BSAS

Practice Guidance:  Treatment Services Lesbian, Gay, 
Bisexual, Transgender and Queer Adults

I.  Rationale:  

BSAS is committed to equality in treatment services regardless of sexual orientation or gender identity.  Access to and quality of treatment services should not vary because of the individual’s gender, sexual orientation or gender identity.  Therefore, deliberate and thorough attention must be paid to groups whose substance use is exacerbated by discrimination and hostility, and whose treatment access is hampered by the same forces.  These effects are felt particularly by lesbian women, gay men, bisexual adults, transgender adults, and queer adults (LGBTQ).  
One symptom of discrimination is the lack of comprehensive, reliable data describing precise rates of substance use and abuse among this population. Epidemiological studies rarely ask about sexual orientation or gender identity – a gap which inhibits design of evidence-based prevention and treatment.  Further, the distinction between sexual orientation – the emotional and physical attraction to others – and gender identity – the gender a person identifies and lives as – is frequently misunderstood.
A handful of illuminating studies bridge gaps in knowledge and understanding.  A comprehensive review of research literature reports rates of use and abuse by LGBTQ adults are at least equal to, and possibly greater than, rates in the general population.  In some studies more than 30% of lesbians reported alcohol problems, compared to a rate of 6.1% for women in general.  Drug use among men with same sex partners was twice the rate of use by men with opposite sex partners.  Transgender individuals reported between 18% (female to male) and 34% (male to female) lifetime IV drug use.  Surveys in Massachusetts reveal that lesbian, gay and bisexual individuals are more likely to report binge drinking and illicit drug use than are heterosexuals.
Rates of tobacco use are even higher, with estimates ranging from 35% to 200% higher than rates in the general population.  Persons with substance use disorders who smoke are more likely to die from tobacco related causes than from substance abuse. 
Risks related to custom -- such as amphetamine use in some gay male social settings-- or related to establishing gender identity -- such as use of illicit hormones by transgender individuals -- present problems about which the treatment system may be poorly informed. 
Substance use among the LGBTQ population carries with it at least the same risks as for the heterosexual population, but other factors increase risk.  LGBTQ individuals face discrimination, heterosexism, homophobia, bi-phobia, trans-phobia and sexism, all of which contribute to isolation, fear and self-loathing.  These can lead to depression, anxiety, and increased risk of self-harm, suicide, substance use and dependence.  LGBTQ individuals are more likely to report lifetime sexual assaults than heterosexuals, and even those who have not experienced direct assaults are subject to secondary trauma through reports of violence directed at LGBTQ persons.
Despite equal need for effective intervention, reports document disparities in health care access.  Lack of health insurance and of civil sanction of family relationships, and legal gender definition which contradicts the identity, contribute to low rates.  More directly relevant is fear of discrimination or hostility – a fear that is not unfounded.  Shame and stigma associated with substance abuse compound shame and stigma resulting from heterosexism, homophobia, bi-phobia, trans-phobia and sexism, making it more difficult to seek help.  

II. Guidance:  

A.  Organization: 
Policy:
•	Policies state that the agency is affirmatively responsive to lesbian women, gay men, bisexual adults and transgender adults, i.e. that the agency builds its resources and skill in providing treatment to this population.
•	Agency employment policies and practices promote development of a workforce that is knowledgeable, skilled and effective in engaging LGBTQ adults.
•	Policies affirmatively define safeguards for LGBTQ staff and individuals served.
•	Policies clearly describe how the agency establishes and maintains a safe and respectful environment.
Operations:
•	Outreach efforts are directed to community agencies and organizations which have demonstrated ability to engage and support LGBTQ individuals and their families.
•	Posters, brochures and other materials in public spaces affirm the agency’s commitment to respectful engagement of the LGBTQ population, e.g. by use of inclusive visual images.
•	Agencies seek out and establish Qualified Service Organization Agreements with other entities providing effective services for LGBTQ individuals and their families.
•	Agencies advertise employment opportunities in LGBTQ community media.
•	Unisex restrooms are visible and accessible.
•	Agencies develop and implement approaches based on best practices which aim to reduce impact of homophobia, heterosexism, bias and discrimination in substance abuse treatment, and improve retention of LGBTQ individuals as staff and in the population served.
•	In designing gender-specific services, agencies provide for participation by transgender individuals as the gender the person identifies and lives as.
•	Data collection forms provide mechanism of choice in disclosing sexual orientation and gender identity.
•	Agencies establish mechanisms to ensure that individual’s name and gender a person identifies and lives as are used in all interactions.
•	Confidentiality and data safeguards specifically address security of sexual orientation and gender identity information.
•	Agencies conduct annual surveys of staff and the population served to assess experiences and perceptions of the agency’s competence in engaging LGBTQ individuals, and the agency’s effectiveness in establishing a safe environment.
Supervision, Training & Staff Development:
•	Staff at all levels participates in annual LGBTQ cultural competence training, which includes understanding the distinction between sexual orientation and gender identity.
•	All staff, including reception, clerical and clinical staff display cultural competence in interactions with each other and with the population served.
•	Supervisors and staff are able to identify and effectively address assumptions, bias, stereotypical thinking and discriminatory beliefs and actions.
•	Staff is knowledgeable about shared history, cultural legacies, values and beliefs of the LGBTQ population.
•	Staff is skilled in identifying and addressing heterosexism, homophobia, bi-phobia, trans-phobia and sexism.
•	Staff is knowledgeable about risks specific to the LGBTQ population, including trauma, depression, anxiety, internalized heterosexism, homophobia, bi-phobia, trans-phobia and sexism.
•	Staff is knowledgeable about the phases and process of coming out.
B.  Service Delivery and Treatment:  
Assessment:
•	Assessments recognize that existing valid and reliable tools are unlikely to have been adequately tested with LGBTQ adults, and that additional assessments will be needed to explore and understand factors such as:  
o	the degree to which a person is ‘out’; 
o	family of choice vs. family of origin; 
o	violence trauma related to heterosexism, homophobia, bi-phobia, trans-phobia and sexism; 
o	preferred pronouns.
•	Assessment address sexual history, current sexual activity, and sexual health; tobacco use; and depression and anxiety.
 Planning:
•	Treatment plans identify individuals’ formal and informal support systems.
•	Treatment plans identify additional safeguards needed when an individual’s legal name differs from chosen name, for example, in providing insurance documentation.
Service Provision:
•	Staff is knowledgeable about risks related to substance use and abuse for LGBTQ individuals.
•	Staff is able to discuss losses and trauma experienced or likely to be experienced as a result of heterosexism, homophobia, bi-phobia, trans-phobia and sexism.
•	Staff is able to discuss harm reduction strategies specific to varieties of LGBTQ social activities and life styles.
•	Staff is able to discuss discrimination and hostility among the client population as a whole.
•	Staff is able to discuss sexual health concerns that are specific to the LGBTQ population.
•	Staff is able to address tobacco use, and treatment of nicotine addiction.
•	Staff is able to assess whether individuals struggle with self-acceptance, and is able to provide support as needed. 
•	Staff is able to assess mental status and determine whether intervention related to anxiety, depression and suicidality is needed.
•	Treatment modalities and groups accommodate sexual orientation and gender identity.
Education of Individuals
•	Individuals are provided with information about what is documented to be effective versus what is not known in substance abuse risk and treatment for LGBTQ individuals.
•	Individuals are provided information about community resources known to be safe for and respectful toward LGBTQ individuals.

III. Measures:  

Programs can assess their effectiveness by formulating questions specific to their goals in applying standards.  Some examples of questions related to serving LGBTQ individuals include:
•	Results of annual surveys;
•	Comparison of data describing population served and characteristics of the community.
•	QSOA’s and active referrals with agencies serving LGBTQ individuals and their families;
•	Training topics such as: understanding the process of ‘coming out’; assertive LGBTQ cultural awareness.

IV. Resources:  

Massachusetts Department of Public Health Resources:
A Health Profile of Massachusetts Adults by Sexual Orientation Identity: Results from the 2001-2006 Behavioral Risk Factor Surveillance System Surveys
Office of Health Equity, provides resources and tools to assist agencies with implementing Culturally and Linguistically Appropriate Services
Making Smoking History:  provides information about smoking and tobacco use and a wide range of resources for help in quitting.
A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual and Transgender Individuals, Substance Abuse and Mental Health Services Administration, 2001
Gay and Lesbian Medical Association:  Offers a range of resources on their publications page including:
Same-Sex Marriage and Health:  Gay and Lesbian Medical Association Marriage Equality Index (2008) 
Guidelines for Care of Lesbian, Gay, Bisexual and Transgender Patients (2006) 
Healthy People 2010: Companion Document for Lesbian, Gay, Bisexual, and Transgender Health (2001) 
Human Rights Campaign Health Care Equity Index
The National Association of Lesbian and Gay Bisexual and Transgender Addiction Professionals:  a membership organization dedicated to the prevention and treatment of alcoholism, substance abuse, and other addictions in lesbian, gay, bisexual, transgender, queer communities.
National LGBT Tobacco Control Project 
National Coalition for LGBT Health
LGBT Aging Project: an advocacy organization for lesbian, gay, bisexual and transgendered older adults.  The website lists resources and links.

V.  Forms  

Gay and Lesbian Youth Support project: provides a wide array of resources including model agency assessment tools.  

BSAS welcomes comments and suggestions.  Contact:  BSAS.Feedback@state.ma.us