With the number of specialized addiction treatment programs for lesbian, gay, bisexual and transgender (LGBT) individuals remaining stagnant and likely under 100 nationally, author Michael Shelton has long concluded that rather than wait for the number to rise, all treatment organizations need to acquire cultural competence in working with the LGBT population. It is not nearly enough as an organization to profess that LGBT patients are treated well there because everyone in the facility is treated the same, Shelton adds.
Shelton's latest book, Fundamentals of LGBT Substance Use Disorders (Harrington Park Press), can serve as a primer on the issues that patients bring to treatment and the special considerations in assisting various subpopulations. “There is a whole separate set of problems, concerns and issues in working with this population,” says Shelton, who has served as a board member for NALGAP, The Association of Lesbian, Gay, Bisexual, Transgender Addiction Professionals and Their Allies and has been a frequent blogger and article contributor for Addiction Professional.
Shelton says he fell into the book project after the co-founders of NALGAP who authored the seminal Counseling Lesbian, Gay, Bisexual, and Transgender Substance Abusers: Dual Identities indicated they were not going to pursue further writing. Shelton says that while the earlier book, originally published under a different title in 1987, used many clinical anecdotes, changes in the field since then allowed him to be significantly more research-based in his approach.
Still, he says that much of the book's section on working with special populations, such as the elderly and individuals in the criminal justice system, is aspirational because research on LGBT individuals in these areas remains so limited.
While substance use issues continue to pose a significant concern in the LGBT population, it is important at the start to erase some misconceptions about the extent of the problem. Some of the initial prevalence studies that were conducted with gay men and lesbians, such as those that surveyed individuals in bars, were so methodologically flawed that they seriously overstated prevalence of use, Shelton says.
Advocates for the LGBT population constantly must combat a lack of awareness about treatment considerations specific to the population, as well as outright prejudice from both providers and the surrounding community. Shelton vividly recalls a comment from a fellow attendee of a National Conference on Addiction Disorders (NCAD) meeting who said that if he were to decide to be more openly welcoming to LGBT patients in his program, he would immediately lose customers.
Shelton says any treatment organization that seeks greater cultural competence in working with LGBT individuals should begin with an organizational assessment of where it is and where it want to go. A telltale sign of an organization's status, in Shelton's eyes: “How it treats its LGBT employees is reflective of how it will treat clients,” he says.
Beyond the self-evaluation, he says, organizations need to take three additional steps:
Make a commitment to offering trauma-informed treatment, as the experience of trauma in both subtle and brutally obvious forms plays a significant role in behavioral health issues in the LGBT population. “NIDA and SAMHSA are pushing for this,” says Shelton.
Adopt an LGBT-affirming approach, shifting from the mindset that negative life outcomes stem not from being LGBT, but from how society looks upon sexual minorities.
Look beyond the confines of the program and become an advocate for stamping out prejudice in communities. “The problems are not going to be solved in one 30-day rehab,” Shelton says. “We need to ask questions such as, 'Why are you as a recovery house not willing to take this LGBT client?'”
Order of topics
The book's section on LGBT-specific substance use patterns places chapters on transgender and bisexual individuals ahead of those on gay men and lesbians. Shelton says the ordering of topics was intentional: With so much information needed out there about the often-misunderstood transgender and bisexual populations, he wanted to make sure there was no way these chapters would end up falling out of the book.
The book's appendices offer treatment facility self-audits to assist organizations in reviewing their policies and procedures in order to become more LGBT-welcoming. “We can make changes in our organizations,” says Shelton. “A lot of organizations are oblivious to this population.”