Ryan White Care Act—Federal legislation that 

authorizes funding for the support of people 

with HIV/AIDS. 

Seropositive—Serotype that suggests 

someone has experienced infection in the past. 

Sex Industry Workers—Individuals (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 Harassment—An 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 Orientation—The erotic, 

physical, and emotional attraction to members 

of one’s own gender, the opposite gender, or 

both genders and one’s conscious or subconscious decision to define and label this affinity 

and attraction. 

Significant Other—A life partner, domestic 

partner, lover, boyfriend, or girlfriend. Because 

gays and lesbians still are not allowed to be 

legally married in many parts of the United 

States (although they are allowed to in some 

European countries), significant other is 

equivalent to the term “spouse.” 

Sodomy Laws—State 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). 

Synthesis—Combining of often diverse 

conceptions into a coherent whole. 

Transference—Redirection of feelings and 

desires. 

Transgender Person—One 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. 

Transphobia—Irrational fear or dislike of 

transgender individuals. 

Transsexual—Individual 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 Readiness—Stage 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 A–Glossary of Terms

 

 

 

 

 

Appendix B References

Acuff, C., J. Archambeaul, B. Greenberg, J. Hoeltzel, J.S. McDaniel, P. Meyer, C. Packer, 

F.J. Parga, M.B. Pillen, A. Ronhovde, M. Saldarriaga, M.J.W. Smith, D. Stoff, D. Wagner, 

1999. Mental Health Care for People Living With or Affected by HIV/AIDS: A Practical Guide. 

Project No. 6031. Research Triangle Park, NC: Research Triangle Institute. 

Alport, G., 1952. Nature of Prejudice. New York, NY: Doubleday. 

American Association of Physicians for Human Rights (AAPHR), 1994. Discrimination in 

Medicine: Results of a National Survey of Lesbian, Gay, and Bisexual Physicians. San 

Francisco, CA: AAPHR. 

American Federation of State, County, and Municipal Employees (AFSCME), 1994. Managed 

 Care: Community-Based Strategies for Improving Quality. Washington, DC: AFSCME. 

American Psychiatric Association, 1995. Practice guidelines for psychiatric evaluation of adults. 

American Journal of Psychiatry 152(November Suppl):65-70. 

American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders 

(4th Edition). Washington, DC: American Psychiatric Press. 

American Psychiatric Association, 1968. Diagnostic and Statistical Manual of Mental Disorders 

(2nd Edition). Washington, DC: American Psychiatric Press. 

American Psychological Association. Guidelines for psychotherapy with lesbian, gay, and 

bisexual clients. American Psychologist, in press. 

American Society of Addiction Medicine (ASAM), Working Group of the ASAM Managed Care 

Initiative, 1999. Impact of Managed Care on Addiction Treatment: A Problem in Need of a 

Solution. 

Bailey, J.M., R.C. Pillard, 1991. Genetic study of male sexual orientation. Archives of General 

Psychiatry 48:1089-1096. 

Bailey, J.M., R.C. Pillard, M.C. Neale, Y. Agyei, 1993. Heritable factors influence sexual 

orientation in women. Archives of General Psychiatry 50:217-223. 

Bartholow, B.N., L.S. Doll, D. Joy, J.M. Douglas, G. Bolan, J. Harrison, P. Moss, D. 

McKirnan, 1994. Emotional, behavioral and HIV risks associated with sexual abuse among 

adult homosexual and bisexual men. Child Abuse and Neglect 18:747-761. 

173 
174 

 

 

 

 

Appendix B–References

Bell, A.P., M.S. Weinberg, 1978. Homosexualities: A Study of Diversities Among Men and 

Women. New York, NY: Simon & Schuster. 

Bell, A.P., M.S. Weinberg, S.K. Hammersmith, 1981. Sexual Preference: Its Development 

in Men and Women. Bloomington, IN: Indiana University Press. 

Bell, P., 1981. Counseling the Black Client: Alcohol Use and Abuse in Black America. 

 Minneapolis, MN: Hazelden. 

Bennett, L.W., 1995. Substance abuse and the domestic assault of women. Social Work

 40(6):760-771. 

Berger, R.M., J.J. Kelly, 1996. Gay men and lesbians grown older. In: R.P. Cabaj, T.S. Stein (eds.), 

Textbook of Homosexuality and Mental Health. Washington, DC: American Psychiatric Press, 

pp. 305-316. 

Bieber, I., H.J. Dain, P.R. Dince, M.G. Drellich, H.G. Grand, R.H. Gundlach, M.W. Kremer, 

A.H. Rifkin, C.B. Wilbur, T.B. Bieber, 1962. Homosexuality: A Psychoanalytic Study. New York, 

NY: Basic Books, p. 313. 

Bloomfield, K., 1993. Comparison of alcohol consumption between lesbians and heterosexual 

women in an urban population. Drug and Alcohol Dependence 33(3):257-269. 

Bockting, W.O., E. Coleman, 1993. Gender Dysphoria: Interdisciplinary Approaches in 

 Clinical Management. New York, NY: Haworth Press. 

Bockting, W.O., B.E. Robinson, B.R.S. Rosser, 1998. Transgender HIV prevention: A 

qualitative needs assessment. AIDS Care 10:505-526. 

Boxer, A., 1990. Life course transitions of gay and lesbian youth: Sexual identity 

development and parent-child relationships. Doctoral dissertation, University of Chicago. 

Bradford, J., C. Ryan. 1988. The National Lesbian Health Care Survey: Final Report. 

 Washington, DC: National Lesbian and Gay Health Foundation. 

Bradford, J., C. Ryan, 1987. Mental Health Implications—National Lesbian Health Care 

Survey. Washington, DC: National Lesbian and Gay Health Foundation. 

Bradford, J., C. Ryan, E.D. Rothblum, 1994. National Lesbian Health Care Survey: Implications for 

mental health care. Journal of Consulting and Clinical Psychology 62(2):228-242. 

Bradshaw, J.E. 1988. Healing the Shame That Binds You. Deerfield Beach, FL: Health 

Communications. 

Briere, J., D. Evans, M. Runtz, T. Wall, 1988. Symptomology in men who were molested as 

 children: A comparison study. American Journal of Orthopsychiatry 58:457-461. 
175 

 

 

 

 

 

 

 

 

 

 

Bureau of Justice Statistics, 1994. Violence Between Intimates: Domestic Violence. 

 Washington, DC: U.S. Department of Justice, Office of Justice Programs. 

Byrne, W., 1996. Biology and homosexuality: Implications of neuroendocrinological and 

neuroanatomical studies. In: R.P. Cabaj, T.S. Stein (eds.), Textbook of Homosexuality and 

Mental Health. Washington DC: American Psychiatric Press, pp. 129-146. 

Cabaj, R.P., 1996. Substance abuse in gay men, lesbian, and bisexual individuals. In: R.P. 

Cabaj, T.S. Stein (eds.), Textbook of Homosexuality and Mental Health. Washington, DC: 

American Psychiatric Press, pp. 783-799. 

Cabaj, R.P., 1988. Gay and lesbian couples: Lessons on human intimacy. Psychiatric Annals 

18(1):21-25. 

Cabaj, R.P., D.W. Purcell (eds.), 1998. On the Road to Same-Sex Marriage: A Supportive Guide to

 Psychological, Political, and Legal Issues. San Francisco, CA: Jossey-Bass. 

Caseres, C., J.I. Cortifias, 1996. Fantasy island: An ethnography of alcohol and gender roles in a 

Latino gay bar. Journal of Drug Issues 26(1):245-260. 

Cass, V.C., 1979. Homosexual identity formation: A theoretical model. Journal of Homosexuality

 4(3):219-235. 

Cassel, J., 1976. Contributions of the social environment to host resistance. American Journal of 

Epidemiology 104:107-123. 

Center for Substance Abuse Prevention (CSAP), 1994. Following Specific Guidelines Will 

Help You Assess Cultural Competence in Program Design, Application, and Management. 

Rockville, MD: CSAP. 

Center for Substance Abuse Prevention (CSAP), 1992. Cultural Competence for Social Workers: 

A Guide for Alcohol and Other Drug Abuse Prevention Professionals Working With Ethnic/ 

Racial Communities. CSAP Cultural Competence Series 4. Special collaborative NASW/CSAP 

Monograph. J. Philleo, F.L. Brisbane, L.G. Epstein (eds.). Rockville, MD: CSAP. 

Center for Substance Abuse Treatment (CSAT), 2000. Substance Abuse Treatment for Persons 

With HIV/AIDS. Treatment Improvement Protocol Series 37. DHHS Publication No. (SMA) 

00-3410. Rockville, MD: CSAT. 

Center for Substance Abuse Treatment (CSAT), 1999a. Confidentiality of Patient Records for 

Alcohol and Other Drug Treatment. Technical Assistance Publication 13. BKD156. Rockville, 

MD: CSAT. 

Center for Substance Abuse Treatment (CSAT), 1999b. Cultural Issues in Substance Abuse 

Treatment. DHHS Publication No. (SMA) 99-3278. Rockville, MD: CSAT. 

Center for Substance Abuse Treatment (CSAT), 1999c. Treatment of Adolescents With Substance

 Use Disorders. Treatment Improvement Protocol 32. BKD307. Rockville, MD: CSAT. 

Appendix B–References
176 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix B–References

Center for Substance Abuse Treatment (CSAT), 1999d. Welfare Reform and Substance Abuse 

Treatment Confidentiality: General Guidance for Reconciling Need To Know and Privacy. 

Technical Assistance Publication 24. BKD336. Rockville, MD: CSAT. 

Center for Substance Abuse Treatment (CSAT), 1998a. Action Steps Report: The Northwest 

Regional Workshop on HIV Prevention Approaches for AOD Among Men Who Have Sex With 

Other Men. U.S. Department of Health and Human Services. Centers for Disease Control and 

Prevention, Atlanta, GA, and Substance Abuse and Mental Health Services Administration, 

Center for Substance Abuse Treatment. Rockville, MD: CSAT. 

Center for Substance Abuse Treatment (CSAT), 1998b. Addiction Counseling Competencies: 

The Knowledge, Skills, and Attitudes of Professional Practice. Technical Assistance 

Publications 21. BKD246X. DHHS Publication No. (SMA) 98-3171. Rockville, MD: CSAT. 

Center for Substance Abuse Treatment (CSAT), 1997a. A Guide to Substance Abuse Treatment 

for Primary Care Clinicians. Treatment Improvement Protocol 24. BKD234. Rockville, MD: 

CSAT. 

Center for Substance Abuse Treatment (CSAT), 1997b. Proceedings of the National Consensus 

Meeting on the Use, Abuse, and Sequelae of Abuse of Methamphetamine With Implications for 

Prevention, Treatment, and Research. Rockville, MD: CSAT. 

Center for Substance Abuse Treatment (CSAT), 1997c. Substance Abuse Treatment and 

Domestic Violence. Treatment Improvement Protocol 25. BKD239. Rockville, MD: CSAT. 

Center for Substance Abuse Treatment (CSAT), 1996. Checklist for Monitoring Alcohol and 

Other Drug Confidentiality Compliance. Technical Assistance Publication Series 18. DHHS 

Publication No. (SMA) 96-3083. Rockville, MD: CSAT. 

Center for Substance Abuse Treatment (CSAT), 1995. Treatment for HIV-Infected Alcohol and 

Other Drug Abusers. Treatment Improvement Protocol 15. DHHS Publication No. (SMA) 

95-3038. BKD163. Rockville, MD: CSAT. 

Center for Substance Abuse Treatment (CSAT), 1994a. Recommendations on Access to 

Substance Abuse Services for the Lesbian and Gay Communities. Rockville, MD: CSAT. 

Center for Substance Abuse Treatment (CSAT), 1994b. Confidentiality of Patient Records for 

Alcohol and Other Drug Treatment. Technical Assistance Publication 13. Adapted from 

F. Lopez. Rockville, MD: CSAT. 

Centers for Disease Control and Prevention (CDC), 1998. HIV/AIDS Surveillance Report 10(2):

 1-43. 

Centers for Disease Control and Prevention (CDC), 1996. Youth risk behavior surveillance–United 

 States, 1995. Morbidity and Mortality Weekly Report 45(No.SS-4):1-86. 
177 

 

 

 

 

 

 

 

 

Centers for Disease Control and Prevention (CDC), 1995. Increasing morbidity and mortality 

associated with abuse of methamphetamine–United States, 1991-1994. Morbidity and Mortality 

Weekly Report 44(47):882-886. 

Centers for Disease Control and Prevention (CDC), 1989. Update: Acquired human 

immunodeficiency syndrome–United States, 1981-1988. Morbidity and Mortality Weekly Report 

38(14):1-28. 

Clatts, M.C., W.R. Davis, 1999. Demographic and behavioral profile of homeless youth in New 

York City: Implications for AIDS outreach and prevention. Medical Anthropology Quarterly 

13(3):365-374. 

Clements, K., R. Marx, R. Guzman, S. Ikdea, M. Katz, 1998. Prevalence of HIV Infection in 

Transgender Individuals in San Francisco. Unpublished manuscript. San Francisco, CA: San 

Francisco Department of Public Health. 

Cochran, S., V.M. Mays, 1988. Disclosure of sexual preference to physicians by black lesbian and 

bisexual women. Western Journal of Medicine 149:616-619. 

Cochran, S.D., C. Keenan, C. Schober, V. M. Mays. Estimates of alcohol use and clinical 

treatment needs among homosexually active men and women in the U.S. population. Journal 

of Consulting and Clinical Psychology, in press. 

Cochran, S.D., V.M. Mays, 2000. Relation between psychiatric syndromes and behaviorally 

defined sexual orientation in a sample of the U.S. population. American Journal of 

Epidemiology Mar 1; 151(5):516-523. 

Coleman, E., 1987. Assessment of sexual orientation. Journal of Homosexuality 14:1-2. 

Coleman, E., 1981/1982. Developmental stages of the coming out process. Journal of 

Homosexuality 7(2/3):31-43. 

Coleman, V., 1990. Violence Between Lesbian Couples: A Between Groups Comparison. 

 Unpublished doctoral dissertation, University Microfilms International, 9109022. 

Corey, G., 1991. Theory and Practice of Counseling and Psychotherapy, (4th Edition). Pacific 

 Grove, CA: Brooks/Cole Publishing Company. 

Crosby, G.M., R.D. Stall, J.P. Paul, D.C. Barrett, 1998. Alcohol and drug use patterns have 

declined between generations of younger gay-bisexual men in San Francisco. Drug and 

Alcohol Dependence 52(3):177-182. 

Cross, W.E., 1971. Discovering the black referent: The psychology of black liberation. In: 

V.J. Dixon, B.G. Foster (eds.), Beyond Black or White: An Alternate America. Boston, MA: 

Little, Brown, pp. 95-110. 

Appendix B–References
178 

 

 

 

 

 

 

 

 

 

 

 

Appendix B–References

Curry, H., D. Clifford, R. Leonard, F. Hertz, 1999. A Legal Guide for Lesbian and Gay Couples 

(10th Edition). Berkeley, CA: Nolo Press. 

D’Augelli, A.R., 1996. Lesbian, gay, and bisexual development during adolescence and 

young adulthood. In: R.P. Cabaj, T.S. Stein (eds.), Textbook of Homosexuality and Mental 

Health. Washington, DC: American Psychiatric Press, pp. 267-288. 

D’Augelli, A.R., L.J. Dark, 1995. Vulnerable populations: Lesbian, gay, and bisexual youth. 

In: L.D. Eron, J.H. Gentry, P. Schlegel (eds.), Reason To Hope: A Psychosocial Perspective on 

Violence and Youth. Washington, DC: American Psychological Association, pp. 177-196. 

D’Augelli, A.R., S.L. Hershberger, 1993. Lesbian, gay, and bisexual youth in community 

settings: Personal challenges and mental health problems. American Journal of Community 

Psychology Aug; 21(4):421-448. 

D’Augelli, A.R., S.L. Hershberger, N.W. Pilkington, 1998. Lesbian, gay, and bisexual youth and 

their families: Disclosure of sexual orientation and its consequences. American Journal of 

Orthopsychiatry 68:361-371. 

Dean, L., S. Wu, J.L. Martin, 1992. Trends in violence and discrimination against gay men in New 

York City: 1984 to 1990. In: G.M. Herek, K.T. Berrill (eds.), Hate Crimes: Confronting Violence 

Against Lesbians and Gay Men. Newbury Park, CA: Sage Publications, pp. 46-64. 

DeCecco, J., M.G. Shively, 1985. Origins of Homosexuality. Old Saybrook, CT: Harrington Park 

Press. 

Denny, D., 1994. Gender Dysphoria: A Guide to the Research. New York, NY: Garland Publishing, 

Inc. 

Derlet, R., B. Heischober, 1990. Methamphetamine: Stimulant of the 1990s? Western Journal of 

Medicine 153:625-628. 

Descamps, M.J., E. Rothblum, J. Bradford, C. Ryan. Mental Health Impact of Child Sexual 

Abuse, Rape, Intimate Partner Violence, and Hate Crimes in the National Lesbian Health Care 

Survey, submitted for publication. 

Diamond-Friedman, C., 1990. Multivariant model of alcoholism specific to gay-lesbian 

populations. Alcoholism Treatment Quarterly 7(2):11-117. 

Diaz, T., S.Y. Chu, R.H. Byers, B.S. Hersh, L. Conti, C. Rietmeijer, E. Mokotoff, A. Fann, 

D. Boyd, L. Iglesias, P. Checko, M. Frederick, P. Hermann, M. Herr, M. Samuel, 1994. 

Types of drugs used by injection drug users with HIV/AIDS in a multisite surveillance project: 

Implications for intervention. American Journal of Public Health 84:1971-1975. 

Dimock, P.T., 1988. Adult males sexually abused as children. Journal of Interpersonal Violence

 3:203-221. 
179 

 

 

 

 

Docter, R.F., 1990. Transvestites and Transsexuals: Towards a Theory of Cross-Gender Behavior. 

 New York, NY: Plenum Press. 

Drug Abuse Warning Network, 1998. Data from the Drug Abuse Warning Network, ADAM. 

Rockville, MD: Substance Abuse and Mental Health Services Administration. 

Duncan, D., R. Petosa, 1994. Social and community factors associated with drug use and abuse 

among adolescents. In: T. Gullotta, G. Adams, R. Montemayor (eds.), Substance Misuse in 

Adolescents. Thousand Oaks, CA: Sage Publications, pp. 56-91. 

Elliot, P., 1996. Shattering illusions: Same sex domestic violence. Journal of Gay and Lesbian 

Social Services 4(1):1-8. 

Faller, K.C., 1988. Child Sexual Abuse: An Interdisciplinary Manual for Diagnosis, Case 

Management, and Treatment. New York, NY: Columbia University Press. 

Farley, N., 1996. Survey of factors contributing to gay and lesbian domestic violence. Journal of 

 Gay and Lesbian Social Services 4(1):35-42. 

Ferrando, S., K. Goggin, M. Sewell, S. Evans, B. Fishman, J. Rabkin, 1998. Substance use 

 disorders in gay-bisexual men with HIV and AIDS. American Journal on Addictions 7(1):51-60. 

Fifield, L., T.A. DeCrescenzo, J.D. Latham, 1975. Alcoholism and the gay community. In: 

Summary: On My Way to Nowhere: Alienated, Isolated, Drunk—An Analysis of Gay Alcohol 

Abuse and Evaluation of Alcoholism Rehabilitation Services for Los Angeles County. Los 

Angeles, CA: Los Angeles Gay Community Services Center. 

Finnegan, D.G., E.B. McNally, 1987. Dual Identities: Counseling Chemically Dependent Gay Men 

 and Lesbians. Center City, MN: Hazelden. 

Fortenberry, J.D., 1995. Adolescent substance use and sexually transmitted disease risk: A 

review. Journal of Adolescent Health 16:304-308. 

Fox, R.C., 1996. Bisexuality: An examination of theory and research. In: R.P. Cabaj, T.S. 

Stein (eds.), Textbook of Homosexuality and Mental Health. Washington, DC: American 

Psychiatric Press, pp. 147-171. 

Fox, R.C., 1995. Bisexual identities. In: A.R. D’Augelli, C.J. Patterson (eds.), Lesbian, Gay, and 

Bisexual Identities Over the Lifespan: Psychological Perspectives. New York, NY: Oxford 

University Press, pp. 48-86. 

Freese, T.E., J. Obert, A. Dickow, J. Cohen, R.H. Lord, 2000. Methamphetamine Abuse: 

Issues for Special Populations. Journal of Psychoactive Drugs 32(2):177-182. 

Freud, E. (ed.), 1960. Letters of Sigmund Freud. New York, NY: Basic Books, pp. 423-424. 

Appendix B–References
180 

 

 

 

 

Appendix B–References

Freud, S., 1963. Analysis termination and interminable (1937). In: P. Reiff (ed.), Therapy and 

Technique. New York, NY: Collier, pp. 233-272. 

Futterman, D., K. Hein, N. Ruben, R. Dell, N. Shaffer, 1993. HIV-infected adolescents: The first 50 

patients in a New York City program. Pediatrics 91:730-735. 

Garnets, L., G.M. Herek, B. Levy, 1992. Violence and victimization of lesbians and gay men: 

Mental health consequences. In: G. Herek, K. Berrill (eds.), Hate Crimes: Confronting Violence 

Against Lesbians and Gay Men. Newbury Park, CA: Sage Publications, pp. 207-226. 

Gartrell, N., 1994. Boundaries in lesbian therapist-client relationships. In: B. Greene, G.M. Herek 

(eds.), Psychological Perspectives on Lesbian and Gay Issues: Vol.1, Lesbian and Gay 

Psychology: Theory, Research, and Clinical Applications. Thousand Oaks, CA: Sage 

Publications, pp. 98-117. 

Gay and Lesbian Community Action Council, 1987. Survey of the Twin Cities Gay and Lesbian 

Community: Northstar Project. Unpublished manuscript. Minneapolis, MN: Author. 

Gay and Lesbian Medical Association, 1998. Call for HMOs/PPOs To Provide LGBT-Sensitive 

Referrals, Resolution. 111-98-111. San Francisco, CA: Author. 

Ghindia, D., L. Kola, 1996. Co-factors affecting substance abuse among homosexual men: An 

 investigation within a midwestern gay community. Drug and Alcohol Dependence 41(3):

 167-177. 

Golay, M., C. Rollyson, 1997. Where America Stands on Today’s Most Critical Issues. New York, 

NY: John Wiley & Sons. 

Gondolf, E., 1995. Alcohol abuse, wife assault, and power needs. Social Service Review 69(2):

 274-284. 

Gonsiorek, J.C. (ed.), 1985. Guide to Psychotherapy With Gay and Lesbian Clients. New York, 

 NY: Harrington Park Press. 

Gonzalez, F.J., O.M. Espin, 1996. Latino men, Latino women, and homosexuality. In: R.P. 

Cabaj, T.S. Stein (eds.), Textbook of Homosexuality and Mental Health. Washington, DC: 

American Psychiatric Press, pp. 583-601. 

Gordon, J.U. (ed.), 1994. Managing Multiculturalism in Substance Abuse Services. Thousand 

 Oaks, CA: Sage Publications. 

Gorman, E.M., 1996. Speed use and HIV transmission. FOCUS: Guide to AIDS Research and 

Counseling 11(7):4-6. 

Gorman, E.M., B.D. Barr, A. Hansen, B. Robertson, C. Green, 1997. Speed, sex, gay men, and 

HIV: Ecological and community perspectives. University of Washington. Medical Anthropology 

Quarterly Dec; 11(4):505-515. 
181 

 

 

 

 

 

 

 

 

Gorman, E.M., P. Morgan, E.Y. Lambert, 1995. Qualitative research considerations and other 

issues in the study of methamphetamine use among men who have sex with other men. In: R. 

Needle, L. Ey (eds.), Qualitative Methods in Drug Abuse and HIV Research. NIDA Research 

Monograph Series 157. Rockville, MD: National Institute on Drug Abuse. 

Greene, B., 1994. Lesbian women of color. In: L. Comas-Diaz, B. Greene (eds.), Women 

of Color: Integrating Ethnic and Gender Identities in Psychotherapy. New York, NY: Guilford 

Press, pp. 389-427. 

Guinier, L., 1994. Tyranny of the Majority: Fundamental Fairness in Representative Democracy. 

 New York, NY: Free Press. 

Haldeman, D.C., 1994. Practice and ethics of sexual orientation conversion therapy. Journal of 

 Consulting and Clinical Psychology 62:221-227. 

Hamer, D.H., P. Copeland, 1994. Science of Desire: The Search for the Gay Gene and the 

Biology of Behavior. New York, NY: Simon & Schuster. 

Hanley-Hackenbruck, P., 1989. Psychotherapy and the “coming out” process. Journal of Gay and 

Lesbian Psychotherapy 1(1):21-39. 

Harris, N., H. Theide, J. McGough, D. Gordon, 1993. Risk factors for HIV infection among 

injection drug users: Results of blinded surveys in drug treatment centers, King County, 

Washington, 1988-1991. Journal of Acquired Immune Deficiency Syndrome 6(1):1275-1282. 

Hays, R.B., S.M. Kegeles, T.J. Coates, 1990. High HIV risk taking among young gay men. 

San Francisco, CA: Center for AIDS Prevention Studies, Division of General Internal Medicine, 

University of California. AIDS Sept; 4(9):901-907. 

Health Care Financing Administration, 2000. Quality Improvement System for Managed Care 

(QISMC) Year 2000 Standards & Guidelines (pending Office of Management and Budget 

approval, July 26, 2000). 

Heffernan, K., 1998. The nature and predictors of substance use among lesbians. Addictive 

Behaviors 23(4):517-528. 

Hellman, R.E., M. Stanton, J. Lee, A. Tytun, R. Vachon, 1989. Treatment of homosexual 

alcoholics in government-funded agencies: Provider training and attitudes. Hospital Community 

Psychiatry 40(11):1163-1168. 

Herdt, G., 1996. Issues in the cross-cultural study of homosexuality. In: R.P. Cabaj, T.S. Stein 

(eds.), Textbook of Homosexuality and Mental Health. Washington, DC: American Psychiatric 

Press, pp. 65-82. 

Herdt, G., A. Boxer, 1993. Children of Horizons: How Gay and Lesbian Teens Are Leading a New 

 Way Out of the Closet. Boston, MA: Beacon Press. 

Appendix B–References
182 

 

 

 

 

 

 

 

 

 

 

Appendix B–References

Herek, G.M., 1990. Context of anti-gay violence: Notes on cultural and psychological heterosexism. Journal of Interpersonal Violence 5:316-333. 

Herek, G.M., 1989. Hate crimes against lesbians and gay men: Issues for research and policy. 

American Psychologist 44(6):948-955. 

Hetrick, E.S., A.D. Martin, 1987. Developmental issues and their resolution for gay and lesbian 

adolescents. Journal of Homosexuality 14(1-2):25-43. 

Hoffman, N., D. Futterman, A. Myerson, 1999. Treatment issues for HIV-positive adolescents. 

AIDS Clinical Care 3:11. 

Hooker, E., 1957. Adjustment of the male overt homosexual. Projective Technique 21(1):18-31. 

Hubbard, R.L., M.E. Marsden, J.V. Rachal, H.J. Harwood, E.R. Cavanaugh, H.M. Ginsberg, 1989. 

Drug Abuse Treatment: A National Study of Effectiveness. Chapel Hill, NC: University of North 

Carolina Press. 

Hughes, T., 1999. Sexual Identity and Alcohol Use: A Comparison of Lesbians’ and Heterosexual 

Women’s Patterns of Drinking. Presentation conducted at the National Institute of Mental 

Health (November), Bethesda, MD. 

Hughes, T.L., A.P. Haas, L. Avery, 1997. Lesbians and mental health: Preliminary results from the 

Chicago Women’s Health Survey. Journal of Gay and Lesbian Medical Association 1(3):

 133-144. 

Hughes, T.L., S.C. Wilsnack, 1997. Use of alcohol among lesbians: Research and clinical 

implications. Department of Public Health, Mental Health and Administrative Nursing, University 

of Illinois, Chicago, IL. American Journal of Orthopsychiatry Jan; 67(1):20-36. 

Hunter, J., 1996. Emerging From the Shadows: Gay, Lesbian and Bisexual Adolescents. 

Personal Identity Achievement, Coming Out, and Sexual Risk Behaviors. Unpublished doctoral 

dissertation, City University of New York. 

Hunter, J., R. Haymes, 1997. It’s beginning to rain: Gay/lesbian/bisexual adolescents and AIDS. 

In: M.S. Schneider (ed.), Pride and Prejudice: Working With Lesbian, Gay and Bisexual Youth. 

Toronto, ON: Central Toronto Youth Services, pp.137-163. 

Hunter, J., G. Mallon, 1999. Lesbian, gay, and bisexual adolescent development: Dancing 

with your feet tied together. In: B. Greene, G.L. Croom (eds.), Education, Research, and 

Practice in Lesbian, Gay, Bisexual, and Transgendered Psychology: A Resource Manual. 

Psychological Perspectives on Lesbian and Gay Issues, Vol. 5. Thousand Oaks, CA: Sage 

Publications, pp. 226-243. 

Hunter, J., R. Schaecher, 1995. Gay and lesbian adolescents. In: R.L. Edwards (ed.), 

Encyclopedia of Social Work. Washington, DC: National Association of Social Workers, pp. 

1055-1063. 
183 

 

 

 

 

Iglehart, J.K., 1996. Health policy report: Managed care and mental health. New England 

Journal of Medicine 334(2):131-138. 

Imhof, J.E., 1995. Overcoming countertransference and other attitudinal barriers in the treatment 

of substance abuse. In: A.M. Washton (ed.), Psychotherapy and Substance Abuse: A 

Practitioner’s Handbook. New York, NY: Guilford Press, pp. 3-22. 

Institute of Medicine, 1997. Managing Managed Care. Washington, DC: National Academy Press. 

Institute of Medicine, 1996. Pathways of Addiction: Opportunities in Drug Abuse Research. 

Washington, DC: National Academy Press. 

Institute of Medicine, 1990. Broadening the Base of Treatment for Alcohol Problems. 

Washington, DC: National Academy Press. 

Island, D., P. Letellier, 1991. Men Who Beat the Men Who Love Them. New York, NY: 

Harrington Park Press. 

Jean, L.L., 1998. A ward of our own. Advocate 7 October 13, p. 9. 

Johnston, L., P. O’Malley, J. Bachman, 1995. National Survey Results on Drug Abuse From the 

Monitoring the Future Study 1975-1995. Rockville, MD: National Institute on Drug Abuse. 

Jones, B.E., M.J. Hill, 1996. African American lesbian, gay men, and bisexual individuals. In: R.P. 

Cabaj, T.S. Stein (eds.), Homosexuality and Mental Health: A Comprehensive Review. 

Washington, DC: American Psychiatric Press, pp. 549-561. 

Kantor, G., M. Strauss, 1987. “Drunken bum” theory of wife beating. Social Problems 34(3):

 213-227. 

Kennedy, N.J., 1999. Behavioral medicine: Cost effectiveness of primary prevention. In: 

T.P. Gullotta, R. Hampton, G. Adams, B. Ryan, R. Weissberg (eds.), Children’s Health Care: 

Issues for the Year 2000 and Beyond. Thousand Oaks, CA: Sage Publications, pp. 229-282.
 

Kerner, K., 1995. Health care issues. In: K. Jay (author, ed.), Dyke’s Life: A Celebration of the 

Lesbian Experience. New York, NY: Basic Books. 

Kertzner, R.M., M. Sved, 1996. Midlife gay men and lesbians: Adult development and 

mental health. In: R.P. Cabaj, T.S. Stein (eds.), Textbook of Homosexuality and Mental Health. 

Washington, DC: American Psychiatric Press, Inc., pp. 289-303. 

Kinsey, A.C., W.B. Pomeroy, C.E. Martin, 1948. Sexual Behavior in the Human Male. Philadelphia, 

 PA: W.B. Saunders. 

Kinsey, A.C., W.B. Pomeroy, C.E. Martin, P. Gebhard, 1953. Sexual Behavior in the Human 

Female. Philadelphia, PA: W.B. Saunders. 

Appendix B–References
184 

 

 

 

 

 

Appendix B–References

Klein, K., T.J. Wolf, 1985. Bisexualities: Theory and Research. New York, NY: Haworth Press. 

Klinger, R.L., R.P. Cabaj, 1993. Characteristics of gay and lesbian relationship. In: J.M. 

Oldham, M.B. Riba, A. Tasman (eds.), American Psychiatric Press Review of Psychiatry, Vol. 

12. Washington, DC: American Psychiatric Press, pp. 101-125. 

Kominars, S.B., K.D. Kominars, 1996. Accepting Ourselves and Others: A Journal in Recovery 

From Addictive and Compulsive Behavior for Gays, Lesbians, Bisexuals, and Their Therapists. 

Center City, MN: Hazelden. 

Kondratas, A., A. Weil, N. Goldstein, 1998. Assessing the new federalism: An introduction. 

Health Affairs May/June; 17:24. 

Kreiss, J.L., D. Patterson, 1997. Psychosocial issues in primary care of lesbian, gay, bisexual, and 

transgender youth. Journal of Pediatric Health Care 11:266-274. 

Kruks, G.P., 1991. Gay and lesbian homeless/street youth: Special issues and concerns. 

Journal of Adolescent Health 12:515-518. 

Kus, R.J., 1989. Bibliotherapy and gay American men of Alcoholics Anonymous. Gay and 

Lesbian Psychotherapy 1(2):73-86. 

Kus, R.J., 1985. Stages of coming out: An ethnographic approach. Western Journal of Nursing 

Research 7(2):177-198. 

Larsen, E., 1991. Stage II Recovery: Life Beyond Crisis. San Francisco, CA: Harper San 

Francisco, audiocassette. 

Leonard, K., T. Jacob, 1987. Alcohol, alcoholism, and family violence. In: V.R. Van Hasselt, 

A. Morrison, A. Bellack, M. Herson (eds.), Handbook of Family Violence. New York, NY: 

Plenum, pp. 383-406.
 

Letellier, P., 1996. Twin epidemics: Domestic violence and HIV infection among gay and 

bisexual men. Journal of Gay and Lesbian Studies 4(1):69-81. 

LeVay, S., 1996. Queer Science: The Use and Abuse of Research Into Homosexuality. 

 Cambridge, MA: MIT Press. 

Lewis, C.E., M.T. Saghir, E. Robins, 1982. Drinking patterns in homosexuality and 

 heterosexual women. Journal of Clinical Psychiatry 43:277-279. 

Lewis, J.A., R.Q. Dana, B.A. Gregory, 1994. Substance Abuse Counseling (2nd Edition). 

 Belmont, CA: Brooks/Cole Publishing Company. 

Li, K.C., 1996. Private insurance industry’s tactics against suspected homosexuals: Based on 

occupation, residence, and marital status. American Journal of Law and Medicine 22(14): 

477-502. 
185 

 

 

 

 

Lobel, K. (ed.), 1986. Naming the Voice: Speaking Out About Lesbian Battering. Seattle, WA: Seal 

Press. 

Lombardi, E.L., R.A. Wilchins, D. Priesing, D. Malouf. Gender Violence: Transgender Experiences 

 With Violence and Discrimination, submitted for publication. 

Longshore, D., M.D. Anglin, K. Annon, S. Hsieh, 1993. Trends in self-reported HIV risk behavior: 

Injection drug users in Los Angeles. Journal of Acquired Immune Deficiency Syndrome 6:

 82-90. 

Longshore, D., J. Annon, M.D. Anglin, 1998. Long-term trends in self-reported HIV risk behavior: 

Injection drug users in Los Angeles, 1987-1995. Journal of Acquired Immune Deficiency 

Syndrome and Human Retrovirology 18:64-72. 

Longshore, D., S. Hsieh, 1998. Drug abuse treatment and risky sex: Evidence for a cumulative 

teatment effect? American Journal of Drug and Alcohol Abuse 24:439-451. 

Los Angeles County Task Force on Runaway and Homeless Youth, 1988. Report and 

Recommendations of the Task Force on Runaway and Homeless Youth. Los Angeles County, 

CA: Author. 

Lu, F.G., 1996. Getting to cultural competence: Guidelines and resources. Behavioral Healthcare 

Tomorrow 5(2):49-51. 

MacKenzie, R.G., 1993. Influence of drug use on adolescent sexual activity. Adolescent Medicine: 

 State of the Art Reviews 4(2):112-115. 

Magee, M., D.C. Miller, 1998. Psychoanalytic views of female homosexuality. In: R.P. Cabaj, T.S. 

Stein (eds.), Textbook of Homosexuality and Mental Health. Washington, DC: American 

Psychiatric Press, pp.191-206. 

Marmor, J. (ed.), 1980. Homosexual Behavior: A Modern Reappraisal. New York, NY: Basic 

Books. 

Mason, J.L., 1995. Cultural Competence Self-assessment Questionnaire: A Manual for Users. 

Portland, OR: Portland State University Research and Training Center on Family Support and 

Children’s Mental Health. 

McKirnan, D., P.L. Peterson, 1989. Alcohol and drug abuse among homosexual men and women: 

 Epidemiology and population characteristics. Addictive Behaviors 14:545-553. 

McNally, E.B., 1989. Lesbian Recovering Alcoholics in Alcoholics Anonymous: A Qualitative Study 

of Identity Transformation. Unpublished doctoral dissertation, New York University. 

Meyer, C.H., 1993. Assessment in Social Work. New York, NY: Columbia University Press. 

Appendix B–References
186 

 

 

 

 

 

 

 

 

 

Appendix B–References

Michaels, S., 1996. The prevalence of homosexuality in the United States. In: R.P. Cabaj, T.S. 

Stein (eds.), Textbook of Homosexuality and Mental Health. Washington, DC: American 

Psychiatric Press, pp. 43-63. 

Miller, A., 1981. The Drama of the Gifted Child. New York, NY: Basic Books. 

Miller, B., W. Downs, D. Gondolfi, 1989. Spousal violence among alcoholic women as 

compared to a random household sample of women. Journal of Studies on Alcoholism 

50(6):533-535. 

Mongeon, J.E., T.O. Ziebold, 1982. Preventing alcohol abuse in the gay community: Toward a 

theory and model. Journal of Homosexuality 7(4):89-99. 

Morales, E.S., M.A. Graves, 1983. Substance Abuse: Patterns and Barriers to Treatment 

for Gay Men and Lesbians in San Francisco. San Francisco, CA: San Francisco Prevention 

Resource Center. 

Morgan, P., D. McDonnell, J. Beck, K. Joe, R. Gutierrez, 1993. Ice and methamphetamine use: 

Preliminary findings from three sites. In: B. Sowder, G. Beschner (eds.), Methamphetamine: An 

Illicit Drug With High Abuse Potential. Rockville, MD: T. Head and Company. 

Moriarty, H.J., A. Thiagalingam, P.D. Hill, 1998. Audit of service to a minority client group: Male to 

female transsexuals. International Journal of STD and AIDS 9:238-240. 

Nakajima, G.A., Y.H. Chan, K. Lee, 1996. Mental health issues for gay and lesbian Asian 

Americans. In: R.P. Cabaj, T.S. Stein (eds.), Textbook of Homosexuality and Mental Health. 

Washington, DC: American Psychiatric Press, pp. 563-581. 

National Association of Social Workers, 1996. Lesbian, Gay and Bisexual Issues: Policy 

Statement. Approved by the NASW Delegate Assembly. Washington, DC: Author. 

National Coalition of Anti-Violence Programs, 1997. Report on Hate-motivated Violence Against 

Lesbians, Gay Men, Bisexuals, and Transgender Individuals. New York, NY: Author. 

National Institute on Drug Abuse (NIDA), 1994. Community Epidemiology Work Group. 

Epidemiology Trends in Drug Abuse. Rockville, MD: NIDA. 

Neisen, J., 1993. Healing from cultural victimization: Recovery from shame due to heterosexism. 

Journal of Gay and Lesbian Psychotherapy 2(1):49-63. 

Neisen, J., 1990. Heterosexism: Redefining homophobia for the 1990s. Journal of Gay and 

Lesbian Psychotherapy 1(3):21-35. 

Neisen, J.H., 1997. Inpatient psychoeducational group model for gay men and lesbians 

with alcohol and drug abuse problems. In: L.D. McVinney (ed.), Journal of Chemical 

Dependency Treatment: Innovative Group Approaches. New York, NY: Haworth Press, pp. 

37-51. 
187 

 

 

 

 

 

 

 

New York State Office of Alcoholism and Substance Abuse Services, Academy of Addiction 

Studies, 1996. Working With Lesbian, Gay, Bisexual, and Transgender Clients in Alcoholism 

and Substance Abuse Services Trainers Manual. New York, NY: Community Health Project. 

Nichols, L.M., L.J. Blumberg, 1998. Different kind of “New Federalism.” Health Affairs May/June; 

17(3):25-42. 

Office of Applied Studies, Substance Abuse and Mental Health Services Administration 

(SAMHSA), 1999. Summary of Findings From the 1998 National Household Survey on Drug

 Abuse. Rockville, MD: SAMHSA. 

O’Hanlan, K., 1995. Lesbian health and homophobia: Perspectives for the treating 

obstetrician/gynecologist. Current Problems in Obstetrics and Gynecology 18(4):96-101. 

Ostrow, D.G., 1996. Mental health issues across the HIV-1 spectrum for gay and bisexual men. In: 

R.P. Cabaj, T.S. Stein (eds.), Textbook of Homosexuality and Mental Health. Washington, DC: 

American Psychiatric Press, pp. 859-879. 

Ostrow, D.G., E.D. Beltran, J.G. Joseph, W. DiFrancesco, J. Wesch, J.S. Chmiel, 1993. 

Recreational drugs and sexual behavior in the Chicago MACS/CCS cohort of homosexually 

active men. Journal of Substance Abuse 5(4):311-325. 

Patterson, C.J., 1995. Lesbian mothers, gay fathers, and their children. In: A.R. D’Augelli, C.J. 

Patterson (eds.), Lesbian, Gay and Bisexual Identities Over the Lifespan. New York, NY: 

Oxford University Press, pp. 262-290. 

Paul, J.P., R.D. Stall, G.M. Crosby, D.C. Barrett, C.T. Midanik, 1994. Correlates of sexual 

risk-taking among gay male substance abusers. Addiction 89(8):971-983. 

Paul, J.P., R.D. Stall, F. Davis, 1993. Sexual risk for HIV transmission among gay/bisexual men in 

 substance-abuse treatment. AIDS Education and Prevention 5(1):11-24. 

Pernanen, K., 1991. Alcohol Human Violence. New York, NY: Guilford Press. 

Peterson, M.R., 1992. At Personal Risk: Boundary Violations in Professional-Client Relationships. 

 New York, NY: Norton. 

Picucci, M. 1998. Journey Toward Complete Recovery: Reclaiming Your Emotional, Spiritual, and 

Sexual Wholeness. Berkeley, CA: North Atlantic Books. 

Pillard, R.C., 1996. Homosexuality from a familial and genetic perspective. In: R.P. Cabaj, 

T.S. Stein (eds.), Textbook of Homosexuality and Mental Health: A Comprehensive Review. 

Washington, DC: American Psychiatric Press, pp. 115-128. 

Prochaska, J., J. Norcross, C. DiClemente, 1994. Changing for Good. New York, NY: William 

Morrow & Co. 

Appendix B–References
188 

 

 

 

 

 

 

 

 

 

 

Appendix B–References

Ratner, E.F., 1993. Treatment issues of chemically dependent lesbians and gay men. In: 

L.D. Garnets, D.C. Kimmel (eds.), Psychological Perspectives on Lesbians and Gay Male 

Experiences. New York, NY: Columbia University Press, pp. 567-578. 

Ratner, E.F., T. Kosten, A. McLellan, April 1991. Treatment outcome of PRIDE Institute patients: 

First wave—Patients admitted from September 1988 through February 1989. In: A.T. McLellan, 

(ed.) Outcome Report. Eden Prairie, MN: PRIDE Institute. 

Reback, C.J., E.L. Lombardi, 1999. HIV risk behaviors of male-to-female transgenders in a 

community-based harm reduction program. International Journal of Transgenderism 3(1,2 

combined). 

Remafedi, G., 1987. Adolescent homosexuality: Psychosocial and medical implications. 

Pediatrics 79:331-333. 

Rodgers, L., 1995. Transgendered youth fact sheet. In: Transgender Protocol Team (ed.), 

Transgender Protocol: Treatment Services Guidelines for Substance Abuse Providers. San 

Francisco, CA: Lesbian, Gay, Bisexual, Transgender Substance Abuse Task Force, pp. 7-8. 

Rosario, M., J. Hunter, M. Gwadz, 1997. Exploration of substance use among lesbian, gay and 

bisexual youth: Prevalence and correlates. Thousand Oaks, CA: Sage Publications. Journal of 

Adolescent Research 12(4):454-476. 

Rosario, M., H.F.L. Meyer-Bahlburg, J. Hunter, T.M. Exner, M. Gwadz, A.M. Keller, 1996. 

Psychosexual Development of Lesbian, Gay and Bisexual Youths: Sexual Activities, Sexual 

Orientation and Sexual Identity. Paper presented at the Second International Conference on 

Biopsychosocial Aspects of HIV Infection, Brighton, United Kingdom. 

Rothblum, E., 1994. I only read about myself on bathroom walls: The need for research on the 

mental health of lesbians and gay men. Journal of Consulting and Clinical Psychology 

62(2):213-220. 

Rotheram-Borus, M.J., J. Hunter, M. Rosario, 1994. Suicidal behavior and gay-related stress: Gay 

 and bisexual male adolescents. Journal of Adolescent Research 9:498-508. 

Rotheram-Borus, M.J., M. Rosario, H. Meyer-Bahlburg, 1994. Sexual and substance use acts of 

gay and bisexual male adolescents in New York City. Journal of Sex Research 31:47-57. 

Rotheram-Borus, M.J., M. Rosario, H. Reid, C. Koopman, 1995. Predicting patterns of sexual acts 

 among homosexual and bisexual youths. American Journal of Psychiatry 152(4):588-595. 

Ryan, C., D. Futterman, 1998. Adolescent HIV counseling and testing protocol. In: C. Ryan, D. 

Futterman (eds.), Lesbian and Gay Youth: Care and Counseling. (Guidelines for providing HIV 

counseling and testing in all settings that provide adolescent care). New York, NY: Columbia 

University Press, pp. 152-161. 
189 

 

 

 

 

 

 

 

Ryan, C., D. Futterman, 1997. Lesbian and Gay Youth: Care and Counseling. Philadelphia, PA: 

Hanley & Belfus. 

Saghir, M.T., E. Robins, B. Walbren, K.A. Gentry, 1970. Homosexuality IV. Psychiatric disorders 

 and disability in the male homosexual. American Journal of Psychiatry 126:1079-1086. 

San Francisco Department of Public Health, AIDS Office, 1997. HIV Prevention and Health 

Service Needs of the Transgender Community in San Francisco: Results From Eleven Focus 

Groups. San Francisco, CA: Author. 

Savin-Williams, R.C., 1995. Lesbian, gay, and bisexual adolescence. In: A.R. D’Augelli, C.J. 

Patterson (eds.), Lesbian, Gay, and Bisexual Identities Over the Lifespan. New York, NY: 

Oxford University Press, pp. 165-189. 

Savin-Williams, R.C., 1994. Verbal and physical abuse as stressors in the lives of lesbian, gay 

male, and bisexual youths: Association with school problems, running away, substance abuse, 

prostitution, and suicide. Journal of Consulting and Clinical Psychology 62(2):261-269. 

Schaef, A., 1988. When Society Becomes an Addict. San Francisco, CA: Harper. 

Schoenbaum, M., W. Zhang, R. Sturm, 1998. Costs and utilization of substance abuse care in 

 privately insured populations under managed care. Psychiatric Services 49:1573-1578. 

Seattle Commission on Children and Youth, 1988. Report on Gay and Lesbian Youth in Seattle. 

 Seattle, WA: Department of Human Resources. 

Seil, D., 1996. Transsexuals: The boundaries of sexual identity and gender, 1996. In: R.P. Cabaj, 

T.S. Stein (eds.), Textbook of Homosexuality and Mental Health. Washington, DC: American 

Psychiatric Press, pp. 743-762. 

Simpson, B., 1994. Making Substance Abuse and Other Services More Accessible to Lesbian, 

 Gay, and Bisexual Youth. Toronto, ON: Central Toronto Youth Services. 

Skinner, W.F., 1994. Prevalence and demographic predictors of illicit and licit drug use among 

lesbians and gay men. American Journal of Public Health 84:1307-1310. 

Skinner, W.F., M.D. Otis, 1996. Drug and alcohol use among lesbian and gay people in a 

southern U.S. sample: Epidemiological, comparative, and methodological findings from the 

Trilogy Project. Journal of Homosexuality 30(3):59-62. 

Sophie, J., 1985/1986. A critical examination of stage theories of lesbian identity development. 

Journal of Homosexuality 12(2):39-51. 

Stall, R., J. Wiley, 1988. Comparison of alcohol and drug use patterns of homosexuality and 

heterosexual men: The San Francisco Men’s Health Study. Drug and Alcohol Dependence 

22:63-73. 

Appendix B–References
190 

 

 

 

 

 

 

 

Appendix B–References

Stark, E., A. Filcraft, 1988. Violence among intimates: An epidemiological review. In: V.D. Van 

Hasselt, R.L. Morrison, A.S. Bellack, M. Herson (eds.), Handbook of Family Violence. New 

York, NY: Plenum, pp.159-199. 

Stricof, R.L., J.T. Kennedy, J.C. Natell, I.B. Weisfuse, L.F. Novick, 1991. HIV seroprevalence in a 

facility for runaway and homeless adolescents. American Journal of Public Health 

81(Suppl):50-53. 

Substance Abuse and Mental Health Services Administration (SAMHSA), 1998. Legal Issues 

Associated With Development and Implementation of a Provider-Sponsored Managed Care 

Organization. Managed Care Technical Assistance Series 6. BKD296. Rockville, MD: 

SAMHSA. 

Substance Abuse and Mental Health Services Administration (SAMHSA), 1996. National 

 Household Survey on Drug Abuse, Main Findings of 1996. Rockville, MD: SAMHSA. 

Surles, R.C., R.I. Fox, 1998. Behavioral health: A view from the industry. In: D. Mechanic (ed.), 

Managed Behavioral Health Care: Current Realities and Future Potential. San Francisco, CA: 

Jossey-Bass, pp. 25-29. 

Tafoya, T.N., 1996. Native two-spirit people. In: R.P. Cabaj, T.S. Stein (eds.), Homosexuality and 

Mental Health: A Comprehensive Review. Washington, DC: American Psychiatric Press, 

pp. 603-617. 

Tewksbury, R., Gagne, P., 1996. Transgenderists: Products of non-normative intersextion of sex, 

gender, and sexuality. Journal of Men’s Studies 5:105-129. 

Tims, F.M., B.W. Fletcher, R.L. Hubbard, 1991. Treatment outcomes for drug abuse clients. In: 

R.W. Pickens, C.G. Leukefeld, C.R. Schuster (eds.), Improving Drug Abuse Treatment. NIDA 

Research Monograph 106. DHHS Pub. No. (ADM) 91-1754. Rockville, MD: National Institute 

on Drug Abuse, pp. 93-113. 

Transgender Protocol Team, 1995. Transgender Protocol: Treatment Services Guidelines for 

Substance Abuse Treatment Providers. San Francisco, CA: Lesbian, Gay, Bisexual, 

Transgender Substance Abuse Task Force. 

Travers, R., M. Schneider, 1996. Barriers to accessibility for lesbian and gay youth needing 

addictions services. Youth and Society 27(3):356-378. 

Tremble, B., M. Schneider, C. Appathurai, 1989. Growing up gay or lesbian in a multicultural 

context. Journal of Homosexuality 17:253-267. 

Troiden, R.R., 1988. Gay and Lesbian Identity. New York, NY: General Hall Press. 

Vaid, U., 1995. Virtual Equality: The Mainstreaming of Gay and Lesbian Literature. New York, NY: 

Anchor Books. 
191 

 

 

 

 

 

 

Waldorf, D., S. Murphy, 1990. IV drug use and syringe sharing practices of callmen and hustlers. 

 In: M. Plant (ed.), AIDS, Drugs and Prostitution. London, England: Routledge. 

Warren, B., 1997. The transgender experience: Identity, community, and recovery. Counselor

 May/June; 37-39. 

Weinberg, G., 1983. Society and the Healthy Homosexual. New York, NY: St. Martin’s Press. 

Weinberg, G., 1972. Society and the Healthy Homosexual. New York, NY: St. Martin’s Press. 

Weinberg, M., C. Williams, 1974. Male Homosexuals: Their Problems and Adaptations. New York, 

NY: Oxford University Press. 

Weinberg, M., S. Williams, D. Pryor, 1994. Dual Attraction: Understanding Bisexuality. New York, 

NY: Oxford University Press. 

Welch S., P. Howden-Chapman, S.C.D. Collings, 1998. Survey of drug and alcohol use by lesbian 

 women in New Zealand. Addictive Behaviors 23(4):543-548. 

Windle, M., R. Windle, D. Scheidt, G. Miller, 1995. Physical and sexual abuse and associated 

 mental disorders among alcoholic inpatients. American Journal of Psychiatry 152:1322-1328. 

Winnicott, D.W., 1965. Maturational Processes and the Facilitating Environment: Studies in the 

Theory of Emotional Development. Madison, CT: International Universities Press, Inc. 

Woititz, J.G., 1990. Adult children of alcoholics. Deerfield Park, FL: Health Communications. 

Woll, C., 1996. What difference does culture make? Providing treatment to women different from 

you. Journal of Chemical Dependency 6:67-85. 

Wong, F.Y., C.L. Ching, M.W. Ross, K.H. Mayer, 1998. Sexualities as social roles among Asian 

and Pacific Islander American gay, lesbian, bisexual, and transgender individuals: Implications 

for community-based health education and prevention. Journal of the Gay and Lesbian Medical 

Association 2(4):157-166. 

Woodman, N.J., 1989. Mental health issues of relevance to lesbian women and gay men. Journal 

 of Gay and Lesbian Psychotherapy 1(1):53-63. 

Woody, G.E., D. Donnell, G.R. Seage, D. Metzger, M. Marmor, B.A. Koblin, 1999. Non-injection 

substance use correlates with risky sex among men having sex with men: Data from HIVNET. 

Drug and Alcohol Dependence 53(3):197-205. 

Woolf, D., 1983. CSN depressants alcohol. In: G. Bennett, C. Vourakis, D. Woolf (eds.), 

Substance Abuse: Pharmacological Development and Clinical Perspectives. New York, NY: 

John Wiley & Sons, pp. 39-56. 

Appendix B–References
192 

 

Appendix B–References

Ziebold, T.O., J.E. Mongeon (eds.), 1985. Gay and Sober: Directions for Counseling and Therapy. 

 New York, NY: Harrington Park Press. 

Zierler, S., L. Feingold, D. Laufer, P. Velentgas, I. Kantrowitz-Gordon, K. Mayer, 1991. Adult 

survivors of childhood sexual abuse and subsequent risk of HIV infection. American Journal of 

Public Health 81:572-575. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 It’s 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 

193 
194 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix C–Acronyms

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 
195 

Appendix D Studies on LGBT Substance Abuse

Study Study Population Substance

Use/Abuse 

Methodology Comparison Group Outcome Comments on

Outcome 

Saghir etal., 19701 

LesbiansN=200 

Alcohol Convenience

sample 

None 33% reported having a

problem with alcohol 

No comparisons canbe made at this time

Fifield etal., 19771 

LesbiansN=57 

Alcohol Convenience

sample 

None 35% reported having a

problem with alcohol 

No comparisons canbe made at this time

Lewis etal., 19821 

LesbiansN=57 

Alcohol Convenience

sample 

None 28% reported having a

problem with alcohol 

No comparisons canbe made at this time

Morales &Graves,19831

LesbiansN=129 

Alcohol Convenience

sample 

None 27% reported having a

problem with alcohol 

No comparisons canbe made at this time

Bradford &Ryan,19871 

LesbiansN=1,917 

Alcohol Population-based

(National Lesbian Health Care Survey) 

None 6%—daily drinkers 

25%—drink 1+/wk30%—drink 1+/mo17%—abstainers 

No comparisons canbe made at this time

Stall &Wiley,1988 

Gay men Alcohol &

drugs 

Population-based

(San Francisco Men’sHealth Study) 

Heterosexual men in San Francisco 

Gay men had greatersubstance use(excluding alcohol) thanheterosexual men 

McKirnan &Peterson,19891 

LesbiansN=748 

Alcohol Convenience

sample 

General populationwomen (Clark &Midinak, 19921 

76% vs. 59%—Moderate 9% vs. 7%—Heavy 23% vs. 8%—Problems 

Lesbians had greateralcohol use than generalpopulation women 

Bloomfield,19931 

LesbiansN=58 

Alcohol Convenience

sample 

Heterosexual women (N=397) 

69% vs. 74%—Moderate 11% vs. 10%—Heavy 13% vs. 3%—In recovery 20% vs. 16%—Abstainers 

Lesbians had greateralcohol use thanheterosexual women
196 Appendix D–Studies on LGBT Substance Abuse

Study Study Population Substance

Use/Abuse 

Methodology Comparison Group Outcome Comments on

Outcome 

Skinner,1994

Lesbians & gay 

men 

Alcohol, cigarettes,

marijuana & other 

illegal drugs 

Convenience

sample 

Heterosexuals Lesbians & gay men had

greater substance usethan heterosexuals 

Skinner &Otis, 19961

 Lesbians

N=500 

Alcohol Convenience

sample

 General population

women

N=725 

32% vs. 28%—1-4 drinks/mo 

26% vs. 11%—5-19 drinks/mo 

12% vs. 2%—20-30 drinks/mo 

 28% vs. 9%—5+ drinks/occasion

Lesbians used more

alcohol than generalpopulation women

Hughes etal., 1997

Lesbians

N=284 

Alcohol or drug

problems 

Conveniencesample

 Heterosexual women 

N=134 

10% vs. 2%

77% vs. 85%—Light/moderate 2% vs. 2%—Heavy 

19% vs. 13%—Alcohol problems

 Lesbians used more

substances than

heterosexual women 

Clements etal., 1998

Transgender

persons(N=515) 

Intravenous druguse

 Convenience

sample 

None 34% MTF w/lifetime IV drug use 

18% FTM w/lifetime IV drug use 

No comparisons can bemade at this time

Woody etal., 1999

 Men who have sex

with men (MSM)

and are at specificrisk for HIV/AIDS(N=3,212)

Alcohol, nitrite

inhalants,

hallucinogens,

stimulants, sedatives,

tranquilizers,marijuana, cocaine 

Convenience

sample

 General population

men 

 This nongeneral sample of MSM 

who were specifically at risk 

for contracting HIV disease was21 times more likely to usenitrite inhalants, 6 times morelikely 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

MSM used more

substances than general

population men

Cochran &Mays, 2000 

Same gender (male)

partners (N=98)

Same gender

(female) partners

(N=96) 

Alcohol

dependence (DSM–IV) 

Drug dependence

(DSM–IV) 

Populationbased (1996 National

Household Survey of 

Drug Abuse)

 Opposite-gender

(female) partner(s)

only (N=3,922)

Opposite-gender

(male) partner(s)

only (N=5,792) 

10% of males with partners of

the same gender vs. 7.6% of 

males with partners of the opposite gender exhibited symptoms of alcohol dependence.

7% of females with partners of

 the same gender vs. 2% of females with partners of the opposite 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 opposite gender exhibited symptoms

of drug dependence.5% of females with partners of

 the same gender vs. 1.3% of

females with partners of the opposite gender exhibited symptoms of drug dependence. 

Same-sex partners used

more substances than

opposite-sex partners
197 

Study Study Population Substance

Use/Abuse

 Methodology Comparison Group Outcome Comments on

Outcome 

Cochranet al.,in press 

Same gender

partners (gay and

lesbian) (N=194)

Opposite gender

partners (N=9,714)

Alcohol

dependence (DSM-IV) 

Population-based

(1996 National

Household

Survey of DrugAbuse)

Same gender partner

(male) vs. opposite 

gender partners (male)

Same gender partner

 (female) vs. opposite 

gender partners(female) 

Lesbians were 2 times more 

likely to use alcohol in the past 

month, 3.5 time more likely in

the past year, 5 times more

likely to use alcohol every day,

2.25 times more likely to get

intoxicated, and 4 times more

likely than heterosexual women to get intoxicated weekly. There

were no differences betweengay and straight men.

Lesbians were at higher

risk for alcohol use than

heterosexual women

Welch,HowdenChapman &Collings,1998 

New Zealandlesbians

N=200 

Drugs Survey None 76% reported using cannabis

once (lifetime) and 33% reporteduse in the last year31% used recreational drugsother than alcohol and cannabis at some time, and 4.5%

reported past year use

 No comparisons can

be made at this time

1As cited in Hughes, T. (November 1999). Sexual Identity and Alcohol Use: A Comparison of Lesbians’ and Heterosexual Women’s Patterns of Drinking. 

 Presentation conducted at the National Institute of Mental Health. 

Appendix D–Studies on LGBT Substance Abuse


HHS Publication No. (SMA) 12–4104

Substance Abuse and Mental Health Services Administration

First printed 2001

Revised 2003, 2005, 2009, and 2012