Substance Abuse Treatment within the Transgender

Community

Karen Feuerman, Ph.D.Assistant Professor, Albizu Universitykfeuerman@albizu.edu

Jessica J. Ruiz, Psy.D. Assistant Professor, Albizu Universityjruiz@albizu.edu

Objectives Be able to accurately define

transgender

Differentiate between transgender and gender dysphoria

Identify substance abuse treatment needs within the transgender population

Binary System

Who’s the girl and who’s the boy?

Assumptions –Binary Model

Biological Sex Gender Expression Sexual Orientation

Female Feminine Male

Male Masculine Female

Gender Continuum

What is gender?Sex- “Biological indicators of male and female…such as sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia” (APA, 2013 p. 451).

Gender – The psychological, biological or cultural characteristics associated with maleness and femaleness (Kessler & McKenna, 1978; Ruble, Martin, & Berenbaum, 2006).

Gender Identity-Refers to a person’s basic sense of being male, female, or of indeterminate sex (Stoller, 1968).

Gender Role- Gender role refers to behaviors, attitudes, and personality traits that a society, in a given historical period, designates as masculine or feminine-that is more typical of the male or female social role (Ruble et al., 2006).

Gender Expression Refers to the way in which a person acts to communicate gender

within a given culture; for example, in terms of clothing, communication patterns, and interests.

A person’s gender expression may or may not be consistent with socially prescribed gender roles, and may or may not reflect his or her gender identity

(APA Task Force on Gender Identity and Gender Variance, 2009)

Transgender- The “Silent T”

LGBTLesbian Gay Sexual Orientation

Bisexual

Transgender – Gender Identity

Transgender/Gender Variant

 Transgender- or gender variant refers to the behavior, appearance, or identity of persons who cross, transcend, or do not conform to culturally defined norms for persons of their biological sex (APA Task Force on Gender Identity and Gender Variance, 2009)

Transgender - An umbrella term used to encompass any self-expression or identity that does not conform to a binary concept of female and male (YES Institute, 2015).  

Gender Dysphoria https://

www.youtube.com/watch?v=MsVu8my2wRY

Gender DysphoriaDSM IV-TR - Gender Identity Disorder

DSM 5- Gender DysphoriaMarked incongruence between one’s

experienced/expressed gender and assigned gender of at least 6 month durationChildren- Need at least 6 symptomsAdolescents and Adults- Manifests at least 2

Condition is associated with clinically significant distress or impairment in social, school, or other important functioning

APA, 2013

Eg SymptomsChildren Desire to be of the other gender or insistence that

one is of the other gender A strong preference for toys, games or activities

stereotypically used or engaged in by the opposite gender

A strong rejection of typically masculine toys (in boys) and of feminine toys (girls)

A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender

APA, 2013

Adults Eg Symptoms Strong incongruence between experienced/expressed

gender and primary and/or secondary sex characteristics

Strong desire to be rid of one’s primary and/or secondary sex characteristics

Strong desire to be of other gender Strong conviction that one has the typical feelings and

reactions of the other gender (or some alternative gender different from one’s assigned gender)

A strong desire to be treated as the other gender

APA, 2013

Language How we refer to our clients Which pronoun would you like me to use? (e.g.

he, she) Use the (WPATH) model

Diversity Among the Transgender Population

Cultural Sensitivity and Cultural Competence is important for providers administering services to various groups; programming needs to be sensitive to varying populations with diverse issues

Considerations: Age MTF or FTM Race Religion/Spirituality Geographic Region SES

Williams Institute RECOMMENDATIONS for Transgender Youth of Color

1. Increase inclusion and participation of GBTQ youth of color in school-based educational and after school programs such as athletics, academic clubs, and college preparation courses.

2. Develop specialized services for subgroups of GBTQ youth, including transgender youth, closeted or questioning youth, and bisexual youth. These subgroups of youth often have distinct needs relative to gay male youth, such as the unique healthcare needs of transgender youth, or are disconnected from services, such as youth who are reluctant to disclose or who are unsure of their sexual orientation.

3. Create, expand, or enhance (as appropriate) availability of needed services including, mental health services, mentorship programs, life skills training, vocational and workforce training, and health education programs that cater to the special needs of GBTQ youth of color.

4. Connect GBTQ youth with adult LGBT role models to facilitate mentorship relationships not always available to youth. This is particularly significant with regard to modeling diversity within an organization. Role models are also helpful for parents and families of GBTQ youth of color as family members see successful LGBT people of color and can promote family acceptance. 5. Widely publicize resources through youth networks and creative marketing strategies so that more GBTQ youth (and their families) are aware of the services available to them. Publicizing effort should target youth themselves, their families, and non-LGBT organizations so that they can make appropriate referrals to GBTQ youth they see. To design effective advertising campaigns, agencies ought to tailor messages to subgroups of GBTQ youth

Rates of Substance Abuse

Rates are likely to be underestimated given fear to self-identify, research in infancy with this population; high rates of use shown in a meta-analysis by Herbst et al., in 2008.

Garofalo, et al. (2008) found approximately 25% of transgender women in U.S. convenience sample studies report nonmarijuana illicit drug use, such as cocaine, crack, amphetamine, or heroin

HIV has also been reported at a higher incidence among this population (Reisner, 2014; Herbst et al., 2008; SAMHSA, 2012)

Disproportionally higher rates of smoking and tobacco use has been consistently documented (Wisneski, 2011; Conron et al., 2012)

“Emerging evidence demonstrates among transgender persons, there are higher rates of non-medical use of prescription drugs among those experiencing discrimination based on transgender identity” (Benotsch et al., 2013)

More on Rates of Use Findings from the NY Transgender Project

(Nuttbrock et al., 2009) yielded prevalence rates of self-reported substance use during the prior 6 months as 60,4% for heavy alcohol use, 40% for THC (marijuana), 21.7% for cocaine (crack or powder), 3.9% for stimulants, and 3.5% for opiates.

Flentije (2014) found transgender women to endorse significantly greater primary methamphetamine use

Substance Abuse and Transgender

Issues in treatment include: Societal and Internalized transphobiaViolenceDiscriminationFamily problemsIsolationLack of Educational and Job OpportunitiesAccess to health careLow Self-Esteem

(A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual and Transgender Individuals, 2012)

Substance Abuse Treatment with LGBT

https://www.youtube.com/watch?v=LcJ0CBSPpLY

Assessment What your agency may want to include in

biospychosocial assessments E.g. surgeries Transition/hormone replacements Identified Gender (not only male/female) Evaluate relationship between substance use and

issues related to gender and social acceptance Assessment of family acceptance Suicidality; including history of self-injury Bullying

Hormone Therapy Considerations

Clients may need assistance in education regarding the effects of treatment; physical and emotional (changes in mood)

Education regarding the interaction of hormone therapy and substance use/abuse

Risks of “black market” hormones, such as testosterone

Triggers of hormonal injection to addiction: Teach coping strategies

Assist with compliance with medical regimens

Treatment GuidelinesSAMHSA (2012). A provider’s Introduction to substance abuse treatment for lesbian, gay, bisexual, and transgender individuals. World Professional Association for Transgender Health (WPATH). (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (7th ed.). International Journal of Transgenderism, 13(4), 165–232. doi:10.1080/15532739.2011.700873

American Psychological Association. (2008). Report of the APA task force on gender identity and gender violence. Washington, DC: Author.

Treatment Challenges Support Stages of Gender Identity Coming out: Substance Use and Recovery interact with experience of sexual

identity Suicide Laws Awareness of staff and clients Facilities (bathrooms) Medical Issues Increase likelihood co-occurring disorders (past traumas, PTSD, substances, Mood

Disorders) Community resources are minimal

Correctional Settings: Housing Risk Management Mental Health Units Medical Issues

SAMHSA Guidelines: DO’s

“Use the proper pronouns based on their self-identity when talking to/about transgender individuals.

• Get clinical supervision if you have issues or feelings about working with transgender individuals.

• Allow transgender clients to continue the use of hormones when they are prescribed. Advocate that the transgender client using “street” hormones get immediate medical care and legally pre scribed hormones.

• Require training on transgender issues for all staff. • Find out the sexual orientation of all clients. • Allow transgender clients to use bathrooms and showers based on

their gender self-identity and gender role. • Require all clients and staff to create and maintain a safe

environment for all transgender clients. Post a nondiscrimination policy in the waiting room that explicitly includes sexual orientation and gender identity.”

SAMHSA GUIDELINES: DON’TS

“Don’t call someone who identifies himself as a female he or him or call someone who identifies herself as male she or her.

• Don’t project your transphobia onto the transgender client or share transphobic comments with other staff or clients.

• Never make the transgender client choose between hormones and treatment and recovery.

• Don’t make the transgender client educate the staff. • Don’t assume transgender women or men are gay. • Don’t make transgender individuals living as females use

male facilities or transgender individuals living as males use female facilities.

• Never allow staff or clients to make transphobic comments or put transgender clients at risk for physical or sexual abuse or harassment.”

On the Forefront… Florida –Bathrooms Lift of Military Ban Legal Documents Charting (look at WPATH)

IN HONOR and MEMORY of Kyler

Prescott Kyler’s Poem My mirror does not define me: Not the stranger that looks back at me Not the smooth face that belongs to someone else Not the eyes that gleam with sadness When I look for him and can only see her. My body does not define me: Not the slim shoulders that will not change Not the hips that give me away Not the chest I can’t stand to look at When I look for him and can only see her. My clothes do not define me: Not the shirt and the jeans That would look so perfect on him But that I know would never fit me When I look for him and can only find her. And I’ve been looking for him for years, But I seem to grow farther away from him With each passing day. He’s trapped inside this body, Wrapped in society’s chains That keep him from escaping. But one day I will break those chains. One day I will set him free. And I’ll finally look in the mirror And see me- The boy I was always meant to be. - Kyler Prescott nydailynews..com

July 7, 2000 – May 18, 2015

Questions?

ReferencesAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.American Psychological Association. (2008). Report of the APA task force on gender identity and gender violence. Washington, DC: Author. Conron, K. J., Scott, G., Stowell, G. S., & Landers, S. J. (2012). Transgender health in Massachusetts: results from a household probability sample of adults. American Journal of Public Health, 102(1), 118-122. doi:10.2105/AJPH.2011.300315Lyons, T., Shannon, K., Pierre, L., Small, W., Krusi, A., & Kerr, T. (2015). A qualitative study of transgender individuals’ experiences in residential addiction treatment settings: Stigma and inclusivity. Substance Abuse Treatment, Prevention, and Policy, 10(17), 2-6. doi:10.1186/s13011-015-0015-4. Garofalo, R. Deleon, J., Osmer, E., Doll, M., & Haper, G.W (2006). Overlooked, misunderstood and at-risk of ethnic minority male-to- female transgender youth. Journal of Adolescent Health, 38, 230-236. doi:10.1016/j.jadohealth.2005.03.023. Herbst, J. H., Jacobs, E. D., Finlayson, T. J., McKleroy, V. S., Neumann, M. S., & Crepaz, N. (2008). Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS and Behavior, 12(1), 1-17. doi:10.1007/s10461- 0079299-3.Nuttbrock, L. (2012). Culturally competent substance abuse treatment with transgender persons. Journal of Addictive Disease, 31, 236-241. doi:10.1080/105550887.2012.694600. Reisner, S. L., Gamarel, K. E., Nemoto, T., & Operario, D. (2014). Dyadic effects of gender minority stressors in substance use behaviors mong transgender women and their non-transgender male partners. Psychology of Sexual Orientation and Gender Diversity, 1(1), 63- 71. doi:10.1037/0000013.SAMHSA (2012). A provider’s Introduction to substance abuse treatment for lesbian, gay, bisexual, and transgender individuals. Rockville, MD: U.S. Government Printing Office. Stotzer, R., Silverschanz, P, & Wilson, A. (2013). Gender identity and social service: Barriers to care. Journal of Social Service Research, 39, 63-77. doi:10.1080/01488376.2011.637858. Walls, E., & Wisneski, H. (2011). Evaluation of smoking cessation classes for the lesbian, gay, bisexual, and transgender community. Journal of Social Service Research, 37, 99-11. doi: 10.1080/01488376.2011.5245531World Professional Association for Transgender Health (WPATH). (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (7th ed.). International Journal of Transgenderism, 13(4), 165–232. doi:10.1080/15532739.2011.700873