Lgbtq training august 18 2015

1. Best Practices for Serving
LGBTQI2-S Populations
Course Writers: Michele J. Eliason, PhD; Ken Einhaus, BA; Jeanna Eichenbaum, LCSW; Migdalia
Reyes, EdD, MSW; Daniel Toleran, MS; and Bartholomew Casimir, MA, MFTI.
Copyright, 2011
Modified Arrangement and Additional
Information provided and presented by:
Ebony M. Williams, Psy.D.
drwilliams1055@gmail.com
1

2. “I’m a gay alcoholic. Those two labels have informed my life.
At age 15 I went to the library in our home town and looked
up every reference the card catalog had on homosexuality. I
learned that I was psychologically abnormal, that I was
illegal, that I was immoral, and that I was unacceptable.”
2

3. Although adults who identify as LGBTQ in the United States
typically are well adjusted and mentally healthy, the Institute of
Medicine (IOM) (2011) reports:
LGBTQ populations are at substantially greater risk for
substance use and mental health problems.
3

4. More Quick Stats…
 Gay men are at greater risk for suicide attempts and
completions
 Depression affects gay men at higher rates, often with more
severe problems for men who remain “in the closet”
 Women with same-sex partners have higher rates of major
depression, simple phobias, and PTSD
 Bisexual men and women report consistently igher levels of
depression and anxiety
 Rates of depression and suicide attempts among both male-to-
female and female-to-male transgender individuals are higher
than nontransgender populations
4

5. Quick Stats: LGBTQ Youth
According to GLSEN (Gay, Lesbian, Straight Education Network):
 90% of LGBTQ hear anti-gay comments in school
 On average, an LGBTQ high school student will hear 26 anti-LGBTQ slurs per day; 1.3 of which come
from a school staff member
 84% of LGBTQ youth report verbal harassment at school based on their gender identity and expression
 74% of Transgender youth report sexual harassment at school based on their gender identity and
expression
 25% of LGB students have been physically hurt by another student because of their sexual orientation
 55% of Transgender youth report physical attacks based on their gender identity and/or expression
 28% of LGBT youth drop out of school due to this harassment
5

6. More Quick Stats (Youth)…
 A multistate study of high school students found a greater
likelihood of engagement in “unhealthy risk behaviors such as
tobacco use, alcohol and other drug use, sexual risk
behaviors, suicidal behaviors, and violence” among LGB
students and students who report having sexual contact only
with persons of the same or both sexes, than heterosexual
students
6

7. More Quick Stats (Youth)…
 “Adverse, punitive, and traumatic reactions from parents and
caregivers in response to the children’s LGB identity” closely correlate
with LGB adolescents’ use of illegal drugs, depression, and suicide
attempts
 Conversely, recent research inks accepting family attitudes and
behaviors toward their LGBT children (i.e, advocacy and support)
significantly decreased risk and better general health in adulthood
7

8. Research Difficulties in LGBTQ
Communities
 Reliable information on the size of the LGBTQ 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
8

9. To eliminate:
 Heterosexism
A subtle form of oppression which reinforces realities of silence
and invisibility.
To eliminate:
 Homophobia
 Transphobia
Includes prejudice, discrimination, harassment, and acts of
violence brought on by fear and hatred.
This occurs on personal, institutional, and societal levels.
Why Focus on LGBTQ?
9

10. How Heterosexism Contributes to
Substance Abuse SAMHSA (2012)
 Self-blame for the victimization one has suffered
 A negative self-concept as a result of negative messages
about same-sex attractions
 Anger directed inward resulting in destructive patterns such as
substance abuse
 Self-victimization that may hinder emotional growth and
development
 Feelings of inadequacy, hopelessness, and despair that
interfere with leading a fulfilling life 10

11. 11
Why Focus on LGBTQ?
 All clients deserve respect
 Stereotypes harm people by reducing them to a narrow set of
characteristics that erase their individuality
 Equal access to treatment does not mean that all clients or
communities have the same needs; they may need to receive
different services according to unique characteristics
 All agencies can and should be LGBTQ-responsive; some
agencies may go further and provide LGBTQ-specific services

12. 12
Why Focus on LGBTQ?
 Some clients have sexual issues or concerns related to their
substance use and abuse; so learning to talk about sexuality and
gender more openly will help most clients.
 All agencies should provide physical, emotional and spiritual
safety for all clients. To feel safe, marginalized group members
need to feel that they are being seen as who they are by
treatment providers.

13. 13
Standards of Cultural Responsiveness…
Why?
 Without standards of care and training about LGBTQ issues,
many LGBTQ clients will experience the same types of
harassment, discrimination, or invalidation as they experience
elsewhere in society
 Such stigmatizing experiences may harm LGBTQ clients;
decrease rates of program enrollment, engagement, and
retention; and diminish positive outcomes
Cochran, Peavy, & Cauce, 2007; Eliason, 2000; Eliason & Hughes, 2004

14. 14
Action Plan:
The Five Standards
of LGBT CLAS

15. 15
LGBT CLAS Standards
The LGBT Constituent Committee is affiliated with the
Department of Health Care Services, formerly, the California
Department of Alcohol & Drug Programs
It is one of eight committees that advise the Department in
developing strategies to plan and implement culturally-competent
alcohol and other drug abuse prevention, treatment and recovery
services
In 2008, the Committee and LGBT-TRISTAR the Department’s
LGBTQ TA contractor developed five voluntary standards of
care for providing culturally and linguistically responsive services
for LGBTQ populations, including action steps to promote them.
We refer to them as the 5 - LGBT CLAS Standards

16. 16
Five LGBTQ CLAS Standards
1. LGBTQ-Inclusive Policies and Procedures
2. LGBTQ Basic Training and Staff Supervision
3. Appropriate Language
4. Welcoming and Inclusive Climate
5. Linkages, Referrals and Resources

17. 17
LGBT CLAS Standard 1:
LGBT-Inclusive Policies and Procedures
Standard #1:
Agency policies and procedures are inclusive of LGBT staff,
clients and communities
◦ Most agencies are heterosexist, meaning that there is no
indication in their daily operations that some of the staff,
clients, and communities they serve are LGBTQ
◦ The first step an agency can take is to examine their policies
and procedures for evidence that LGBTQ people exist and
are addressed in the agency documents

18. 18
LGBT CLAS Standard 2:
LGBT Basic Training and Supervision
Standard #2:
 Staff members at substance abuse treatment or
prevention agencies receive LGBT basic training as part
of their larger diversity training experiences, and
receive appropriate supervision to provide inclusive
services. Staff members who provide poor quality care
are appropriately sanctioned.

19. 19
LGBT CLAS Standard 3:
Appropriate Language
Standard #3:
 Written forms and documents, and oral language used in
assessment and interventions are inclusive and respectful
of LGBT people
◦ Written documents such as client brochures, intake forms,
and outreach materials, and oral language used in
assessments and interventions set the tone for inclusion or
exclusion

20. 20
LGBT CLAS Standard 4:
Welcoming and Inclusive Climate
Standard #4:
 The climate of the substance abuse treatment and
prevention agency is welcoming and inclusive of all
clients

21. 21
LGBT CLAS Standard 5:
Linkages, Referrals and Resources
Standard #5:
 Substance abuse treatment and prevention agencies
create linkages with local LGBT communities and use
appropriate referral sources and resources for their
LGBT clients

22. 22
Treatment
Considerations
69

23. Aspects to consider…
 Role of religion
 Experience of prejudice or
discrimination
 Circumstances around
migration and immigration
status
 Acculturation and
assimilation
 Past/Current SES
 Family structure and roles
 Gender-Related issues and
roles
 Co-existing diagnoses
 Educational attainment
 Language
 Identity development
23

24. “There is never a discussion about the
intersection of identity within LGBTQ
populations and it is not embedded in
[our] trainings.”
County Staff Advisory Group member
24

25. Minority Stress Theory
H. Meyer (2003) states three assumptions underlying the concept
of minority stress:
 1. Minority stress is unique and in addition to stressors faced by
all people. Individuals experiencing minority stress are therefore
required to make a greater adaptation effort than those who are
not members of a stigmatized minority.
 2. Minority stress is chronic.
 3. Minority stress is socially based and “stems from social
processes, institutions, and structures beyond the individual” and
which the individual has minimal to no control over.
25

26. Intersecting Identities
 Because LGBTQ individuals are so diverse, it is important
practitioners recognize the influence and impact of multiple
identities and multiple oppressions.
 This is particularly true for those working with LGBTQ people
of color.
 Focusing on only one identity can cause the therapist to
neglect the struggles and challenges of those who have
multiple and intersecting identities
(Fukuyama & Ferguson, 2000) 26

27. Seeking Cultural Proficiency
27

28. “Do No Harm”
Harm may be caused through well-meaning, though detrimental
actions due to:
lack of education
lack of adequate supervision
heterosexist ideology
firmly held religious beliefs or, a combination of any of
these
(Crisp, 2006; R.-J.Green, 2000, 2004; Guthrie, 2006; Hunter & Hickerson, 2003; Morrow, 2000; Twist, et al., 2006; Van Den Bergh & Crisp, 2004; Van
Voorhis & Wagner, 2002).
28

29. “Self-awareness of one’s internal
heterosexism or homophobia is the
critical first step toward cultural
competence.”
(Van Den Bergh and Crisp, 2004)
29

30. Coming Out “No-No” Responses
30

31. “No-No” Responses
How do you know?
31

32. “No-No” Responses
Bringing up politics or religion,
offering unsolicited advice or
making rash decisions.
32

33. Seeking Cultural Proficiency
Achieving competency includes:
 Acquiring accurate and scientifically valid knowledge regarding
the unique needs, challenges, and issues of LGBTQ communities
and individual members (Bieschke, et al., 2000; Hunter & Hickerson, 2003; Reynolds & Hanjorgiris, 2000)
 Practitioners must also educate themselves regarding the stigma,
discrimination and oppression these populations endure (Kulkin, et al., 2000)
 Novices in the field need to seek supervision or consultation on a
regular basis from those professionals who have the necessary
knowledge and experience working with LGBTQ clients (Hunter & Hickerson,
2003) 33

34. LGBTQQIAA Symbols All symbols researched: Lambda.org
34

35. 35

36. Seeking Cultural Proficiency
 Practitioners should also honor the experiences of each
individual LGBTQ client, learning that every person also has
their own unique story to tell (Hunter & Hickerson, 2003).
 When working with LGBTQ individuals, mental health
providers should not overly attribute a client’s issues to their
LGBTQ status, nor should their LGBTQ identity be
dismissed or ignored (Matthews & Selvidge, 2005; Morrow, 2000; Van Den Bergh & Crisp, 2004).
36

37. Appropriate Coming Out Responses
37

38. Appropriate Coming Out Responses
Listen to what he or she has to
say and let them set the tone of
the conversation.
38

39. Appropriate Coming Out Responses
Thank them for trusting you.
39

40. 40
LGBTQ Basic Terms

41. 41
Language Continues to Evolve
 The language used to refer to sexuality and gender is
constantly changing, and preferred terms vary by age group,
ethnicity, geographic region, and other factors.
 Clients appreciate health care professionals’ efforts to be
inclusive and culturally competent. This includes a willingness
to adopt and use appropriate terminology when delivering
services to their community.
 If clients use a term you don’t know, ask them what they
mean when they use it.

42. 42
Language Continues to Evolve
 Sex
 Gender
 Sexual Identity
 Gender Identity
 Gender Expression
 Intersex

43. 43
Sex and Gender
 Sex = two meanings
◦ Male or female bodied
◦ A set of behaviors that culture designates as related to
reproduction and/or intimacy
 Gender = where we fit on the male/female and
masculine/feminine continua
The concepts of sexuality and gender are independent:
We all have both a sexual and a gender identity

44. 44
Sexual Orientation
 Refers to core sexual attractions and influences who people
have sex with, who they love, and with whom they create
family
 May have a biological basis
 Is on a continuum
 Most common: straight or heterosexual, gay, lesbian,
bisexual, asexual

45. Terms and Definitions Specific to
Sexual Orientation
 Bisexual
 Gay
 Lesbian
 Heterosexual
 MSM
 WSW
 Queer
 Asexual
45

46. 46
Can Sexual Orientation be Changed?
 While there is no scientific evidence that these efforts are
effective, there is evidence that they are harmful
psychologically, socially and spiritually
 Efforts to change someone’s sexual orientation in youth or
adulthood are opposed by:
◦ the American Medical Association
◦ the American Psychiatric Association
◦ the American Psychological Association
◦ the National Association of Social Workers
◦ Many other professional organizations
◦ LGBT community organizations and leaders

47. 47
Gender Identity
 Gender identity describes people’s innermost experience and
understanding of their gender
 Gender binary refers to the cultural belief that there are only
two genders (men and women), and that gender must conform
to biological sex (male and female)
 Gender non-conforming refers to a person whose gender
expression is different from societal expectations related to their
perceived gender
 “Transgender” or “Trans” are umbrella terms for people who
have a significant cross-gender identification from the sex
assigned at birth

48. 48
Terms and Definitions Specific to Gender
Identity
Identities also considered to be under the “Transgender” or
“Trans” umbrella:
◦ Transsexual is the medical term for people who live full-time
in a cross-gender identity regardless of their surgical status
◦ Transwoman, MTF or transfemale refers to a person
assigned male at birth who currently identifies as female
◦ Transman, FTM or transmale refers to a person assigned
female at birth who currently identifies as male
◦ Genderqueer describes people who reject the gender binary
and identify other than solely male or female

49. 49
Can Gender Identity be Changed?
Efforts to change gender identity are no more
effective than efforts to change sexual
orientation: instead of helping, they can cause
lasting harm.

50. 50
How to connect with transgender people?
 To connect with transgender clients, ask two questions:
◦ 1. Current gender (gender identity):
 Do you currently consider yourself as
 a) A man
 b) A woman
 c) Transgender
 d) Another identification (specify: ____________________)
◦ 2. Birth gender:
 At the time of your birth, were you considered to be
 a) A boy
 b) A girl
 c) Intersex (the doctors could not tell my sex at first)

51. 51
Terms and Definitions Specific to Gender
Expression
Expressions considered to be under the “Transgender” or
“Trans” umbrella:
◦ Cross-dresser describes a person (such as a straight male) who
dresses in the clothing and adopts the characteristics of the other
sex part-time. The medical equivalent is “transvestite” implying
illness.
◦ Drag Queens and Kings: men who occasionally cross dress
are typically called “drag queens” and women who occasionally
cross dress are called “drag kings.” The context is usually for
entertainment, historical and cultural, or political reasons.
Transgender people can be straight, lesbian, gay, bisexual, or
another sexual identity.

52. Terms and Definitions Specific to
Gender Expression
 “Passing” has different meanings for LGB and Transgender
individuals in the U.S. dominant culture:
◦ For LGB, passing can be a derogatory term to imply that
someone is deliberately hiding their sexuality and passing
as heterosexual
◦ For transgender people, passing could mean being read
as the gender they want to express, and thus is a sign that
they have been successful at transitioning
52

53. 53
Terms and Definitions Specific to
Gender Expression
 Transition refers to a term used to describe the period during
which an individual who identifies as transgender begins to
express their gender identity.
◦ During transition, a person may change their name, take hormones,
have surgery, and/or change legal documents
 Not all individuals find it necessary to complete their transition with
surgery or a combination of any of the above in order to identify as
transgender.

54. 54
Gender Expression
 Gender expression does not predict sexual identity:
◦ masculine women can be straight
◦ feminine women can be lesbian or bisexual
◦ masculine men can be gay or bisexual
◦ feminine men can be straight
 Gender non-conforming people, regardless of their sexual
or gender identity are at risk to experience more
◦ harassment and bullying,
◦ anti-gay discrimination, and
◦ hate-crime violence including murder

55. 55
Intersex
A wide variety of biological differences of genitals, hormones,
and/or internal reproductive organs
 Sexual ambiguity is present in 1% of live births; between 0.1%
and 0.2% involve specialist medical attention; some intersex
conditions do not become apparent until puberty or later.
 Some identify as intersex, some do not; some identify as
lesbian, gay, bisexual, or transgender, others as heterosexual.
For more information, visit the websites of the Intersex Society of North America (www.isna.org) or the Accord Alliance (www.accordalliance.org)

56. LGBTQ Terminology
2010, Gay and Lesbian Alliance Against Defamation, Inc.
Terms to Avoid
 “homosexual”
 “homosexual relationship”
 “sexual preference”
 “gay lifestyle” or
“homosexual lifestyle”
Terms Preferred
 “gay, gay man, lesbian, gay
person/people”
 “relationship”
 “sexual orientation” or
“orientation”
 “gay lives” or “gay and
lesbian lives”
56

57. Defamatory Language
2010, Gay and Lesbian Alliance Against Defamation, Inc.
 “deceptive,” “fooling,”
“pretending,” “posing,”
“masquerading”
 “she-male,” “he-she,” “it,”
“trannie,” “tranny,” “shim,”
“gender-bender,”
 “bathroom bill”
 “diseased,” “perverted,”
“destructive”
 “fag,” “faggot,” “dyke,”
“homo,” “sodomite”
 “deviant,” “disordered,”
“dysfunctional”
57

58. Associating gay, lesbian, bisexual and transgender people or
relationships with pedophilia, child abuse, sexual abuse,
bestiality, bigamy, polygamy, adultery, and/or incest.
58
Defamatory Language
2010, Gay and Lesbian Alliance Against Defamation, Inc.

59. 59
Appropriate Terms Used
 Lesbian, gay, bisexual, and transgender (LGBT) are terms of
the communities’ own choosing.
◦ LGBTQQDIPA
◦ LGBTQQIAA
◦ “Two Spirit” (among many Native American individuals)
◦ “Genderqueer” or “queer” (among many youth)

60. Is (Homo)Sexuality A Choice?
60

61. “Relying on deviation from the norm as the
definer of dysfunction raises questions of
how much gender conformity is enough
and how much gender nonconformity is
too much—and who will be the arbiters of
normal versus pathological gender
expression.”
(Brownlie, 2006)
61

62. Is (Homo)Sexuality A Choice?
Historically, there have been three basic positions in this
discussion:
1. the cause is biological
2. the cause is environmental
3. both biological and environmental causes are the source
(Ellis & Symonds, 1897; Gibson, 1997; Kennedy, 1997; Nicolosi & Nicolosi, 2002; Rothblum, 2000; Sullivan, 2003; Wikholm, 1999)
There’s also a presumption that heterosexuality is the normative
and therefore natural sexual orientation (Long & Lindsey, 2004)
In addition, there is the supposition that heterosexuality and
homosexuality are opposites, rather than “variations on a single
theme of human romantic attachments, sexual attraction, and the
capacity for love” (R.-J.Green, 2004, p.xiv).
62

63. “The belief that homosexuality is a choice
is used to “blame the victim” and justify
discrimination.”
(LaSala, 2006)
63

64. Treatment Strategies
64

65. “…One of the biggest problems for the trans
community is that transgender appears in the
DSM as sexual identity disorder. That really
causes problems. Every time I’ve gotten
counseling for depression and anxiety, they
call it being transgender. For me, anxiety
and depression come from not being
accepted in society—it’s not an issue of
mental illness.”
65

66. Gay Affirmative Practice (GAP)
Six major themes of the GAP model are in the following framework:
Attitudes
 1. Same gender sexual desires and behaviors are viewed as a normal
variation in human sexuality.
 2. The adoption of a GLBT [sic] identity is a positive outcome of any
process in which an individual is developing a sexual identity.
Knowledge
 3. Service providers should not automatically assume that a client is
heterosexual.
 4. Important to understand the coming out process and its variations.
Skills
 5. Practitioners deal with their own heterosexual bias and homophobia.
 6. When assessing a client, practitioners should not automatically assume
that the individual is heterosexual. 66

67. 67
Stigma-Related Mental Health Care
LGBT clients should be assessed for the following:
 Recovery from past and current minority stress and trauma
 Coping strategies for internalized and external stigma
 Assess higher likelihood of exposure to trauma
 Assess for symptoms of Post-Traumatic Stress Disorder (PTSD),
a risk factor for substance abuse
 Experiencing or fearing hate crimes increases daily levels of
stress, and for some, results in PTSD
 Provide referrals for responsive therapy and medication when
appropriate

68. Trauma-Informed Care

69. Trauma Informed Care vs. Trauma
Specific Services
 Trauma Informed Care is
about imparting a
philosophy, culture, and
understanding about trauma
at a systemic,
organizational, and service
level.
Hopper, 2010
 Trauma Specific Services
refer to programs that
address trauma with a
continuum of interventions
from screening to treatment
to recovery supports.
 Designed to “directly
address the impact of
trauma, with goals of
decreasing symptoms and
facilitating recovery”
Hopper, 2010

70. Trauma Informed Approach
In this approach, all components of the organization incorporate:
 a thorough understanding of the prevalence and impact of
trauma,
 the role that trauma plays, and the complex and varied paths
in which people recover and heal from trauma.
A trauma-informed approach is designed to avoid re-
traumatizing those who seek assistance, to focus on
"safety first" and a commitment to "do no harm.”
(Harris and Fallot, 2001)

71. The Four R’s
Incorporates four key elements:
1. REALIZING the prevalence of trauma
2. RECOGNIZING how trauma affects all individuals involved
with the program, organization, or system, including its own
workforce
3. RESPONDING by putting this knowledge into practice
4. RESIST RE-TRAUMATIZATION of clients as well as staff
SAMHSA, 2014

72.  Lack of understanding the effects of trauma
 Inability to recognize traumatic triggers and responses
 Unfamiliarity with client’s history/culture
 Moving too fast through the client’s process
◦ Not moving at the client’s pace
◦ If the “Four R’s” are not exercised
 Body Language
 Voice Tones
 Environment
Re-Traumatization:
Provider Examples

73. Trauma Informed Approach:
Six Key Principles SAMHSA, 2014
 Safety
 Trustworthiness and transparency
 Peer Support
 Collaboration and mutuality
 Empowerment, Voice and choice
 Cultural, Historical, and Gender Issues

74. Motivational Interviewing*Miller and Rollnick

75. Transtheoretical Model or
Stages of Change Prochaska and DiClemente

77. Pre-contemplation
Contemplation
Preparation/Determination
Action
Maintenance
Relapse Gold, M. (2006)
Transtheoretical Model or
Stages of Change

79. OARS SMART Recovery: Get Smart Fast Distance Learning Program

80. Open-ended questions
Affirmations
Reflective Listening
Summary Statements
OARS

81. In conclusion…
“There is a myth that LGBTQ is one
community, once we get beyond the “gay”
we still need to support one another—we are
more than just labels. We are individuals.”
Desert Valley Community Dialogue participant
81

82. Goal:
To Build a Better World
82

83. Questions?
83

84. References/Resources
 Amodeo and Jones, 1998.
 APA, 2012.
 Bockting, W.O.; Robinson, B.E.; and Rosser, B.R.S. Transgender HIV prevention: A qualitative needs
assessment. AIDS Care 10:505-526, 1998.
 Center for Mental Health Services. 1997.
 Education-portal.com
 Gold, M. (2006). Stages of Change. Psych Central.
 Hanh D. Truong. HH Counseling Consulting Services. Contacthhccs@gmail.com. Slides 21-25.
 McKirnan and Peterson, 1997.
 Mikalson, P., Pardo, S., Green, J. (2012). Do No Harm: Reducing Disparities for Lesbian, Gay, Bisexual,
Transgender, Queer and Questioning Populations in California. The California LGBTQ. Reducing Mental
Health Disparities Population Report
 ncss.org
 Orlandi, 1992.
 Ptsd,about.com
 San Francisco Department of Public Health, AIDS Office, 1997.
 SAMHSA, 2012
 SAMHSA, 2014
 Straussner, S. 2001. Ethnocultural Factors in Substance Use Treatment.
 Tirado, 1998.
 UC Davis Health System
http://www.ucdmc.ucdavis.edu/cne/resources/multicultural/guidelines.html
84

85. References/Resources
Harris, M. & Fallot, R. (2001). Using trauma theory to design
service systems.
Headington Institute (2014)
HealthcareTOOLBOX (2013)
Hopper, 2010
Huckshorn, K. & Lebel, J.L. (2013). “Trauma Informed Care”.
Modern Community Mental Health: An Interdisciplinary
Approach. Oxford University Press: New York.
Yeager, K., Cutler, D., Svendsen, D., & Sills, G.M. (Eds.). 2013.
Modern Community Mental Health: An Interdisciplinary
Approach. Oxford University Press: New York.