L G B T Q Individuals Seth Edwards Student at UNCChapel Hills School of Social Work This presentation was completed for UNC PrimeCareOUD program a program funded by the Health Resources and Services Administration HRSA ID: 915185
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Substance Use Treatment for LGBTQ+ Individuals
Seth EdwardsStudent at UNC-Chapel Hill’s School of Social WorkThis presentation was completed for UNC PrimeCare-OUD program, a program funded by the Health Resources and Services Administration (HRSA).
Slide2Objective:This presentation will seek to inform behavioral health providers about the prevalence of this issue, special considerations, and recommendations for treatment.
Slide3Why? Programs that offer treatment with specialized groups or services for LGBTQ+ people show better outcomes than non-specialized programs (Senreich, 2010). When comparing outcomes of gay/bisexual men and heterosexual men in a traditional, non-specialized program (Senreich, 2010):
Gay and bisexual men dropped out at higher rates, reported low rates of abstinence and reported feeling lower levels of connectedness, satisfaction, honest/openness, and support in traditional treatment Some reports show that people who identify as transgender are much more likely to drop out of addictions treatment due to feelings of isolation and conflict with their providers (American Addiction Centers, 2020). Ethical responsibility as providers to ensure the needs of all people are being met.
Slide4LimitationsFew empirical, large scale, or national epidemiological studies have assessed sexual orientation/gender identity in relation to the prevalence of substance use disorders (McCabe, Hughes, Bostwick, West, & Boyd, 2009).
Due to an absence of data on how many people identify as LGBTQ+, its very difficult to predict the percentage of LGBTQ+ who have a substance use disorder (SAMHSA, 2012).Studies that seek to understand how many people in the US are LGBTQ+ haven’t assessed for substance use (SAMHSA, 2012).
Slide5Limitations (continued)There continues to be very limited data on people who identify as bisexual and/or transgender in relation to substance use (Anderson, 2009).
Research often lacks an intersectional framework and is heavily skewed towards gay men, HIV positive individuals or very specific and ungeneralizable studies (i.e. transgender folks who use substances and engage in sex work in ____(city/state)). Research is outdated and does not reflect advances and/or setbacks in LGBTQ+ rights. Marriage equality
Trans military policy
Increase in violence and murder perpetrated towards trans people especially among BIPOC (National Center for Transgender Equality, 2020)
Increased politicization of trans issues
A 2017 literature review published by the American Psychological Association documented only 8 research articles with information on integrated healthcare for LGBTQ+ individuals since 2000 (Hughes, Damin, & Heiden-Rootes, 2017).
Slide6BackgroundClinical reports and theory-based publications across the last few decades, have suggested that lesbian and gay people are at an increased risk of having a substance use disorders (McCabe, Hughes, Bostwick, West, & Boyd, 2009).
Exposure within clubs and bars, and normalization of drinking and using substances (McKirnan & Peterson, 1989 & Hughes, 2005) Stress of discrimination, harassment, and violence (McKirnan & Peterson, 1989) Family rejection (Ryan, Huebner, Diaz, & Sanchez, 2009) Greif associated with AIDS epidemic (Ryan, Huebner, Diaz, & Sanchez, 2009) Likelihood of being married or parenting (Hughes, 2005). Same risk factors as everyone else
Slide7National Survey on Drug Use and Health (NSDUH)
Annual survey of civilian, noninstitutionalized populations (i.e. active military, long-term hospital, prison populations, homeless not in shelter) of the United States aged 12 years and older (Medley, et al., 2016).Survey is designed to be representative of the nation, with a target sample of ~70,000 (25% adolescents, 25% young adults, 50% adults age 26+ (Medley, et al., 2016).In 2015, the National Survey on Drug Use and Health included questions for the first time about sexual identity and sexual attraction (Medley, et al., 2016) As of 2019, NSDUH continues to only distinguish participants as male or female (SAMHSA, 2019). 2015 Data showed notable differences in substance use between LGB and heterosexual people (Medley, et al., 2016).
The trends in the data show that lesbian, gay, and bisexual persons are more likely to use illicit drugs, engage in binge drinking or heavy drinking, use tobacco, and have a substance use disorder than their heterosexual counterparts when controlling for age and gender (Medley, et al., 2016) .
Slide8(Medley, et al., 2016)
Slide9Co-Occurring Issues for LGB persons with a mental health condition
(SAMHSA, 2020)
Slide10Substance Use and Sexual HealthMSM are significantly more likely to use nitrite inhalants, hallucinogens, stimulants, sedatives, and tranquilizers than their heterosexual counterparts (SAMHSA, 2012).
Use of methamphetamine among MSM, male-to-female transgender populations, and among some groups of lesbians is growing (SAMHSA, 2012). Methamphetamine and other party drugs are increasingly popular at predominantly gay events, parties and clubs. These drugs are known to cause judgement impairment and increase sexual risk taking (SAMHSA, 2012). Some research has linked use of nitrite inhalants or “poppers” with increased risk of contracting HIV and hepatis C (SAMHSA, 2012). Gay and bisexual men who use injectable drugs show higher rates of sexually transmitted infectious diseases than heterosexual men who use injectable drugs (SAMHSA, 2012). For those who are HIV positive, dangerous side effects and deaths have been documented due to the use of party drugs in conjunction with some HIV medications (SAMHSA, 2012).
Slide11Slide12Treatment Accessibility LGBT clients may find it difficult and uncomfortable to access treatment due to fears of homophobia, transphobia, or discrimination (SAMHSA, 2012).
LGBT clients have potentially had prior negative experiences with treatment providers, or with other professionals. Staff may be uninformed or insensitive to the unique needs of this population (SAMHSA, 2012)Staff may hold harmful biases towards LGBT people or want to change their sexual orientation/gender identity (SAMHSA, 2012). Programs that require an observer during urine drug screens may make LGBT clients particularly uncomfortable, and they should be asked who they would be least uncomfortable with observing (SAMHSA, 2012).Residential facilities should consider clients concerns around bathroom or shower facility use, offering a non-gendered bathroom if possible (SAMHSA, 2012).
Treatment providers and other clients should not assume LGBT individuals are flirting or acting out sexually (SAMHSA, 2012).
Slide13Recommendations
Slide14Improve staff competencySAMHSA (2012) recommendations: Train staff on federal and state antidiscrimination laws as it pertains to sexual orientation and gender identity, as well as disability laws pertaining to HIV/AIDS and substance use.
b. Provide staff with training to increase awareness of and sensitivity to LGBTQ+ issues. www.samhsa.gov/behavioral-health-equityhttps://www.ymsmlgbt.org/education/ - SAMHSA’s recommended training resource:A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender IndividualsIntensive full day training with seven modules covering various topics such as legal issues, ”coming out” as it relates to behavioral health, instructions for developing a more LGBT+ friendly agency, and specific clinical guidance
Slide15Cultural HumilityDefined: “willingness to act on the acknowledgement that we have not and will not arrive at a finish line” (American Psychological Association, 2013)
https://www.naadac.org/cultural-humility-LGBTQIA-webinarhttps://www.naadac.org/cultural-humility-LGBTQIA-webinar
Cultural Humility Series
Free pre-recorded training focusing specifically on LGBTQIA+ issues, $20 to take CE quiz
Teaches:
Historical roots and current issues impacting the community
Reasons that potentially create disparities of SUDs among LGBTQ+ populations
Learn the minority stress theory
-
Slide16Organizational Recommendations (SAMHSA, 2012)a. Establish clear policies requiring equal treatment b. Establish grievance procedures for clients wishing to file complaints. Complaints should be taken seriously, and program rules should be enforced promptly.
c. Establish personnel policies to prohibit workplace harassment and unequal treatmentd. Actively recruiting LGBT individuals. e. Establish clear written job descriptions that require equal treatment of all clients f. Establish methods for screening out job applicants that express problematic bias.
Slide17ScreeningThe following are special considerations treatment planners and assessors should take when working with LGBT individuals. (SAMHSA, 2012)
How comfortable and accepting is the client of themselves? How comfortable is the individual with expressing their sexual feelings, sexuality, or gender identity? What stage is the individual in their coming-out process? What consequences have occurred since coming out? What consequences might occur?What supports, social network or current relationships does the person have? What is their relationship with their family of origin?Are there any health factors of concern? For example, HIV status. Has the client experienced legal problems related to drug use? Have they experienced police harassment due to their identity?
Has the person ever been assaulted or attacked for being an LGBT person?
If the client has been in treatment before, was it affirming of their identities?
What is the social context in which the client uses substances? I.e., LGBT bars/clubs, with hookups/dates, sex clubs/parties, etc.
Slide18Culturally Sensitive Care (SAMHSA, 2012)
Slide19Culturally Sensitive Care (continued)Traditional modes of treatment such as group and family counseling presents unique challenges and needs for LGBTQ+ individuals (SAMHSA, 2012).
Providers should be cautious of placing LGBTQ+ persons in groups with homophobic/transphobic clients (SAMHSA, 2012). Providers should provide strong verbal directives for clients that illustrate bias and hostility (SAMHSA, 2012).Typical procedures for clients not following rules should be carried out (SAMHSA, 2012).When possible, programs for special populations should be available (SAMHSA, 2012).
Slide20SummaryDisparities in the prevalence of substances use among LGBTQ+ populations Gaps in the research
Sexual healthAccessibility concerns Recommendations:Staff training, organizational structure, screening, culturally sensitive care
For questions and/or clarification, please contact Seth Edwards at snedwar2@ad.unc.edu
Slide21References
American Addiction Centers. (2020, February 4).
Transgender and Addiction
. Retrieved from https://americanaddictioncenters.org/transgender
American Psychological Association. (2013, August).
Reflections on cultural humility
. Retrieved from https://www.apa.org/pi/families/resources/newsletter/2013/08/cultural-humility
Anderson, S. (2009).
Substance use disorders in lesbian, gay, bisexual, and transgender clients: Assessment and treatment.
New York: Columbia University Press.
https://ebookcentral-proquest-com.libproxy.lib.unc.edu/lib/unc/reader.action?docID=908584
.
Hughes, R. L., Damin, C., & Heiden-Rootes, K. (2017). Where's the LGBT in integrated care research? A systematic review.
Families, Systems, and Health, 35
(3), 308-319. http://web.b.ebscohost.com.libproxy.lib.unc.edu/ehost/pdfviewer/pdfviewer?vid=1&sid=e2377a2f-a478-4c9e-8d87-6e589da7e8de%40sessionmgr102
Slide22References
Hughes, T. (2005). Chapter 9: Alcohol use and alcohol-related problems among lesbians and gay men. In Annual Review of Nursing Research (pp. 283-325). New York: Springer Publishing Company. http://libproxy.lib.unc.edu/login?url=https://www-proquest-com.libproxy.lib.unc.edu/scholarly-journals/chapter-9-alcohol-use-related-problems-among/docview/197288531/se-2?accountid=14244.
McCabe, S. E., Hughes, T. L., Bostwick, W. B., West, B. T., & Boyd, C. J. (2009). Sexual orientation, substance use behaviors and substance dependence in the United States.
Addiction, 104
, 1333-1345. com.libproxy.lib.unc.edu/doi/epdf/10.1111/j.1360-0443.2009.02596.x.
McKirnan, D. J., & Peterson, P. L. (1989). Alcohol and drug use among homosexual men and women: Epidemiology and population characteristics.
Addictive Behaviors, 14
(5), 545-553.
https://www-sciencedirect-com.libproxy.lib.unc.edu/science/article/pii/0306460389900750?via%3Dihub
.
Slide23References
Medley, G., Lipari, R. N., Bose, J., Cribb, D. S., Kroutil, L. A., & McHendry, G. (2016, October). Sexual orientation and estimates of adult substance use and mental health: Results from the 2015 National Survey on Drug Use and Health. Retrieved from NSDUH Data Review: https://www.samhsa.gov/data/sites/default/files/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015.htm#end1
National Center for Transgender Equality. (2020, August 7).
Murders of transgender people in 2020 surpasses total for last year in just seven months
. Retrieved from https://transequality.org/blog/murders-of-transgender-people-in-2020-surpasses-total-for-last-year-in-just-seven-months
Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, J. (2009, January). Family rejection as a predictor of negative health outcomes in white and latino lesbian, gay and bisexual young adults.
Pediatrics, 123
(1), 346-352. org.libproxy.lib.unc.edu/content/123/1/346
Slide24References
SAMHSA. (2012, August). A provider's introduction to substance abuse treatment for lesbian, gay, bisexual, and transgender individuals. Retrieved from https://store.samhsa.gov/product/A-Provider-s-Introduction-to-Substance-Abuse-Treatment-for-Lesbian-Gay-Bisexual-and-Transgender-Individuals/SMA12-4104
SAMHSA. (2017).
National Survey of Substance Abuse Treatment Services (N-SSATS): 2017
. Retrieved from https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/2017_NSSATS.pdf
SAMHSA. (2019).
2019 National Survey of Drug Use and Health (NSDUH) releases
. Retrieved from https://www.samhsa.gov/data/release/2019-national-survey-drug-use-and-health-nsduh-releases
SAMHSA. (2020, January 14).
2018 National survey on drug use and health: lesbian, gay, & bisexual (LGB) adults
. Retrieved from https://www.samhsa.gov/data/report/2018-nsduh-lesbian-gay-bisexual-lgb-adults
Senreich, E. (2010). Are specialized LGBT program components helpful for gay and bisexual men in substance abuse treatment?
Substance Use & Misuse
, 1077-1096.
Slide25This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS), Behavioral Health Workforce Education and Training (BHWET) Program
under M01HP31370, UNC-PrimeCare, $1,920,000.00, or the Opioid Workforce Expansion Program -- Professional, under
T98HP33425,
UNC-PrimeCare-OUD
,
$1,350,000. Both programs are 100% financed with governmental sources. This information or content and conclusions are those of the author/s and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.