This document provides an overview of substance abuse issues within the LGBT community. It discusses factors that can contribute to higher rates of substance abuse, such as experiences with heterosexism, discrimination, and internalized homophobia. It also covers approaches to treatment, including the importance of addressing issues related to sexual orientation and gender identity as part of the recovery process. Barriers to treatment like fear of discrimination are outlined, along with solutions like creating an affirming and inclusive environment for LGBT clients.

1. Welcome Substance Abuse and the LGBT Community Knoll Larkin MPH Mautner Project-”Removing the Barriers” Funded by the Centers for Disease Control and Prevention Affirmations—”The Community Center for Lesbian, Gay, Bisexual, Transgender People and their Allies” T0

2. Part I Module One  Setting the Stage - Making the Case T1

3. Training Guidelines 1. Confidentiality 2. Agree to disagree 3. Use “I” statements 4. You are responsible for your comfort 5. Ask questions and be willing to take risks 6. Have FUN!! T1:1

4. Assumptions You currently provide quality care to people. You are interested in increasing your ability to provide quality care to people. If you are treating people, you are also treating lesbians, gays, bisexuals and transgender and same gender loving individuals. T 1:2

5. What are LGBT Health Issues? Health Issues General Risk & Protective Factors Lifespan Development Mental Health Cardiovascular Disease Cancer Substance Abuse HIV/AIDS STDs Service delivery/Access T1:3

6. Part I Module Two  Defining Culture T2

7. Cultural Indicators Ethnicity Race Sex Socioeconomic class Age Sexual orientation Gender identity Faith practices Style of dress T2:1

8. What does culture impact? How we regard time. What we find attractive or interesting. How we dress. What we eat or don’t eat. How we view other people. Our worldview. T2:2

9. Benefits of Culture Culture gives us a starting place to reference who we are in relationship to the world and others. Provides a buffer and place of refuge to the outside world. T2:3

10. Summary: Defining Culture Be aware of your areas of personal privilege. Ask, rather than make assumptions. Be respectful and non-judgmental. Educate yourself. Learn about the history of oppression of other groups as it relates to medical care. T2:4

11. Part I Module Three  Defining Cultural Competence In the Healthcare System T3

12. How does culture impact healthcare? Culture is the complex interplay of all the facets of individual’s experience, which informs: Specific health concerns How they present for care Style of communication Access to medical services Level of trust in the medical system Compliance Outcome of patient encounters T3:1

13. What is individual cultural competence? Individual cultural competence is a set of: congruent behaviors, attitudes, and knowledge that enable a person to effectively interact with an individual or a group different from them. T3:2

14. What is organizational cultural competence? Organizational cultural competence is a set of: congruent behaviors, attitudes, and policies that come together in a system, an agency or among professions that enable the system, agency or profession to work effectively in cross cultural situations. T 3:3

15. Culturally Competent System of Care Should.. Acknowledge and incorporate: the importance of culture, the assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to meet culturally unique needs. T 3:4

16. What is culturally competent care? A system of: clinical practices, standards of care, management policies, and institutional philosophies that takes into consideration and is responsive to the cultural factors that influence the attitudes and behaviors of every patient. T3:5

17. Cultural Sensitivity Awareness of impact of culture State of desiring to provide culturally appropriate services. Where the journey begins T3:6

18. Benefits of Culturally Competent Care Increased access to services Improved prevention/early intervention Better communication and rapport More accurate diagnoses Improved adherence and compliance More effective treatment outcomes T3:7

19. Benefits of Culturally Competent Care (cont.) Greater consumer satisfaction Increased patient retention More word-of-mouth referrals Cost savings Reduced malpractice liability Greater provider satisfaction T3:8

20. Summary: Cultural Competence Cultural Competence: is a skill that can be learned, requires practice and commitment, is a journey not a destination. Expect to make mistakes in good faith. Have compassion for yourself in the process. T3:9

21. Part I Module Four  Understanding Language: Sex, Gender and Orientation T4

22. Sexual Orientations Homosexual: Attraction to individuals of the same sex Heterosexual: Attraction to individuals of the opposite sex Bisexual: Attraction to members of either sex T4:1

23. Identity vs. Behavior Health concerns of women who partner with women are impacted by both identity and behavior. Identity- the “label” one applies to oneself and one’s community of affiliation Behavior- the specific activities a person engages in. T 4:3

24. Levels of Identity Involved in gay and lesbian politics or culture “ Closeted and isolated from valuable support resources Sexual orientation may be only a minor part of personal identity T4:4

25. Gender Identity May be: Feminine / Femme Androgynous Masculine / Butch Transgender Gender identity is distinct from erotic orientation. T4:5

26. Gender Identity (cont.) Transgender: Gender expression incongruent with expectations of biological/assigned sex. MTF (male to female) / FTM (female to male) T4:6

27. Using Language: Summary One way to demonstrate inclusiveness in a healthcare setting is through use of language. Use terms preferred by your patients. These may be different for each person, regionally or generationally based. T4:7

28. Common language: Summary (cont.) Preferred vs. Other Terms Lesbian, Gay, Bisexual Homosexual Partner Lover/Roommate Sexual orientation Sexual preference WHEN IN DOUBT… ASK! Words/Phrases Often Used “Within” the Community Dyke, Queer, Family, In the Life T4:8

29. Common language: Summary (cont.) Be aware of the language used by your patients/clients, and use THEIR language. T4:9

30. Part II Module Five  Introduction: Substance Abuse and the LGBT Community T6

31. Epidemiology of substance use and abuse in the LGBT Community Numerous factors predispose to use. The additional tension and stigma of being part of a marginalized community (LGBT) cause some to manage stressors by using.

32. Difficult to determine substance use and abuse in LGBT populations. No one can say with certainty the number of individuals who are LGBT . Alcoholism, drug abuse, and addiction have only recently been highlighted as significant social problems. Denial and secrecy commonly characterize alcoholism and drug abuse in all populations

33. Data? It is frequently reported that people who are LGBT experience increased risk for substance use and abuse. Many sources report that one out of every three gay men and lesbians, or over 8 million LGBT men and women, struggle with alcohol and drug-related problems. Other research studies have found that moderate alcohol use rates in the LGBT communities are similar to those of the mainstream populations, but that the LGBT population is over-represented on both ends of the spectrum (those who abstain and those who are heavy users). More research is needed in order for prevention and treatment efforts to target these communities effectively!

34. Types of Substances Abused Although LGBT people use and abuse all types of drugs, certain drugs seem to be more popular in the LGBT community. Findings include Gay men more likely to hallucinogens, stimulants, inhalants. Lesbians more likely to use alcohol and more likely to get intoxicated than heterosexual women. Meth (Gay men up to 7 times more likely)

35. Heterosexism Contributes to Substance Abuse Heterosexism instills shame in LGBT individuals, causing them to internalize homophobia that is directed toward them by society Some may use intoxicants to cope with shame and other negative feelings

36. Negative effects of heterosexism Self-blame for the victimization one has suffered Negative self concept Anger directed inward resulting in destructive patterns A victim mentality or feelings of hopelessness or despair, interfering with leading a fulfilling life NOT A RESULT OF ONES SEXUALITY!

37. Life Cycle Issues For LGBT Individuals LGBT youth face additional stressors (conformity, and coming out) LGBT young adults (social life revolving around bars and substance use settings) Coupling Parenting Treatment Providers need to consider an LGBT client’s partner, children, family of origin and family of choice when providing care!

38. Part II Module Six  Overview Of Treatment Approaches T6

39. Special Issues Substance Abuse Treatment same for LGBT individuals: focus on stopping the substance abuse that interferes with the well-being of the client. Some LGBT clients will need to address their sexual orientation and gender identity as part of their recovery process. For some this may include addressing the effects of internalized homophobia and internalized transphobia Clinicians sometimes see relapses in LGBT persons with lingering negative feelings about their identity or orientation.

40. LGBT Clients May Be Coping With: Coming out Societal stigmas HIV/AIDS Discrimination Homophobic family members, employers, and work colleagues

41. It Is Important To Understand: that part of substance abuse recovery for many LGBT individuals is accepting themselves as gay, lesbian, bisexual, same gender loving, or transgender and finding a way to feel comfortable in society.

42. Levels of Care LGBT people like all clients should be assessed to determine the range and level of care they require LGBT people may abuse drugs that influence the level and duration of care they need. (Meth: strong cravings, frequent relapse, requiring extensive and highly focused treatment)

43. Principals of Care Flexible and client centered Comprehensive Consistent with each clients needs/expectations Promote self respect and dignity Promote healthier behaviors Empowerment Reduce barriers to services Clinically informed and research based services Work to create a treatment/recovery “community”

44. Special Assessment Questions Determine an individual’s comfort with being an LGBT person If transgender: determine comfort with identity. Determine stage in coming out process. Learn about his or her experiences and consequences (positive and negative) of coming out. Determine social networks. (current and past relationships, relationships with family of origin) Other health factors of concern. HIV status? Most recent drug/alcohol use: With family, friends, partner, alone? At a circuit party, LGBT bar or straight bar?

45. Special Assessment Questions: Injection drug use. Enhance sexual intensity? If client has significant other or partner, do they believe there is a problem? Legal problems related to sexual behavior, harassment, sex marker on documents? Ever attacked or assaulted because they were thought to be an LGBT person? Social problems with lost partners, family, friends? Ever had treatment in the past and if so was their sexual orientation or gender identity discussed?

46. Part II Module Seven  The Coming Out Process T6

47. Coming Out: Refers to the experiences of some, but not all, LGBT people as they work through and accept a stigmatized identity. Transforming a negative self identity into a positive one Important for those trying to recover: Feeling positive and hopeful about themselves is at the heart of recovering from addition

48. What the coming out process means for counselors? Because many recovery programs value authenticity, the process of coming out is crucial to staying sober. Counselors who accept and validate client’s feelings, attractions, experiences, and identities can play an important role in sobriety.

49. Coming Out (cont) There is no correct way to come out Some people may decide they do not want to take on a LGBT identity and may choose not to disclose their feelings and experiences to anyone.

50. Cass Model of Identity Development Stage 1: Identity Confusion Stage 2: Identity Comparison Stage 3: Identity Tolerance Stage 4: Identity Acceptance Stage 5: Identity Pride Stage 6: Identity Synthesis

51. The Big Questions…. Treatment providers need to help people in recovery begin to question, “Who am I, now that I’m clean and sober?” People in recovery often need help sorting out various aspects of themselves, such as, “What does it mean to be a man? Gay? Lesbian? Bisexual?”

52. Part II Module Eight  Barriers To Treatment and Solutions T6

53. Barriers to receiving care: Marginalization and labeling of sexual orientation or gender identity as deviant or pathological in medical or psychiatric communities. Anticipated, perceived, or actual discrimination Fear of mistreatment Lack of research about use patterns, treatment needs, etc. Provider lack of information Fear of being outed will result in loss of job, custody, housing, or social supports. Exclusion of partner and family of choice from health care settings Lack of insurance coverage under partner’s policy Low self-esteem or belief that sexual orientation or gender identity is wrong.

54. Solutions: Before the patient encounter Marketing materials, brochures, ways services are introduced. Are they representative of the diversity of the populations within the service area? Will LGBT people feel like the advertised facility is a comfortable place for them? How is this communicated? What is the current reputation in LGBT community? Is there a need to address past negative experiences?

55. Creating an Affirming Environment: Display health info, magazines, posters, and other decorations that reflect the faces and interests of clients served. Staff should also be representative of clients served. Consider posting a written non-discrimination policy that includes sexual orientation and gender identity.

56. Inclusive Paperwork Getting beyond “Married, Single, Divorced” Consider “partnered, significant relationship, significant other” -Are you involved in a significant relationship? -Is there someone you would like involved in your care? -With whom do you live?

57. Culturally Competent Approach: Is client centered Uses client’s own language Non-judgmental No assumptions Open ended questions Begins with less threatening questions It’s okay to not know!

58. Part III  Case Studies T6

59. Conclusions  Contracting for Change T9

60.  Summary of Key Points T10

61. Cultural Competence Review Assumptions are normal. But they are often not reality. Ask questions - be aware of the type of questions, and how to ask them. You do not have to agree with someone’s behavior or beliefs in order to provide them with respectful, sensitive and well‑informed care. Cultural competence is a journey not a destination. The goal is a health care is to be responsive to all clients. T10:1

62. Applying Solutions Review Become knowledgeable about the range of human sexual behavior and gender expression. Establish rapport before asking intimate questions. Use a private location for conducting an interview and avoid interruptions. Conduct an interview with the patient fully dressed. T10:2

63. Applying Solutions Review (cont.) You cannot assume that: All patients are currently sexually active Older, obese or disabled patients are not sexually active Patients who practice safer sex with one partner do so with all partners, or all the time. T10:4

64. Applying Solutions Review (cont.) Do not assume that: You can identify LGBT people by the way they act or dress. You “know” someone’s gender identity by just looking at them. Heterosexually identified patients do not have same gender partners. Lesbian women or gay men identified do not engage in heterosexual activity. T10:5

65. Questions? Comments?