To meet the needs of LGBT individuals who are seeking substance abuse treatment, treatment providers should take into account certain factors that affect client satisfaction and treatment outcomes. Successful treatment begins with a non-judgmental, all-inclusive assessment containing multiple questions that ask about an individual’s sexual identity, sexual orientation and sexual behavior (Stevens, 2012). During initial and ongoing assessments, clients will be able to answer questions about their “coming out” process and discuss positive or negative experiences related to that process surrounding their sexual minority identity. A thorough assessment enables the addiction treatment counselor to develop a more comprehensive substance abuse treatment plan. An LGBT-informed substance abuse treatment provider would be mindful of language, which would entail advising staff members to refrain from LGBT jokes and asking LGBT clients about their pronoun of choice. Sexual minority men and women who receive LGBT-specific addiction treatment will be able to apply adaptive coping strategies with regard to family issues and LGBT minority stress.
When an individual decides to disclose an LGBT identity to family members, the family’s response can tremendously impact the individual’s trajectory in life, influencing his or her decision to use alcohol and drugs or to move forward in a healthy direction. Positive responses such as acceptance, tolerance and support, serve as protective factors against drug and alcohol use, whereas negative responses such as rejection or abuse can seriously damage vulnerable individuals who have not developed strong coping strategies and lack other resources, such as social support outside the family or financial resources to relocate oneself to a more supportive environment (SAMHSA, 2001).
A study examining the number of rejecting or accepting reactions to LGBT identity disclosure (beyond family rejection) found that experiencing more negative reactions was associated with greater substance use, and positive reactions protected from alcohol use, but not drug use; the findings suggest that non-familial social contexts, such as LGBT-friendly support groups, may serve as a protective factor against future substance use (Rosario, Schrimshaw & Hunter, 2009).
Research has shown a strong association between childhood sexual abuse (CSA) and later substance abuse for both LGBT women and heterosexual women, but data collected from women in substance abuse treatment programs show that rates of CSA are higher for sexual minority women (Stevens, 2012). In adolescence and adulthood, many LGBT individuals experience different forms of harassment based on their gender identity and sexual orientation, such as bullying, teasing, slurs, threats, offensive comments, LGBT micro-aggressions, and institutional discrimination. The high rates of substance abuse among LGBT individuals are attributed to these gender- and sexuality-based forms of harassment (Coulter, Bersamin, Russell & Mair, 2018).
Behavioral therapy interventions within LGBT substance abuse treatment centers equip sexual minority men and women with healthy coping mechanisms such as stress management skills specific to the LGBT experience of discrimination and prejudice. LGBT clients will gain more control over emotional regulation in stressful situations, which would reduce symptoms of depression and anxiety in the future. Clients with underdeveloped intra-personal skills will be strengthened and introduced to resources outside of their family of origin so they can build rapport with peers while they transition from substance use to recovery.
Successful addiction treatment centers for transgender individuals are sensitive to transgender-specific issues, such as gender affirmation (e.g., hormone therapy). Treatment providers that incorporate transgender care for substance abuse will consider the possibility that the client may already be on estrogen or testosterone therapy when they come in for addiction treatment. In such cases, LGBT substance abuse treatment providers will support transgender clients by allowing them to continue with hormone treatment while they receive treatment for drug and alcohol abuse.
In the treatment setting, it is important for substance abuse counselors not to assume that gender issues are the root of their transgender clients’ addiction (SAMHSA, 2001). When conducting an assessment, counselors should ask each transgender client about sexuality, gender identity and comfort level with his or her sex role. An example of non-discriminatory practices can be illustrated in a residential treatment setting. Housing should be all-inclusive, which would allow transgender individuals who identify as women to stay with other women; they would not be treated any differently, and everyone — clients and staff alike — would refer to the transgender individual by her chosen pronoun. The LGBT substance abuse treatment provider would make resources and outside support available for transgender individuals as well.
Culturally competent counselors would be mindful of potential relapse triggers specific to transgender individuals, such as the following:
• Inability to find employment based on transgender expression
• Lack of essential academic and professional skills
• Inability to undergo sex reassignment surgery based on HIV status
• Lack of positive, sober social supports
• Issues of gender identity and sexual orientation
• Needles, a potential relapse trigger for transgender men who inject testosterone
• Treatment providers’ inability to identify with transgender people
On a daily basis, LGBT individuals face the challenge of maintaining a positive sense of self in the face of heterosexism, a system of discrimination that stigmatizes any form of non-heterosexual identity, attitude or behavior (Herek, 1990). Studies show that within the LGBT community, certain subgroups are affected differently by minority stress with respect to their rates of alcohol and substance use. For example, bisexual individuals have higher rates of anxiety, depression, and problematic substance use than their lesbian and gay peers; these rates correspond with more stress, past traumatic events, and less social support than their sexual minority peers (Rogers, Seager, Haines, Hunter, Aldao & Ahn, 2017). Culturally responsive LGBT substance abuse treatment would consider these nuances and apply evidence-based therapies such as cognitive-behavioral therapy to correct internalized negative beliefs.
Through a systematic search, researchers have found 44 promising interventions that could potentially reduce sexual minority stress as well as boost LGBT individuals’ stigma-coping abilities (Chaudoir, Wang & Pachankis, 2017). These community-based interventions, designed to promote empathy and acceptance, have been implemented in various social contexts ranging from academic institutions to health care delivery services. One such intervention, the Rainbow Educator, delivers presentations and workshops to educate communities about heterosexual privilege and to promote an LGBT affirmative climate (Chaudoir et al., 2017). Within the LGBT substance abuse treatment context, it is essential that counselors be knowledgeable about referral sources, meaning that they are resourceful in connecting their clients with LGBT sponsors and introducing them to LGBT-friendly human service providers, such as gay 12-step groups (Matthews & Selvidge, 2008). The group solidarity and cohesiveness provided by such groups will serve as a protective factor for sexual minorities against the adverse effects of minority stress after substance abuse treatment (Meyer, 2003).
1 Chaudoir, S. R., Wang, K., & Pachankis, J. E. (2017). What reduces sexual minority stress? A review of the intervention “toolkit”. The Journal of social issues, 73(3), 586–617. doi:10.1111/josi.12233
2 Coulter R, Bersamin M, Russell ST & Mair C. (2018). The effects of gender- and sexuality-based harassment on lesbian, gay, bisexual and transgender substance use disparities. The journal of adolescent health, 62(6):688-700. doi: 10.1016/j.jadohealth.2017.10.004
3 Herek G. (1990). The context of anti-gay violence: Notes on cultural and psychological heterosexism. Journal of Interpersonal Violence. 1990;5(3):316–333.
4 Matthews CR & Selvidge MD. (2008). Lesbian, gay, and bisexual clients’ experiences in treatment for addiction. Journal of lesbian studies, 9(3):79-90. DOI: 10.1300/J155v09n03_08
5 Meyer I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological bulletin, 129(5), 674–697. doi:10.1037/0033- 2909.129.5.674
6 Rogers AH, Seager I, Haines N, Hunter H, Aldao A & Ahn WY. (2017). The indirect effect of emotion regulation on minority stress and problematic substance use in lesbian, gay, and bisexual individuals. Frontiers in Psychology. doi.org/10.3389/fpsyg.2017.01881
7 Rosario M, Schrimshaw EW, Hunter J. (2009). Disclosure of sexual orientation and subsequent substance use and abuse among lesbian, gay, and bisexual youths: critical role of disclosure reactions. Psychology of Addictive Behaviors, 23(1):175–184.
8 Stevens S. (2012). Meeting the substance abuse treatment needs of lesbian, bisexual and transgender women: implications from research to practice. Substance abuse and rehabilitation, 3(Suppl 1), 27–36. doi:10.2147/SAR.S26430
9 Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment. (2001). A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual and Transgender Individuals. Washington, DC: US Department of Health and Human Services; 2001. Publication No. (SMA) 01-3498.