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Best Practices for Serving , , Bisexual, and Transgendered Individuals in Women’s Treatment Settings By: Willy Wilkinson

California’s distinctive, diverse use to describe themselves and mirroring demographic fabric includes a myriad of them when appropriate. personal experiences, values, and world views that have arisen from differences in Some terms that are used to describe LGBT and circumstance. At approximately identities have been reclaimed by the 4% of the state’s overall population—with community so that they have evolved from much higher rates in urban locales1-- the negative and hateful contexts to positive, lesbian, gay, bisexual, and affirming contexts. For instance, the word (LGBT) community is one such perspective “” was historically used as a derogatory that has contributed to the state’s past, term for a masculine woman or lesbian (a present, and future. As the LGBT woman who sexually or romantically desires community gives rise to many families with women). Though this pejorative usage still children, as well as transgendered and persists, the term “dyke” is generally non-conforming individuals, there recognized within the LGBT community as are unique challenges for substance abuse an empowering, neutral term for lesbian, treatment providers, especially those who regardless of gender presentation. It is serve women. This article provides an sometimes used in conjunction with overview of LGBT culture and health descriptors, such as, for instance, the term disparities, as well as concrete suggestions “butch dyke,” used to describe a masculine for providing effective, non-discriminatory lesbian who may form romantic partnerships services to LGBT populations in women’s with feminine , or “ dykes.” treatment settings. Butch dykes are also known as “studs,” a term that originated in the African American Terms and Identities community.2 It is important to note that The LGBT community represents many while this term is viewed as neutral within different identities, and uses various terms to the community, it is generally not describe them. People in this community appropriate for outsiders such as treatment resonate with different language, depending providers to use it. on their cultural background, geographic location, and generation. Though it’s In 2003 the group “,” also important to have familiarity with some of known as the Women’s Motorcycle these terms, when working with this Contingent, which opens the annual San population, it is generally best to use Francisco LGBT Pride March with a roar, commonly accepted, neutral terms such as tried to patent their name. Over the next two lesbian, gay, bisexual, and transgender. If years, the U.S. Patent and Trademark Office you are not part of the LGBT community, it twice denied their request on the grounds is important to exercise caution around other that “dyke” was an offensive term used to terms until you have a clear understanding disparage lesbians. In 2005, after a about each client’s preferences. Best prolonged court battle that included practices entail honoring the individuality of hundreds of pages of documentation about clients by listening to the words that they the term’s current positive and affirming use

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Best Practices for Serving Lesbian, Gay, Bisexual, and Transgendered Individuals In Women’s Treatment Settings Page 2 of 9 in the lesbian community, the request was the sex they were assigned at birth. Gender finally granted.3 identity is one’s internal sense of being male, , or something in between, Like dyke, the term “” has experienced which is distinct and separate from one’s a similar reclamation within the LGBT (who one desires, has sex community. Though historically used as a with, and creates family with). “Female-to- put down for effeminate and others male transgendered individuals” were who were gender non-conforming,4 the term assigned female at birth and have a has been reclaimed as a source of pride to significant identification with masculine describe both “gay” (same sex orientation) and/or male identities. Also known as or the larger LGBT spectrum, as an “FTMs” and “transmen,” these individuals inclusive, unifying sociopolitical term. may medically transition to a full-time male Though many “older” women (over age 50) identity, access some transgender-related identify with the term lesbian, many young medical care, or choose to express their women identify themselves as “queer identities without the aid of hormones and women” rather than as lesbians, because the surgeries. Similarly, the term “male-to- latter term is seen as expressing an older, female transgendered individual” describes more rigid identity. The term queer also someone who was assigned male at birth recognizes that with the rise in numbers of and has a significant identification with people identifying as transgender, there is feminine and/or female identities. Also currently much more complexity within the known as “MTFs” and “transwomen,” these larger LGBT community than simply same- individuals may or may not seek medical sex orientation. transition to a full-time female identity.

Many incarcerated women form romantic Transition is the process whereby and sexual relationships with other women transgendered individuals socially and in prison but do not identify as lesbians. medically change their outward appearance Known as “gay for the stay” in the prison to fit their internal sense of gender. system, these women experience social and Transition-related care can involve mental emotional support, as well as protection, health therapy, hormones, and surgeries. from a female partner while incarcerated, Because there are economic and health care but upon release often go back to male access barriers to full medical transition, as partners for social acceptance and economic well as people who choose various options, stability. When their female partner is for the purposes of service released, they face challenges negotiating provision is based on one’s identity, rather these relationships. In some cases, women than their biological or surgical status.5 develop romantic loyalties to women in prison but experience social and economic Finally, providers working in women’s barriers to continuing their relationship treatment settings would benefit from an outside of prison walls. Some women make understanding of the term “genderqueer,” relationship choices out of necessity, while used to describe people who feel that there some are authentically bisexual (attracted to are more than two options with regards to both male and female individuals). gender. Genderqueer people express their gender in different ways; some transition The term “transgender” refers to people who medically and others do not change their have a significant cross-gender identity from bodies. Some like to play with gender, O N T R A C K C O M M U N I C A T I O N S

Best Practices for Serving Lesbian, Gay, Bisexual, and Transgendered Individuals In Women’s Treatment Settings Page 3 of 9 expressing themselves in different ways 19.1% of Latinas in same-sex are from day to day, while others have a living in poverty as compared to 5.7% of consistent presentation. Many young white lesbians in couples.8 genderqueer-identified people were assigned female at birth; some transition to a full-time Gender presentation also greatly impacts male presentation, but feel that their gender socioeconomic status. A recent study identity is more complex than their conducted by the Transgender Law Center appearance. Some genderqueer individuals found that transgendered people in require others to refer to them with both are twice as likely to be living male and female pronouns, or a third below the poverty line as the general gender-neutral pronoun such as “they” or population. One in five of the participants “ze.”6 had been homeless since they first identified as transgender.9 Health Disparities For many, the ability to maintain one’s Most research indicates that LGBT people health and well-being is dictated by one’s have higher rates of substance use and access to stable housing, employment, and dependence than the general population. health care. Many lesbians, bisexual women, LGBT people are less likely to abstain from and transgendered people experience alcohol than the general population. Though significant economic strain, health concerns, LGBT people have similar rates of current health care access issues, and heavy drinking as the general population, . A recent study conducted by more report negative consequences of the Williams Institute at UCLA indicated drinking and more are in recovery from drug that lesbian couples have much higher and alcohol problems. In addition, LGBT poverty rates than either different-sex people have less significant declines in couples or gay male couples; lesbians 65 or drinking as they age; lesbians have higher older are twice as likely to be poor as drinking rates than heterosexual women heterosexual married couples.7 Other factors throughout the course of their lifetime, with such as race, ethnicity, health status, family much higher rates as they age. Moreover, of origin issues, English language capability, LGBT individuals are more likely to report and status affect socioeconomic current and lifetime use of most drugs, status among LGBT populations. For many, especially marijuana. Internalized shame, the loss of support from their families of stigma, and negative societal attitudes origin can create financial hardship as contribute to mental health concerns as well; LGBT individuals, particularly youth, are lesbians and bisexual women are more likely cast into sex work, homelessness, unequal to report depressive disorders, and relationships with people who can meet transgendered individuals report high rates economic needs, or choosing between rent of suicide ideation.10 and an education. Lesbians, bisexual women, and In terms of race, African American people in transgendered people face structural, same-sex couples have poverty rates that are financial, personal, and cultural barriers significantly higher than African American when attempting to access health care, people in different-sex married couples, and which results in a lower quality of health are roughly three times higher than those of care and diminished health outcomes. Many white people in same-sex couples. Similarly, providers are not trained in LGBT issues, O N T R A C K C O M M U N I C A T I O N S

Best Practices for Serving Lesbian, Gay, Bisexual, and Transgendered Individuals In Women’s Treatment Settings Page 4 of 9 and do not understand the specific health Family Issues needs of this diverse population. Lack of Because many LGBT people do not have the education about medical issues is support of their biological families, many compounded by insensitivity on the part of create “chosen families,” non-biological health care providers and the individual’s families who care for and support them. In fears of discrimination. In a nationwide addition, more and more LGBT people, study of 2710 adults, nearly one in four gay especially lesbians, have children. Across or lesbian adults lacks health insurance, the U.S., just under half of married about twice the rate as their heterosexual heterosexual couples are raising children counterparts.11 Many transgendered people under the age of 18, while 27.3% of lesbian do not have health insurance, and those that couples have children under the age of 18. do are often discriminated against because Child poverty rates are twice as high for of their transgender status. Most health those raised by same-sex couples than insurance companies do not cover transition- heterosexual couples. Nationwide, one out related care as well as other care unrelated to of every five children 18 years or younger in their transition. Thirty percent of same-sex coupled families is poor compared transgendered people report postponing to one out of every ten in different-sex prevention and care services because of married couple families.15 As previously experience with discrimination at the hands stated, many factors, including loss of of medical providers.12 These barriers act as family support, contribute to this disparity. deterrents that prevent LGBT individuals from seeking prevention and care for acute Of the over 70,000 children being raised by and chronic conditions, with potentially life- same-sex couples in California, 31,000 are threatening consequences. Latino, 4400 are Asian American, 3600 are African American, 4500 are mixed race, and In addition to discrimination in health care 17,600 are “other race.” Same-sex parents settings, LGBT individuals experience are more likely to be of color, Latino, discrimination in housing, employment, Spanish-speaking, non-citizens, disabled, prisons, and public accommodations. and low income than heterosexual parents.16 Individuals who are transgender or gender These factors make it more likely that these non-conforming are especially at risk. In the parents will experience discrimination in California transgender study, seventy employment, housing, and health service percent of participants reported experiencing environments. Nationwide, 31.6% of workplace harassment or discrimination children raised by African American lesbian directly related to their gender identity.13 couples are impoverished, compared to Recently it became known that the largest 13.1% of children raised by heterosexual women’s prison in Virginia segregated, African American couples.17 humiliated, and degraded women who had baggy clothes, short , or an otherwise Many LGBT seniors, particularly gay men masculine appearance. While prison and transgendered individuals, do not have authorities denied the practice, or justified children who can care for them as they age. their actions as a means of controlling same- While some LGBT seniors have chosen sex relationships, civil rights advocates families who can support and care for them, called the moves unconstitutional many struggle with isolation and poverty punishment for “looking gay.”14 because they lose their connection to the LGBT community as they age. Lesbians are O N T R A C K C O M M U N I C A T I O N S

Best Practices for Serving Lesbian, Gay, Bisexual, and Transgendered Individuals In Women’s Treatment Settings Page 5 of 9 twice as likely as heterosexuals to grow old specific needs of your organization, and can un-partnered, and nearly ten times more assist you in developing and implementing likely not to have someone (a spouse, child, an LGBT-friendly environment. or other family member) to care for them in old age.18 Organizations need to develop and implement written policies and procedures Creating a Non-Discriminatory that specifically address LGBT issues, and Environment ensure that staff members are educated There are many tools that substance abuse about appropriate behavior and protocol. organizations can use to create a non- The organization’s non-discrimination discriminatory service environment so that policy should include language protecting all clients can participate fully. Substance against discrimination based on both sexual abuse providers in women’s treatment orientation and gender identity. The term settings can create LGBT-affirming “gender” in a non-discrimination policy environments by handling social interactions does not sufficiently cover transgendered appropriately, employing LGBT-affirming individuals. Implementation and treatment strategies and service approaches, consequences for violation of this policy and developing and implementing LGBT- also need to be clearly stated. inclusive policies and procedures. Service challenges that arise in women’s treatment The key to creating a non-discriminatory settings often involve questions about service environment is in maintaining housing and treating male-to-female consistency in interactions by asking transgendered individuals. Difficulties everyone the same questions. For example, providing non-discriminatory services to intake questions should not assume lesbians, bisexual women, and female-to- or non-transgender status. male transgendered individuals also occur. Intake forms can include “partnered” in the The following are suggestions on how to list of possible relationship status options, as create a non-discriminatory service a way of being LGBT-inclusive. Though not environment for LGBT individuals in used exclusively by LGBT people, this term women’s treatment settings, while ensuring is generally accepted as an appropriate way full participation of non-LGBT clients. of referencing a same-sex relationship. Clients may use other terms, including Since many individuals in LGBT “girlfriend” or “wife.” If the relationship is communities, particularly those who are long-term, it is usually inappropriate to refer transgendered, gender non-conforming, to their partner as their “friend.” In addition, and/or of color, have had multiple negative the gender category can be worded as “male, and discriminatory experiences in health- female, transgender.” While many related services, this marginalized transgendered individuals identify simply as population is best served by organizations male or female, this acknowledgement of that have proactively and systemically transgender status signals to the individual created non-discriminatory measures. The that there is a possibility that they are not the Department of Alcohol and Drug Programs first transgendered client to walk through the contracts with agencies that provide training door. and technical assistance on a number of topics, including LGBT issues. This It is important to recognize that individualized TA can be tailored to the marginalized people assess the safety of a O N T R A C K C O M M U N I C A T I O N S

Best Practices for Serving Lesbian, Gay, Bisexual, and Transgendered Individuals In Women’s Treatment Settings Page 6 of 9 new environment before disclosing transgendered people, it is essential to potentially risky information about consistently refer to them with the name and themselves. Many women in same-sex pronoun that corresponds with their stated relationships may be afraid to come out to gender identity, even if you are not in their service providers because they do not know presence. Organizations should develop if they will be discriminated against, systems for identifying and documenting the humiliated, invalidated, or otherwise singled appropriate name and gender, which may be out. Substance abuse providers in rural areas different from the name and gender on their of California have reported that they have ID. Though it may seem polite, avoid worked with female clients who could addressing the individual with titles such as describe their relationships in detail, “ma’am” or “sir” until you are certain about including dynamics, finances, and other what is appropriate. If you are unsure about issues over the course of months. Only once how to address the individual, including the the client felt safe did they disclose that it appropriate pronoun, ask politely for was a same-sex relationship. Within this clarification. You can say, “How would you population, stress about the risk of coming like to be addressed?” “How would you like out and not being able to be authentic can be me to refer to you?” or “What a barrier to clients fully recovering. Yet the name/pronoun is appropriate?” recovery field emphasizes nonjudgmental approaches to client’s life circumstances In women’s substance abuse treatment including crimes committed and relationship settings, problems may arise because staff destroyed in order to get high. Substance and/or clients are uncomfortable with the abuse counselors can be successful with gender presentation and/or sexual LGBT populations by communicating an orientation of a fellow program participant. open-minded, non-judgmental point of view For instance, there have been incidences in that welcomes diversity in all its forms. which program staff were concerned about the impact of the presence of a lesbian in a Substance abuse programs can create women’s group, so the group facilitator LGBT-affirming environments by asked the other participants for permission acknowledging that their LGBT clients may to include this individual. Clearly, this not have family support, or that they may approach was discriminatory because it 1) have non-blood related family structures, violated the confidentiality of the individual, including partners and children. You can and 2) gave other program participants the demonstrate an LGBT-welcoming power to approve another client’s right to environment by comfortably inquiring about receive treatment. a partner or other family members, and by welcoming the families of LGBT clients in Similarly, some substance abuse program the same manner as you would heterosexual staff and clients have felt discomfort with and non-transgender families. the idea of housing people with a same-sex orientation in a room with other members of In social interactions and counseling the same sex. Lesbian and bisexual women sessions, it is important to demonstrate have the right to be housed with other comfort with the terms and identities women; one’s sexual orientation is lesbian, gay, bisexual, transgender, partner, irrelevant with regards to bed placement. and any other terms that clients use to Keep in mind that organizational policies, describe themselves. When working with such as not engaging in sexual activity, O N T R A C K C O M M U N I C A T I O N S

Best Practices for Serving Lesbian, Gay, Bisexual, and Transgendered Individuals In Women’s Treatment Settings Page 7 of 9 apply to everyone. Address any fears or facilitating a conversation between the conflicts by reminding staff and clients clients in question so that ultimately the about the larger policy issues, rather than transgender issue is demystified and non- singling out or blaming LGBT people for transgendered clients understand that trans the discomfort of others. clients are there for the same reasons as they are. Group client education sessions can also Many providers are confused about where to be helpful in raising awareness and place transgendered individuals, especially addressing conflict.19 with regards to gender-specific environments, such as women’s groups and Female-to-male individuals may also present residential settings. In the state of California, service challenges with regards to residential people have the right to receive services placement. FTMs who are newly in based on their gender identity and transition may prefer to wait until they have expression, which may be different from achieved a certain degree of “passability” as their biological status. That means that the men before being housed with men. Some determination of a client’s gender is based FTMs fully pass as men and room with men on a respectful conversation with the undetected. Potential conflicts and concerns individual about their identity, rather than about safety occur particularly when the invasive questions about genital status, a individual’s transgender status is known. physical exam, or indulging in questions out Transmen are at risk for physical and sexual of curiosity. Though clearly certain violence and may be best housed in a challenges are presented, a transwoman separate room, if available. (male-to-female individual) has the right to participate in women’s treatment settings Gender-specific treatment environments, such as women’s support groups and such as women’s support groups, can also housing. present service challenges. If the individual identifies as female as a long-term identity, Program staff are often concerned that non- she has the right to attend a group transgendered women would be designated for women. If program uncomfortable with the presence of a participants make harassing or otherwise transwoman in women’s groups and dorms. disparaging remarks, it is the facilitator’s Indeed, it is sometimes the case that a few responsibility to immediately and firmly biological express concerns and address conflict and harassment, just as they even hostility. Handle each situation on a would if a disparaging comment were made case-by-case basis. Sometimes with regards to race, ethnicity, class, transgendered people are housed in a disability, or any other protected class. separate room if the space is available, not as a special privilege but as an effort to As substance abuse providers in women’s increase participants’ comfort levels and treatment settings augment their LGBT feelings of privacy and safety. Staff cultural competency, and develop and members should be careful not to violate the implement LGBT-affirming policies and confidentiality of the transgendered procedures, they are on the road to creating individual while addressing any concerns or a non-discriminatory service environment conflicts from non-transgendered clients. where all clients can participate fully and Many programs have had success by receive the vital services they need.

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Willy Wilkinson, MPH has worked extensively with substance abuse, mental health, medical, and other public health providers throughout California, to develop culturally appropriate service approaches for LGBT consumers in urban and rural settings. Nationally known for expertise in transgender public health issues, Willy also has extensive experience with communities of color, substance users, sex workers, youth, and people with disabilities. Willy earned a Masters in Public Health in Community Health Education from UC Berkeley, and a BA in Women’s Studies from UC Santa Cruz. As a trainer, Willy employs a welcoming, interactive, non-punishing approach that honors participants’ expertise and welcomes all questions, at all knowledge levels. For more information, visit www.willywilkinson.com.

Support for this report and the California Women’s TA & Training Project has been provided by the State of California, Department of Alcohol & Drug Programs, Office of Women & Perinatal Services. The opinions, findings and conclusions herein stated are those of the author and not necessarily those of the Department.

The California Women’s TA & Training Project is managed by ONTRACK Program Resources, Inc. ONTRACK offers cost-free consulting services and training on issues related to improving access, improving services and increasing successful treatment and recovery outcomes for women, their children and families. For more information on available services visit: www.getontrack.org

1 Gary J. Gates and Christopher Ramos, The Williams Institute, University of California, , School of Law, “Census Snapshot: California Lesbian, Gay, and Bisexual Population,” 2008, http://repositories.cdlib.org/cgi/viewcontent.cgi?article=1001&context=uclalaw/williams According to recent Census data, lesbian, gay, and bisexual people are approximately 3.2% of California’s population; estimates of the percentage of transgendered people in California vary.

2 For more information about studs, see Willy Wilkinson, “Best Practices for Serving African American LGBTQ Populations in California,” 2009 (to be published on the ADP website).

3 National Center for Lesbian Rights Case Docket: Dykes on Bikes, http://www.nclrights.org/site/PageServer?pagename=issue_caseDocket_dykesonbikes “Trademark office OKs 'Dykes on Bikes'; Motorcycle group's name on its way to becoming registered,” Julian Guthrie, Chronicle, December 9, 2005, http://www.sfgate.com/cgi- bin/article.cgi?file=/c/a/2005/12/09/MNGQOG5D7P1.DTL

4 Wikipedia, “Queer,” updated 6/2/09, http://en.wikipedia.org/wiki/Queer

5 For more information about transgender identities, see Willy Wilkinson, “Culturally Competent Approaches for Serving Transgender Populations,” 2009 (to be published on the ADP website)

6 For more information about genderqueer identity, see www.genderqueerrevolution.com and www.unitedgenders.org.

7 Randy Albelda, M.V. Lee Badgett, Alyssa Schneebaum, Gary J. Gates. “Poverty In The Lesbian, Gay, And ,” The Williams Institute, UCLA, March 2009 http://www.law.ucla.edu/williamsinstitute/pdf/LGBPovertyReport.pdf

8 Ibid. O N T R A C K C O M M U N I C A T I O N S

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9 State of Transgender California, Transgender Law Center, March 2009, http://www.transgenderlawcenter.org/pdf/StateofTransCAFINAL.pdf

10 Cochran BN and Cauce AM.(2006). Characteristics of lesbian, gay, bisexual, and transgender individuals entering substance abuse treatment, Journal of Substance Abuse Treatment, 30(2), 135-146; Drabble L. and Trocki K. (2005) Alcohol consumption, alcohol-related problems, and other substance use among lesbians and bisexual women, Journal of Lesbian Studies, 9(3), 19-30; Cochran SD, Mays VM, Alegria M, Ortega AN, and Takeuchi D. (2007). Mental health and substance use disorders among Latino and Asian American lesbian, gay, and bisexual adults. Journal of Consulting and Clinical Psychology, 75(5), 785-94; and Clements-Nolle K, Marx R, Guzman R, and Katz M. (2001). HIV prevalence, risk behaviors, health care use, and mental health status of transgendered persons in San Francisco: Implications for public health intervention. American Journal of Public Health, 91(6), 915-921.

11 “Nearly One in Four Gay and Lesbian Adults Lacks Health Insurance,” Harris Interactive, May 19, 2008, http://www.harrisinteractive.com/NEWS/allnewsbydate.asp?NewsID=1307

12 State of Transgender California, Transgender Law Center, March 2009

13 Ibid.

14 Dena Potter, Associated Press, “Va. women’s prison segregated lesbians, others” June 10, 2009, http://news.yahoo.com/s/ap/20090610/ap_on_re_us/us_lesbian_cell_block_7

15 Randy Albelda et al, ““Poverty In The Lesbian, Gay, And Bisexual Community.”

16 Brad Sears and M.V. Lee Badgett, The Williams Institute, University of California, Los Angeles, School of Law, “Same Sex Couples and Same Sex Couples Raising Children in California, Data from Census 2000,” 2004. http://repositories.cdlib.org/cgi/viewcontent.cgi?article=1100&context=uclalaw/williams

17 Randy Albelda et al, ““Poverty In The Lesbian, Gay, And Bisexual Community.”

18 Ibid.

19 For more information about transgender identities, see Willy Wilkinson, “Culturally Competent Approaches for Serving Transgender Populations,” 2009 (to be published on the ADP website)

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