Are you L, G, B, or T and recovering from substance abuse and dependence? If so, there are important skills you can learn which will diminish the obstacles to an effective recovery.
NOTE: In many cases a major step you can take is with your health care provider; however, if you are not comfortable with him or her or there are complicating factors (the restrictions of your aid program, for example), you should take these into account before acting on any of these suggestions.

• Invisibility
  Many treatment providers don't screen for sexuality or the nature of domestic partnerships or familial relationships. If your provider is one of these, suggest that these items be added to any screening he or she does. And ask for assurance that such information will remain confidential. Client confidentiality is protected by two federal laws (42 USC, Section 290 dd-2; Vol. 42 of CFD, Part 2), which demand the confidentiality of any information about persons who have applied for, or received, substance abuse assessment, treatment or referral. Violation of these laws can result in fines and loss of federal grant money.

• Stigmatization
  You may fear being stigmatized by staff or other clients in the treatment program and this may cause you to avoid accessing care altogether. Adding the screening information mentioned in the previous item (for sexuality , the nature of domestic partnerships, or familial relationships) may also make you reluctant to seek help. This underscores the importance of confidentiality. If you don't feel that your provider can provide the necessary confidentiality it may be time to go elsewhere.

• Group Modalities
  Most treatment programs use a group as part of the program, but if staff members are not sensitive to our issues of vulnerability and exposure and the need to protect us from the potential homophobia of other group members steps should be taken to rectify their ignorance. Providers must recognize the need to educate their staff and make them aware of our specific needs. You can privately recommend to the staff leaders that the staff take one of our online or 'live' programs. Or if you feel comfortable with it, you can suggest that some time be set aside during which you can present information to the members of your group concerning matters like sexuality, domestic partnerships, and familial relationships among LGBT folk.

• Inability to Avoid "places"
  The advice to avoid "people, places and things" associated with drug and alcohol use can be very frightening if your primary social support are people and places who are also associated with the drinking and using behaviors (i.e., bars). Nonetheless, avoiding the places where the behavior is promoted is essential. Finding a 'partner' in your program who's "in the same boat" might help as will finding alternative places to go--a local LGBT community organization, a church-affiliated recovery group, or other supportive organization.

• Cultural Incompetency
  If you're a member of an ethnic group you may experience insensitive treatment by providers who disregard or simply misunderstand the role your culture plays in your recovery. Staff should be educated about culturally specific issues impacting LGBT clients, including relationship issues, policy and legal complications impacting domestic partnership, child custody, health insurance reimbursement, and confidentiality of records. While we don't cover those specific issues in this program, there are some other sources of information that can be helpful:
  • The University of Michigan's Program for Multicultural Health
  • The North Carolina Latino Health Resource Center
  • From Minority Nurse.com, Treating Muslims with Cultural Sensitivity in a Post-9/11 World
  • From the National Mental Health Association's National Consumer Supporter Technical Assistance Center, A Cultural Competency Toolkit: Ten Grant Sites Share Lessons Learned

• Reliance on Spirituality
  The AA model of treatment is closely linked to spirituality, but you may have experienced some rejection by your religious organization due to intolerance of gender variance and sexual orientation. This may have made you skeptical about trusting a higher power. If this is the case, you should consider pursuing alternative treatment programs, especially if you've expressed this skepticism to the group and they have been unsupportive.

• Presentation and Clothing
  Clients are often "forced" to dress in particular ways that highlight gender differences; females may be encouraged to dress more feminine or might be forbidden to wear jewelry with "gay" symbols, or are not allowed to express their own gender identity if it conflicts with their birth sex. This is just another area that indicates the need to educate providers. Clients must be allowed to dress as they prefer (as long as their clothing is appropriate and clean) expressing their gayness or gender identity through their clothing choices and mannerisms. Managing these issues on a daily basis is not a barrier to recovery, but an integral part of the recovery process. If talking with your provider about this or providing him or her with appropriate information does not resolve the issue, changing providers may be necessary.

To help you overcome these and other barriers, sensitive care is critical. Here are some things you can do to make sure such care is provided.

• Make sure your provider knows that you expect to be treated with the same respect they would accord any other client.
• Don't allow the provider to make an invalid assumption about your sexual orientation or gender. Did they use the wrong pronoun? If they were unsure of your gender, did they ask politely? The provider should refer to you by the gender you are presenting.
• Did they use non-heterosexist terminology (i.e., partner, his or her etc.)? It's often up to us to make the provider aware of their shortcomings. So long as it's done with tact and courtesy, most providers will respond positively to your suggestions.
• If you don't identify LGBT identity as an issue your provider should not assume your needs are based on that. By the same token, the provider should not assume your needs are not based on LGBT identity. You can guide your provider in this, but it should be up to you to make the connection, not the provider.
• You should feel that the clinical/medical environment is safe for you to come out or share information. If it isn't, try to identify the things that get in the way and share that information with the provider.
• Intake forms should be gender neutral and respectful of diverse family forms. If they make heterosexist assumptions (i.e. questions like Do you have a need for birth control? rather than What kind of birth control do you use? and Do you have a significant other or partner? rather than What is your wife (or husband's) name?).
• The provider should approach diagnosis on the basis of of the behavior and associated risk factors and not on sexual orientation or gender identity.
• Practitioners need to understand that we struggle with the same problems as heterosexual people, but sexual orientation and gender identity can complicate our access to support or our ability to disclose issues. We share some of the responsibility for making them aware of this.
• Overall, you should be aware of the support groups that welcome LGBT people in their programs (Alcoholics Anonymous; PFLAG; Domestic violence and Incest groups; etc); such groups can be a positive resource. Don't hesitate to use them.

In addition to individual health and human service workers becoming sensitive caregivers, there are steps that can be taken to make a program clinic, hospital, or practice more effective. Here are some things to look for to assure that your Substance Abuse Treatment Center provides sensitive care. If any of these is absent, you should call it to the attention of the provider.

• Program Safety
  There should be zero tolerance for bias-related harassment, especially within groups. This should be communicated to all clients at intake, with a grievance policy in place to address problems. You should have the choice about how and when to communicate your sexual orientation or gender identity. Development and enforcement of these policies is the responsibilities of all members of a treatment community.
• Creation of a Healthy Community
  Your treatment program should foster an environment that advocates and supports LGBT people, encourages LGBT only groups, and creates a healthy community for recovery by normalizing LGBT relationships, issues, and "lifestyles" throughout all aspects of the treatment program.
• Education
  You should be given information about groups and support networks that will support you in your recovery, as part of the aftercare plan.
• Family Needs
  There should be sensitivity and inclusion of partners and children, as well as confidentiality when speaking with family of origin. This is essential in creating a stable base for recovery.
• Flexibility and Client Centered Approaches
  The provider should recognize the need to maintain flexibility in treatment strategies, as well as remaining focused on the individual needs of LGBT clients, particularly regarding issues for people of color, and those who live rurally, or in poverty.

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EXERCISE 16: Substance Abuse Treatment

CASE STUDY: Denise
What would YOU do?

Denise is a 16-year old white female who entered an inpatient treatment program after being hospitalized twice: once for alcohol poisoning, and once after a suicide attempt. Denise's parents are working professionals with a comfortable income and large home in the suburbs. Denise has been living at home, but does not get along with her two older sisters or her younger brother. She is habitually truant.

Denise confided in her counselor that for some time she has been having a hard time with her attraction to and feelings about other girls. Denise characterizes her parents as homophobic and is terrified about what might happen if they found out. Once, when her father found her watching an episode of the TV program "Ellen," he screamed at her: "Why would you want to watch that disgusting smut?"

Denise has signed a consent form permitting her counselor to speak with her parents about her substance abuse treatment.

After she has been in the program for a month, a staff member discovers her acting out sexually with another girl.

Now...consider the following questions:

• Do the counselor and/or facility have to tell Denise's parents about her sexual attraction to other girls?
• Can Denise's counselor discuss her discovery with other staff?
• Should Denise's counselor discuss her discovery with other staff?

Your coach has provided you with the name and e-mail of a "buddy" taking this course. Compose answers to the above questions and arrange for a 'live' session via AOL/IM to compare your answers with those of your buddy. Include the coach in the IM session. Then review the suggested treatment interventions.