Provider's Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals, A

2012·1.2 MB·English

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 copy­
right 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 posi­
tion 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
s Definitions of Terms .............................................................................................................15

t
n Cultural Competency Overview ...........................................................................................16

e
General Issues in Cross-Cultural Treatment .......................................................................18

t
n
Dimensions of Culture ........................................................................................................ 19

o
C Introduction to the LGBT Community and Culture ..............................................................19

f Ethnic Minority Groups ........................................................................................................22

o
Summary .............................................................................................................................27

e
l
b Chapter 3—Legal Issues for Programs Treating LGBT Clients ...............................................29

a
T Introduction ..........................................................................................................................29

Protecting the Confidentiality of LGBT Individuals in

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

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

Do LGBT Individuals in Substance Abuse Treatment

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

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

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

Chapter 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

iv
Chapter 7—Clinical Issues With Lesbians..................................................................................75
T
a
Introduction ..........................................................................................................................75
b
Destructive Myths and Stereotypes .....................................................................................76
el
Clinical Issues With Substance-Abusing Lesbians..............................................................77

o
Counselors’ Responsibilities ................................................................................................77
f

C

o
Chapter 8—Clinical Issues With Gay Male Clients ....................................................................81
n
Introduction ..........................................................................................................................81
t
e
Being Male and Being Gay ..................................................................................................83
n
Gay Male Social Life ...........................................................................................................84
st
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

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

t
n Introduction ........................................................................................................................117

e
t Counselor’s Professional Responsibility ............................................................................118

n
Helping Clients Heal From the Negative Effects of

o
C Homophobia and Heterosexism .....................................................................................119

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

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

e
l
b
a
T 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

vi
SECTION IV: APPENDIXES T
a
b
Appendix A—Glossary of Terms .......................................................................................169
el
Appendix B—References ..................................................................................................173

o
Appendix C—Acronyms ....................................................................................................193
f

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

o
n
t
e
n
t
s
vii