1. 2.0 TECHNICAL PROPOSAL
2.4 A. Bidder’s Understanding of the Problem
2.4 A. 1. State your understanding of the following as they apply to the provision
of effective treatment/recovery programs for Lesbian, Gay, Bisexual and
Transgender adults and youth in California: a. Research-Based Treatment that is
based on scientifically defensible substance abuse treatment research and
evaluation established by the federal Center for Substance Abuse Treatment
(CSAT); b. “Treatment Principles of Effectiveness” established by the National
Institute on Drug Abuse (NIDA).
Very little precise and reliable research information on substance use/abuse and
on effective treatment/recovery provision in the Lesbian, Gay, Bisexual, Transgender
(LGBT) population exists, primarily because:
1. Quality research on this population has not been well-funded at the local,
state, or federal levels;
2. Reliable demographic information on this population is not available because
large scale studies rarely ask questions about sexual orientation or gender
identity (other than female/male) and self-disclosure is often viewed as
unsafe;
3. We lack consensus-based definitions of relevant terms which are not always
clear enough for research purposes; and,
4. Few treatment and recovery programs address sexual orientation or gender
identity issues directly, nor do they collect such information routinely on their
clients.
However, because of the work of several national groups, including the California-based
National Association of Lesbian and Gay Addiction Professionals (NALGAP) and the
Gay and
Lesbian Medical Association (GLMA), more research on this population is being
conducted and clearer standards of care and cultural competency are being developed.

2. Currently, the standards for working in this field are being set via the Center for
Substance Abuse Treatment (CSAT) publication, A Provider’s Introduction to Substance
Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals, published in
2001. This publication is the result of several years of work by leading researchers,
practitioners, and former program clients in the field of LGBT addictions, including
several Progressive Research and Training for Action (PRTA) consultants, and examines
the impact of homophobia and heterosexism; cultural and legal issues in working with
this population; clinical issues for sub-populations of the LGBT community; and,
administrative quality and standards.
One important area of research relating to the effective provision of services to
the LGBT population addressed by the CSAT publication is the impact of homo/bi/trans-
phobia (generally understood as fear and loathing of LGBT people) and heterosexism
(behaviors that deny, ignore, denigrate, or stigmatize any non-heterosexual form of
expression) on clients and their substance use/abuse patterns. Joe Neisen, Ph.D.’s work
(1990, 1993) indicates that the pervasiveness of heterosexism in society instills shame in
clients, as well as the following negative effects:
 Self-blame for having been victimized;
 Negative self-concepts as a result of negative messages;
 Anger directed inward in destructive patterns such as substance abuse;
 Feelings of inadequacy, hopelessness, and despair; and,
 Self-victimization that may hinder emotional growth and development.
Neisen states that it is imperative for counselors to recognize and work with these effects
and to understand that they are not a direct consequence of a client’s sexual (or gender)
identity, but rather, the result of repeated exposure to heterosexist attitudes and behaviors.

3. LGBT adults and youth often face problems in traditional health care systems and
are stigmatized within programs by staff and other clients (Mongeon & Ziebold, 1982).
Youth face some additional and unique pressures resulting from pervasive societal and
familial heterosexism. At a time in life when youth are under intense pressure to conform
to their peers’ behavior and choices, many youth are extremely reluctant to “come out of
the closet” as lesbian, gay, bisexual, or transgender and may not gain the full benefit of
counseling or treatment if they do not feel safe.
Many mainstream treatment programs are not safe for LGBT people. Establishing
a safe environment is directly related to providing quality and effective treatment. The
following are research-based recommendations put forward in the CSAT publication to
create safe treatment and recovery environments for LGBT clients:
1. Improve knowledge among staff members about the laws affecting LGBT
individuals with substance abuse histories;
2. Ensure that staff members respect LGBT clients with clear policies and
training;
3. Ensure that clients respect LGBT individuals by establishing and enforcing
effective rules, education, and clear grievance procedures;
4. Ensure that clients are safe by informing about and enforcing grievance
procedures;
5. Ensure clients’ confidentiality;
6. Attract and retain LGBT staff; and,
7. Educate LGBT clients about anti-discrimination and other relevant laws.
Transgender individuals face unique challenges when seeking services for
substance abuse treatment, though very little research on this population exists.
According to the CSAT publication, transgender substance abusers face internalized
transphobia, violence, discrimination, lack of familial support, isolation, lack of
education or job opportunities, lack of access to health care, and low self-esteem. For
example, in 1998, PRTA staff had a conversation with a treatment professional in Los

4. Angeles documenting his unsuccessful attempts to place a pre-operative transgender in
residential treatment. The Transgender Substance Abuse Task Force reported that
transgender clients in treatment programs experienced verbal and physical abuse by other
clients and staff; requirements that they wear only clothes judged to be appropriate for
their biological gender; and requirements that they shower and sleep in areas judged to be
appropriate for their biological gender. (Transgender Protocol Team, 1995) Also,
transgender individuals tend to be invisible in program evaluation, intake, assessment,
and other points in substance abuse prevention and treatment. In addition, in the clinical
setting, monitoring hormone therapy—estrogen or testosterone—is often overlooked by
providers.
The following recommendations have been developed by clinical practitioners,
and are outlined in the CSAT publication, to better serve transgender clients:
 Use the pronouns based on the client’s identity when talking to or about
transgender clients;
 Get clinical supervision for issues working with transgender clients;
 Allow clients to use hormones when they are prescribed;
 Require training on transgender issues for all staff;
 Don’t assume the sexual orientation of clients;
 Allow transgender clients to use bathrooms and showers based on their
self-identities; and, require all clients and staff to maintain a safe
environment for transgender clients.
NIDA’s Treatment Principles of Effectiveness relate directly to the provision of
quality treatment and recovery services to the LGBT population. As stated above, LGBT
people need treatment programs that are tailored to their individual situations and that
attend to their multiple needs—family of origin issues, social isolation, the effect of
heterosexism, etc.—to be effective. Their care or case management plans need to be
assessed regularly to ensure a feeling of safety and comfort with the services, staff, and

5. other clients. Additionally, because of the issues outlined above involving lack of safety
or accommodations in treatment programs, retention of LGBT clients can be challenging.
LGBT clients need to complete treatment programs and receive appropriate referrals
when they leave the structured setting. Adequate and compassionate intakes and services
for HIV/AIDS within treatment programs are also very important for many LGBT
clients, as are services for mental health.
Lastly, the principles of care for LGBT populations, outlined in the CSAT
document and based on available research and clinical practice, correspond closely to the
Treatment Principles of Effectiveness developed by NIDA:
 Be flexible and client-centered.
 Be coordinated, integrated, and comprehensive.
 Be consistent with each client’s cultural needs and expectations.
 Promote self-respect and personal dignity.
 Promote healthy behaviors.
 Empower persons in substance abuse treatment to make decisions in
collaboration with the service provider.
 Reduce barriers to services for hard-to-reach populations.
 Develop and deliver services that are clinically informed and research-
based.
 Work to create a treatment/recovery community.
2.4 A. 2. State your understanding of the social and cultural characteristics of the
target population (youth and adults) that: a. impede access to existing AOD
treatment and recovery services; b. affect their participation in AOD treatment
and recovery services.
Homosexuality and bisexuality involve not only sexual interactions between two
people of the same sex, but also loving partnerships; warm extended families of friends
and relatives; and a culture based on common language, experiences, and oppression. For
many people, ignorance and discomfort can lead to the fear and loathing of LGBT

6. people. This fear and loathing leads many mainstream treatment and recovery programs
in California to provide inadequate services.
The following are definitions of the population we will discuss in this proposal.
The terms lesbian, gay, and bisexual refer to a person’s sexual orientation, while the term
transgender refers to a person’s gender identity. A lesbian is a woman whose primary
loving and/or sexual relationships are with other women. Her emotional, erotic, and
romantic orientation is toward other women. Many lesbians, for parenting reasons as well
as other personal reasons, may choose to have a primary relationship with a man, yet still
consider themselves and identify themselves as lesbians. Likewise, a gay man is a man
whose primary loving and/or sexual relationships are with other men. Sometimes,
however, gay men have affectionate or sexual relationships with women. Bisexual men or
women have loving and/or sexual relationships with both men and women, though not
necessarily at the same time. Widespread ignorance of the experience of bisexual people
has lead to a marginilization of bisexuals within the lesbian and gay community.
The term transgender has become an umbrella term to cover a myriad of gender
identities and roles. In the most general usage of the term transgender, it refers to people
whose gender identity differs (somewhat or completely) from their original
anatomic/socially defined gender. The term transgender can refer to someone who for
personal reasons chooses to dress in the clothing of the opposite gender, such as a cross-
dresser or transvestite, or the term can refer to a transsexual who may chose to use
hormones and have surgery to correct the anatomy to more closely reflect the gender
identification they are (Leslie, Patterson; 1995). A transgender person may be
homosexual, bisexual, or heterosexual in orientation.

7. Clearly, these categories are fluid. An individual may choose a particular word to
identify him or herself for a variety of reasons, both political and personal, and some
people choose not to label their sexual or gender identity at all. Many youth, particularly
in urban centers, refer to themselves as queer or questioning (LGBTQQ) as a way to
claim a strong identity without conforming to a rigid definition. It is always important to
remember that a person's sexual orientation or gender identity is one part—albeit and
important part—of their complete identity.
Before discussing the programmatic barriers that prevent LGBT people from
accessing services, it is important to state that this population cuts across all other
traditionally underserved populations. LGBT people come from every geographic
location, socioeconomic class, racial and ethnic group, and every age and disability
group. Because of this, most LGBT people face multiple layers of barriers to accessing
and receiving effective services. While this proposal addresses the issues specific to
LGBT people, additional barriers related to cultural and ethnic background must also be
taken into account. These include language differences, location of services, invisibility
of people from various cultural and ethnic backgrounds in program materials, low
representation of people from various cultural and ethnic backgrounds in staff positions,
unexamined racist attitudes held by service providers, and lack of disability-specific
accommodations. Other technical assistance contractors such as the American Indian
Training Institute and the California Women’s Commission on Alcohol and Drug
Dependencies address these and other issues. But they should be central to any discussion
of LGBT people.

8. We know from self-reports, for example, that American Indians and Alaska
Natives in gay or lesbian relationships report a higher rate of bisexuality than do their
white counterparts. In addition, at least one hundred sixty eight of the two hundred Native
languages spoken today have terms for genders in addition to “male” and “female”, and
some Natives refer to themselves as “two-spirited” as a way to express a combination of
female and male spirit. Some traditional healing practices for Native people, including for
substance abuse, involve talking circle, sweat lodge, four circles, vision quest, and sun
dance, which can involve healers, elders, and holy persons (CSAT, 1999b).
Many African-American LGBT people say that they do not feel welcome or
comfortable in white LGBT settings or service agencies. Participants in focus groups of
African-American gay men and lesbians conducted in California, for example, clearly
stated that they did not want to be called “queer” and considered it a negative term. In
addition, the groups stated that religion remains important and that including appropriate
spiritual content in treatment would be helpful (Browning, Day One). In addition, many
African-American LGBT people operate within both the African-American community at
large and the African-American LGBT community, and coming out publicly may place
an individual at greater risk of losing connection with the first community.
Asian Pacific Islanders (API) consist of more than sixty culturally distinct groups
that speak more than one hundred languages and dialects. For Asian Pacific Islanders, in
general, cohesiveness of the group is an important value and shame can be a factor in
deterring expressions of homosexual behavior (Wong et al., 1998). Family and inter-
dependence are central and varying from one’s gender or sexual role can cause shame for
the entire family. In addition, some API languages have no words for gay or lesbian.

9. Latino Americans are also defined by a wide variety of sub-groups and geographic
locations including people from Mexico, Puerto Rico, Cuba, the Dominican Republic,
Central and South America. Again, the family is the cornerstone and needs to be involved
in treatment. In fact, alcohol is an important part of many Latino family social gatherings.
Homosexuality or transgender identity may be privately acknowledged but is often not
discussed openly. As with other cultures, LGBT identity may be very different from
behavior (for example, some men who have sex with men do not consider themselves
gay) and providers need to respect this distinction.
Despite the many cultural and racial differences, in general, LGBT people live in
a society that routinely stigmatizes and denigrates our basic human qualities: sexuality,
choice of loving partner, and the ability to self-identify. Ignorance and fear of gay,
lesbian, and transgender people promotes prejudice, discrimination, and in extreme cases
assault or violence. "Fag" jokes evoke laughter in schools and workplaces. In some
communities "gay bashing" (hate crimes involving violence or the threat of violence) is
an acceptable pastime, rarely punished by authorities or the judicial system. Many
religious institutions condemn homosexuality as sinful. LGBT people who reveal their
sexual identity risk losing jobs, friends, and families. In some communities, the day to
day life of LGBT people includes verbal assault, disdainful glances, and restrictions from
interacting with children, even relatives. This hostile social environment leads to a variety
of health risks. For example, the Report of the Secretary's Task Force on Youth Suicide,
1989, found that lesbian and gay youth attempt to kill themselves at a rate two to three
times higher than their heterosexual peers (Gibson, 1989).

10. Characteristics That Impede Access to Services
Several issues arise as general barriers for many lesbians or gay men. As Brenda
Underhill notes in her training curriculum Creating Visibility: "These problems are
frequently replications of the circumstances any lesbian faces when trying to conduct an
emotionally healthy life in an environment unsupportive or hostile to her existence." (25)
A primary impediment to accessing services for alcohol and other drug problems
is a general mistrust of services providers (Ziebold and Mongeon, 1990). Traditionally,
service providers have not been supportive of LGBT people. The health system often
labels LGBT people as sick or unnatural, or treats them as completely invisible.
Heterosexism plays out in many ways. Intake forms in health centers and doctors’ offices
often do not have a box to check that accurately describe the family situations or sexual
health histories of LGBT people. In hospitals, visiting rules and regulations often do not
allow their families to visit because these rules are based on biological families and legal
marriages. This pattern of rejection and denigration from those who are supposed to be
helpful and supportive leads to a large amount of fear about disclosing one's sexual
orientation or gender identity in a service delivery setting. For example, in their extensive
review of the literature (1991), EMT Associates states:
“Studies clearly indicate that few programs have made any effort to attract gay
and lesbian AOD abusers or to take into consideration their differences from the
general population in the treatment process. Studies consistently have found a
lack of formal training, limited knowledge of community resources, inability to
identify gay clientele, little or no gay staffing, failure to actively address the
unique treatment issues of this population, judgmental attitudes..., and little or no
priority for creating more supportive treatment environments for them" (50-51).
LGBT people may fear negative reactions from staff (Lewis, 1995) or other
program participants. Negative reactions come in the form of verbal harassment or in

11. some cases physical violence, known as "gay bashing." Gay men, lesbians and
transgender people may be afraid that a staff person or other program participant would
betray their confidence, causing them to lose a job or the support of their family of origin.
LGBT mothers or fathers may fear losing custody of their children. LGBT people living
in committed relationships may be concerned that the program will not acknowledge their
partners or spouses or other alternative family/support system.
A lack of adequate outreach is another issue that keeps LGBT people out of
programs. In the Gay and Lesbian Constituent Committee's "Position Paper in Support of
a Request for Proposals for a Gay/Lesbian Technical Assistance Contract," Maria Morfin
emphasizes the importance of both real and perceived accessibility (3). In order for an
agency to build a trustworthy reputation, it must include gay men, lesbians and
transgender people in brochures, ads, community outreach, and program materials.
Brenda Underhill captures the essence of expressing homophobia as it could be played
out in a program setting:
 Direct statements of disapproval of lesbian or gay lifestyles and behavior
 Blatant or subtle pressure on a lesbian to change her orientation (attempts
to "cure" her)
 Telling of jokes of which gays or lesbians are the target
 Assertions that there is "no difference" between lesbian and non-lesbian
participants ("We're all just alcoholics")
 Communications that discourage openness or disclosure ("Why do you
have to make such a big deal about it?")
 Paranoia regarding a lesbian's behavior (fear that she has or will "come
on" to them)(26)
Affordability is another barrier that particularly affects lesbians and transgender
people, who face discrimination in the workforce based on both their sexual orientation
and their gender. For many parents, a lack of child care also affects program accessibility,
as many lesbians are single parents (Morfin 3).

12. The location of program facilities hinders some LGBT people from participating
in alcohol and other drug programs. Most services that are sensitive or specific to LGBT
people exist in large urban centers. This certainly addresses a need, as urban centers tend
to attract LGBT people in large numbers. Even in urban areas, however, more attention
needs to be paid to locating such services in communities where people of diverse
cultural and ethnic backgrounds live. There is a slogan commonly used in the gay and
lesbian community: We Are Everywhere, that refers to the fact that gay and lesbian
people are present in every occupation, socioeconomic status, disability and age group as
well as all ethnic and geographic communities. Consequently, suburban and rural areas
must also offer lesbian and gay sensitive programs. Morfin suggests that "providers must
locate 'outposts' of outreach and treatment in these areas" (3).
The constellation of impediments to service becomes even more complex for LGBT
people who are from various cultural and ethnic backgrounds. As discussed above, LGBT
Native Americans, African Americans, Asian Americans and Pacific Islanders, and
Latinos/Chicanos have distinct cultural issues that influence the prevalence and risk of
alcohol and other drug problems. Different cultural values influence the relative ease or
difficulty of the coming out process as well as the acceptability of drinking/drug use. It is
impossible to put people from any one cultural or ethnic identify into one category,
summarizing the nuances of how each culture's values affects the risk factors discussed
above. However, some commonalties exist.