Substance Use & Misuse, 42:161–176Copyright © 2007 Informa HealthcareISSN: 1082-6084 (print); 1532-2491 (online)DOI: 10.1080/10826080601094207

Special Populations

Do Specialized Services Exist for LGBT IndividualsSeeking Treatment for Substance Misuse? A Study

of Available Treatment Programs

BRYAN N. COCHRAN, K. MICHELLE PEAVY,AND JENNIFER S. ROBOHM

University of Montana, Missoula, Montana, USA

Substance abuse1 research has demonstrated that client sexual orientation influencestreatment outcomes. Consequently, many substance user treatment programs offer ser-vices for lesbian, gay, bisexual, and transgender (LGBT) individuals. In a recent searchof SAMHSA treatment listings, 11.8% (N = 911) of substance user treatment programs(including residential, outpatient, and partial hospitalization) in the United States andPuerto Rico indicated that they offer specialized services for LGBT clients. However,a telephone survey we conducted in 2003–2004 revealed that 70.8% of these “LGBT”programs were no different from services offered to the general population, and only7.4% could identify a service specifically tailored to the needs of LGBT clients. Impli-cations for LGBT individuals seeking services are discussed, the study’s limitations arenoted, and future research directions are identified.

Keywords LGBT; homosexuality; gay; lesbian; bisexual; transgender; treatment;specialized services; SAMHSA

Introduction

Individuals with substance use disorders (SUD) comprise a heterogeneous group. Althoughwe can make some generalizations based upon a person’s demographic characteristics,patterns of use, external supports, or treatment history, our ability to predict treatment out-come for a given individual is somewhat limited. Consequently, there has been considerableinterest in understanding the relevance of particular patient characteristics to the develop-ment, maintenance, and treatment of SUD (e.g., Foulks and Pena, 1995; Morgenstern andBux, 2003). For example, we know that men are more likely than women to develop se-vere substance dependence (Substance Abuse and Mental Health Services Administration

Address correspondence to Bryan N. Cochran, Ph.D., Department of Psychology, SB #143,University of Montana, Missoula, MT 59812. E-mail: bryan.cochran@umontana.edu

1The journal’s style utilizes the category substance abuse as a diagnostic category. Substancesare used or misused; living organisms are and can be abused. Editor’s note.

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[SAMHSA], 2005), and ethnic minorities may be more likely to drop out of treatmentprematurely (King and Canada, 2004).

Of interest to our research team are studies that have demonstrated that lesbian, gay,bisexual, and transgender (LGBT) individuals may have higher substance use prevalencerates than the general population (Fergusson, Horwood, and Beautrais, 1999; Stall et al.,2001). Researchers in this area have been criticized for relying upon flawed data collectionmethods (e.g., Hughes, 2003). Nonetheless, findings dating back to 1977 (Fifield, Latham,and Phillips, 1977) indicate that LGBT individuals are at greater risk for substance use thantheir heterosexual counterparts, and more recent research (e.g., Hughes and Eliason, 2002;Cochran and Cauce, 2006) provides further evidence for this assertion. The mechanismby which LGBT individuals might be more prone to substance use could be explained byincreased stress associated with the societal stigma attached to being a sexual minority. Thebelief that those in the LGBT population have higher chances of developing substance useproblems is also embodied within the National Survey of Substance Abuse Treatment Ser-vices (NSSATS). The NSSATS, administered annually by the Substance Abuse and MentalHealth Services Administration (SAMHSA), includes the option for treatment programs toindicate that they offer “special programs/groups” for “gays and lesbians.” Individuals canthen search the resulting database for programs that offer LGBT-specific services, as wellas for specialized services geared toward other particular populations (e.g., men or womenonly, DUI/DWI clients, senior or older adults).

Despite accumulating evidence that LGBT individuals have high rates of substanceuse, there is comparatively little known about the most effective way to treat this popula-tion. More than two decades ago, researchers made efforts to determine specific treatmentneeds and recommendations for gay and lesbian “alcoholics” (Colcher, 1982; Zigrang,1982). Colcher reported that gay alcoholics feared coming to treatment more than het-erosexuals, stating that gay clients worried about rejection by treatment staff. Zigrang’spaper complemented this report by outlining the real prejudices the “gay alcoholic” couldencounter at systems like the Veterans Administration Medical Center. To address the prob-lems faced by gay individuals with alcohol problems, Colcher (1982) proposed offeringempathic understanding of the individual and his needs; although such empathy is certainlya basic condition for the development of a treatment alliance, it is possible that some treat-ment staff may have reinforced clients’ fears of rejection based on their sexual orientation.Zigrang (1982) additionally recommended educating treatment staff regarding “homosexualalcoholism, the gay life-style,” further suggesting that the development of special servicesfor this population was needed. Implicitly, at that time, as with other studies, the focus wasalmost exclusively on gay male populations. The literature regarding substance use amonglesbian, bisexual, and transgender individuals remains scant, and while the heterogeneousmembers of the LGBT community are subject to similar experiences (e.g., stigma, discrim-ination), it may also be that there are significant gender and other differences within thecommunity in terms of treatment needs and/or responsiveness to particular interventions.

One might ask, as we did, what has been the response to these recommendationsby researchers and treatment providers (not to mention other relevant stakeholders and“gatekeepers” who control treatment access and availability)? Interestingly, in a study ex-amining the environment faced by LGBT individuals presenting for treatment, Hellman,Stanton, Lee, and Tytun (1989) found that treatment providers in government-funded agen-cies tended to lack training and supervision around treatment issues specific to sexualminorities. More recently, researchers have examined attitudes of service providers towardLGBT substance users (Eliason, 2000; Eliason and Hughes, 2004). These studies foundthat about half of counselors surveyed reported ambivalent or negative attitudes toward

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LGBT clients. Additionally, counselors reported little knowledge of LGBT-specific is-sues that these clients might face, such as difficulties establishing power of attorney ordomestic partnership or trouble managing the effects of internalized homophobia. Whilethe aforementioned studies focused on explicit attitudes, another study (Cochran et al.,in press) also used an implicit measure to access substance user treatment counselors’ so-cially undesirable attitudes. This measure, a modification of the implicit association test(Greenwald, McGhee, and Schwartz, 1998), was used to tap into attitudes that occur atan automatic, uncontrolled level. Participants are requested to respond quickly to a cat-egorization task that asks them to classify photos of couples as either “homosexual” or“heterosexual” (they are told to assume that pairs of individuals depicted in photographsare romantic couples) and are also asked to classify affectively laden adjectives as either“good” or “bad.” Rapid responding, combined with an inherent bias, is presumed to indicatewhether participants have automatic associations between homosexuality and either “good”or “bad” emotional responses. Banse, Seise, and Zerbes (2001) originally piloted this mea-sure with an undergraduate student population, with a similar goal of accessing attitudesthat may not be socially desirable. Indeed, with a sample of treatment counselors, Cochranet al. (in press) surmised that implicit attitudes may be more indicative of counselors’ truefeelings than explicit measures. The findings from this study indicated that heterosexualcounselors and those with few LGBT friends showed a stronger negative bias toward LGBTindividuals.

Taken together, these research findings indicate that LGBT substance users may expe-rience a negative treatment environment or one in which staff are unaware of these clients’needs. The lack of widespread awareness-raising efforts regarding the unique treatmentneeds of this population might be in part due to the way substance misuse is often conceptu-alized. Specifically, the medical model of substance abuse has been predominant in the fieldof chemical dependency (McLellan, Lewis, O’Brien and Kleber, 2000; Vatz and Weinberg,1990). The medical model emerged on the heels of the “moral model,” which purportedthat substance use was due to the person’s flawed morals. And, while the medicalizationof substance use might seem less stigmatizing than its moralization, neither model appearsto be grounded in a strong empirical base. In his discussion of the ethics regarding med-ical interventions for substance users, Kleinig (2004) states that if substance misuse wasindeed a problem of a medical nature, the problem would be dealt with like medical issues:through simple and effective treatments. Kleinig also mentions, however, that substance useis more complicated than medical problems (because of a plethora of psychosocial factors),lending itself to poor outcomes when a simple treatment is employed. Along with the med-ical model of substance use goes the perception that the “illness” should be treated, withrelatively little focus on individual differences as they relate to a person’s recovery. In thecase of LGBT individuals, however, there is some indication that attending to the individualdifference variable of sexuality may improve a client’s engagement in the treatment process.For example, data indicate that LGBT individuals prefer agencies that address LGBT issuesand are more likely to attend treatment if their counselors are also LGBT (Colcher, 1982;Driscoll, 1982). The implication is that special services aimed at LGBT issues might reducerelapse, treatment dropout, and the reinforcement of shame associated with having multiplestigmatized identities (e.g., “substance abuser,” “gay man,” “ethnic minority”). There ap-pears to be consensus in the literature that LGBT substance users fare better when groupsand programs are tailored to address the needs of LGBT clients (e.g., Hicks, 2000; Paul,Barrett, Crosby, and Stall, 1996; Zigrang, 1982). It is useful, then, to consider what thespecialized treatment needs of this community are and what an LGBT-sensitive treatmentprogram might look like.

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The specialized needs of LGBT substance users have been delineated in a small bodyof research conducted within the United States focusing on educating treatment staff aboutLGBT issues and fostering an LGBT-affirmative environment (e.g., Paul, Stall, and Bloom-field, 1991; Barbara, 2002). Specific dilemmas LGB clients face when entering treatmenthave been outlined in one qualitative study in which counselors and other care providerswere interviewed regarding their experiences with LGB clients (Barbara, 2002). The re-sults provide an appropriate starting point for understanding LGBT substance users’ fearsand problems as they begin their journey into the treatment system. In Barbara’s study,eight themes emerged as areas of importance for LGB clients, including “openness aboutsexual orientation” (i.e., being in a treatment environment in which clients are able todisclose their sexual orientation). A study done by Hellman and his colleagues (1989)similarly found that counselors believe that sexual orientation is an important treatmentissue, but that sexual minority issues are seldom talked about in treatment. A numberof factors could constitute sexual minority issues, especially as they relate to substanceuse.

For example, in the aforementioned qualitative study conducted by Barbara (2002),another theme revolved around the difficulty LGB clients face when having to socializeoutside the bar scene. This oft-cited LGBT-specific issue is noted as a risk factor for sub-stance use–related problems in the gay community (e.g., Colcher, 1982; Israelstam andLambert, 1984). The lack of non-drinking venues in which LGBT individuals can social-ize, particularly in rural areas that lack a defined LGBT community, presents a barrierto treatment that is unique to the population. While this concern does not directly pointto a “specialized treatment need” per se, it does underscore the importance of educatingproviders about this issue in order for proper relapse prevention and treatment planning tooccur.

Although there have been no specific guidelines formulated regarding “culturally com-petent” treatment methods for LGBT substance users, Finnegan and McNally (2002)offer some suggestions for what might constitute LGBT-focused treatment. They sug-gest that counselors approach LGBT substance users with an awareness of their mul-tiple oppressions (substance use and sexual orientation certainly, but also other possi-ble stigmas such as gender and ethnicity) and how these might impact their substanceuse. They propose that an awareness of countertransference issues, particularly how thesemight reflect a counselor’s discomfort or ambivalence regarding issues of sexual orien-tation or gender identity, is paramount to preserving the therapeutic relationship as anagent of client change. Finally, they recommend that counselors should work toward de-veloping knowledge regarding LGBT-specific issues and express directly to their clientswhat they do not know. These guidelines, though not subjected to empirical scrutiny,may provide some semblance of what LGBT-specific substance user treatment program-ming could entail. An initial attempt at establishing such practice guidelines is evidencedthrough the publication of a provider’s guide for working with LGBT clients (SAMHSA,2001).

As suggested by the foregoing review, counselor education and training on LGBTissues, as well as acknowledgement of these issues in the treatment setting are both impor-tant for LGBT substance users. However, what constitutes a “specialized service” in thereal world and exactly how many treatment centers offer such services remain empiricalquestions. Olmstead and Sindelar (2004) asked similar questions in a study of substanceuser treatment providers, casting the net more broadly to capture the prevalence of spe-cialized services that were purportedly being offered for several different types of clients(i.e., persons with HIV/AIDS, the dually diagnosed, and adolescents). Their study also

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investigated claims by the treatment providers to see whether other key services wereactually being offered. The methodology used for their research involved the inspection ofdata on substance user treatment facilities provided by SAMHSA. This database containsdata self-reported by agencies across the United States regarding special services offered,as well as other characteristics of the program. Using these data, Olmstead and Sindelar(2004) cross-validated services to determine whether or not a special service was actuallyoffered. For example, facilities that claimed to offer a special program for gay and lesbianclients were examined to see if a related “key service” was also offered. The researchersdefined key services as those that are aimed at a special population and are suggested bythe literature to be integral for their successful treatment. For the purposes of their study,they identified key services for gay and lesbian clients to be testing and counseling forHIV and other sexually transmitted diseases. Results showed that fewer than half of theprograms that offered special programs for gays and lesbians also offered a correspondingkey service.

The provision of key services might be one indicator that an agency is meeting theneeds of its LGBT clients. As cited above, however, the specialized needs of LGBT sub-stance abusing clients suggest a program with more complexity. Not identified in theOlmstead and Sindelar (2004) study was the makeup of the specialized services actu-ally offered to LGBT individuals by agencies. Our research team set out to address thisissue by investigating what kinds of services were being offered to the LGBT substance-abusing population across the country. We used the same SAMHSA data as a startingpoint for analyses, but we employed a different methodology in seeking an answer to ourquestion.

Methods

Participants and Materials

The participants in our study were substance user treatment programs selected from the 2002NSSATS database. Data that appear in the NSSATS online database are obtained throughan annual survey of agencies conducted by SAMHSA. This survey is designed to collectinformation regarding the location, characteristics, and utilization of services at alcohol anddrug user treatment facilities. In terms of program characteristics, agencies surveyed providea range of information, for example types of services they provide and whether or not theyoffer special programs/groups for particular populations, including adolescents, pregnantwomen, the elderly, and gays and lesbians. In 2002, the survey contained 37 questions andwas posted in its entirety online (SAMHSA, 2003).

The database continues to be available online to the general public and is searchable bythe types of services provided. SAMHSA’s original purpose of the survey was to assess thescope of services provided across the United States and to generate the National Directoryof Drug and Alcohol Abuse Treatment Programs. Our use of this database was intended toreplicate the experience of potential clients seeking information about agencies that providespecialized services for LGBT individuals.

We accessed the NSSATS database on November 5, 2003, and searched for all agenciesthat self-identified as providers of substance user treatment services primarily (N = 7691).Within this pool of available agencies, 11.8% (N = 911) indicated that they providedspecialized groups or programs for gays and lesbians. After identifying these programs, wedownloaded their contact information and began our data collection efforts.

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Procedure

As noted earlier, our primary goal was to maximize ecological validity by simulating theprocess that clients might undertake when initially contacting a treatment agency for moreinformation. With this in mind, we placed phone calls to each of the 911 agencies duringtheir office hours and spoke to the person who answered the main phone line for eachagency. We used a standardized script for each call: “Hi, I am calling because your agencyis listed in the SAMHSA directory as one that provides special programs or groups for gaysand lesbians, and I am interested specifically in what those programs are. Could you tellme more about them?”

Calls were placed by 10 research assistants trained in the data collection process.During the phone conversations, callers did not self-identify as researchers, and if agencystaff requested that the caller provide more information about him/herself (e.g., intentionto receive treatment), the caller responded by saying, “At this time, I am just calling to seewhat services are offered.” The response received to the caller’s inquiry was transcribedverbatim and coded into categories of providing/not providing services. A research staffcoding meeting was held to decide on the coding of ambiguous agency responses. In theevent that agency staff were unable to answer our question on the first call (e.g., severalagencies indicated that the staff person best able to answer our question was unavailable),we re-contacted the agencies to follow up with our request. We made at least two attemptsto contact each agency, assuming that clients in an analogous situation would be unlikelyto persist if their questions went unanswered after two attempts.

Because participants in our study were not asked to reveal any personal information andtheir duties performed for our project (i.e., answering questions about services offered attheir clinic) were part of their daily work activities, this project was determined to be exemptfrom full review by the Institutional Review Board (IRB) at the University of Montana.

Calls were placed from the date of the initial NSSATS database extraction untilNovember 3, 2004. Because we were primarily interested in the agency staff members’initial responses to our question, our qualitative analyses of participants’ responses wererelatively uncomplicated. Due to the lack of definition regarding the concept of “LGBTspecific substance user treatment,” we had no a priori expectations regarding the responsesthat we would receive in our study. Research assistants reviewed the responses to determine,initially, if recurrent themes emerged in the staff members’ responses to our inquiry. Afterthese themes were divided into several categories, a research assistant coded each responseto determine if it fit into any of the themes that emerged from the qualitative analysis.

Results

Due to the time delay between the collection of the NSSATS data and our contact withthe treatment agencies, it appears that several agencies had closed, as 57 (6.3%) of theagencies’ phone numbers had been disconnected. These agencies were not considered infurther analyses, resulting in a final sample of 854 agencies.

A substantial number (N = 187; 21.9%) of the agencies in our study were unableto answer our inquiry on the first or second phone call. Several possible scenarios wererepresented by this subsample: callers were transferred to voice mail, asked to leave amessage with someone else at the agency (e.g., the agency’s director or an office manager),told to call back to speak with someone else, or asked to provide their name and number sothat someone could return their call and answer the question. Less frequent responses fromagencies included, “I’m not allowed to give that information out over the phone” and “I’mnot sure who you would have to talk to about that.”

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Table 1

Categorization of agency responses

Frequency

Category of response Example N Percentage

Offered LGBT-specificservices

“There are specific groups for that; werun it as an aftercare group; it is forboth gays and lesbians.”

62 7.3

Offered service in thepast

“There was a group, but that was acouple of years ago. Things changeevery so often.”

16 1.9

Do not discriminate “We don’t have separate groups; wedon’t discriminate. You would beincluded in the general population,we want to help everyone.”

79 9.3

“Accepting” of LGBTclients

“We do have gays and lesbians that areour patients, I wouldn’t say we haveanything special [for them] but we doaccommodate them.”

34 4.0

∗Percentages in the table do not total 100%; 605 (70.8%) agencies did not offer services and 187(21.9%) could not provide an answer to our question after two attempts.

Results from the study are summarized on Table 1. An unexpected finding of our studywas that although all 854 agencies had indicated in the NSSATS survey that they providedLGBT-specific services, the majority (N = 605; 70.8%) indicated during our phone call that,in fact, they offered no such services. In most of these cases, agency staff simply respondedthat no specialized programs for gays or lesbians existed at that agency (e.g., “We don’toffer specific services”).

Sixteen of the agencies (1.9%) indicated that whereas they did not currently offer suchspecialized services, they had done so in the past (e.g., “At one point, we had some specialgroups set up, but we found out that we did not have the need for them;” “We used to havea program but [counselor] transferred to another program”).

A common theme that emerged from qualitative analysis of the agencies’ responseswas that although agencies did not offer LGBT-specific programs, they also did not feel thatthey discriminated against LGBT individuals. A total of 79 programs (9.3% of the studytotal) were classified as “non-discriminating” by virtue of staff comments such as, “Wedon’t discriminate, but we don’t have special services” or “We offer the same thing we offerstraight people. . . we don’t discriminate.” Another emergent theme was that agency staffasserted that their program was “accepting” of people who identified as gay or lesbian (N =34; 4.0%). Representative comments include: “We accept them, we don’t have any specificgroups for them” and “We don’t have special services for gays and lesbians, we just allowthem in our groups.”

A minority of the 854 agencies surveyed indicated that they did offer LGBT-specificservices (N = 62; 7.3%). These agencies represented 23 different states, with almost half ofthese programs (N=31) in two key states (New York and California). In regard to the specifictype of service provided for gay and lesbian individuals, almost half of these programs(N = 31; 49.2%) indicated that they offered a specific group for gay men, lesbian women,

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or both. Thirteen (20.6%) programs indicated that they exclusively served members of theLGBT community. Twelve (19.0%) stated that they had a counselor trained specificallyin LGBT issues, and 7 (11.1%) indicated that they had both groups for gay or lesbianindividuals and individual counseling with specifically trained staff.

Discussion

The current investigation was conducted in order to elucidate what is meant by the term“special programs/groups” for LGBT individuals in substance user treatment. The goal ofthe study was to determine what services are currently being offered for this population,thereby increasing our understanding of the ways in which the needs of LGBT substanceusers in treatment are currently being met. What we discovered, however, was that althougha significant minority of the nation’s substance user treatment agencies indicated that theyoffered LGBT-specific treatment services, only a fraction of those (7.4%) actually offereda service that they could identify when we inquired about the services they had available.

Implications for LGBT Clients Seeking Services

Obviously, for LGBT individuals seeking substance user services, these findings are dis-couraging; although at first glance, it appeared that a plethora of programs exist to meetthe needs of the LGBT community, this is, in fact, not the case. Our study thus raises acritical issue: there is extremely limited access to LGBT-specific treatment services forsubstance misuse. As indicated earlier, some research has suggested that LGBT-specificservices may reduce relapse and enhance treatment effectiveness for this population. Yet,out of 7691 primarily substance user treatment programs in the entire United States, wecould identify only 32 (0.4%) programs specifically designed to address the needs of thoseLGBT substance users who do not live in New York or California.

It is possible that LGBT-specific programs were significantly overrepresented in thesubset of agencies that had closed or in those that were not responsive to our inquiries withinthe first or second phone call. Given that LGBT services are rarely the primary focus of atreatment program, we might speculate that many LGBT-specific programs are “add-on”services that are grant- or under-funded, understaffed, or otherwise more vulnerable (e.g.,developed by an LGBT staff person who has since left the agency). It is also possible thatsome agencies stated that they provided “gay and lesbian services” in a disingenuous attemptto attract more clients. More generous interpretations would be that agencies indicated thatthey provided such services if they had a gay or lesbian client(s) attending one of theirprograms at the time of the survey or if they believed that their services did not discriminateagainst LGBT individuals. Nonetheless, these agencies’ responses to the NSTSS surveycould be experienced as misleading by LGBT individuals seeking services.

A second issue raised by these findings is what was meant when agencies indicated thatthey do not “discriminate” in their service provision, or that they “accept” LGBT clients whotake part in their programs. Do they have non-discrimination on the basis of sexual orienta-tion in their agency policies? Have their providers received training on LGBT issues and con-cerns? Have the special treatment needs of LGBT clients been discussed, such as addressingsocial isolation issues with this population? Do they know that their clients feel safe “comingout” to their treatment providers? Do they know enough to be sensitive to these issues?

Several researchers have demonstrated that LGBT individuals’ unique physical andmental health concerns often go unnoticed in a medical setting that assumes heterosex-uality (Rankow, 1995; Saulnier, 1999). Further, there is a considerable body of research

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demonstrating that LGBT individuals often experience stigma, non-empathic responses,and even discrimination from health care providers, and that they often elect not to dis-close their sexual orientation (despite a desire to do so) because health care settings areperceived as threatening (Eliason and Schope, 2001; Allen, Glicken, Beach, and Naylor,1998; Stevens and Hall, 1988). In one study of gay men and lesbians, almost a quarter ofrespondents reported receiving poor or inappropriate service from a therapist, and close toone half reported having experienced a homophobic therapist (Nystrom, 1997). In another,Eliason and Hughes (2004) demonstrated that many substance user treatment counselorslack knowledge about legal issues and concepts such as domestic partnership and power ofattorney that are key to understanding the experience of LGBT individuals as members of astigmatized and oppressed minority in our society Thus, even though many of the treatmentprograms in our study indicated they do not “discriminate” toward LGBT clients, it is rea-sonable to assume that some of their treatment providers are under-informed, insensitive,or heterosexist, even if not actively discriminatory.

At least one study has shown that lesbian women who are “out” to their primary careproviders are more likely to exhibit positive health behaviors (e.g., seeking preventive care)and are more comfortable discussing sensitive issues (White, 1998), both of which arelikely to improve health and treatment outcomes. Rankow (1995) suggests that by signalingopenness and acceptance, primary health care providers can promote a safe environmentfor rapport and disclosure of crucial information, including a thorough social history. Oneimportant component of substance user treatment that is LGBT specific, therefore, seemsto be sensitivity to and “cultural competence” regarding LGBT clients, thus promotinga treatment atmosphere conducive to recovery. Such behaviors should be operationalizedand incorporated into the definition of “LGBT-specific” treatment.

One way to resolve some of this ambiguity would be to develop definitional guidelinesfor “LGBT-specific treatment services” (e.g., “treatment services designed specifically toaddress the special needs of LGBT individuals who abuse substances,” or “treatment pro-grams that have demonstrated adequate cultural sensitivity to the specific treatment needsand concerns of LGBT clients”) and to establish inclusion criteria (e.g., “sensitivity trainingfor treatment staff”). Additionally, literature regarding treatment alliance can inform cri-teria for LGBT-specific treatment. Specifically, we know that racial dissimilarity betweenclient and therapist can potentially hinder client disclosure (Thompson, Worthington, andAtkinson, 1994). Thus, another criterion might be “at least one LGBT treatment provideron staff”). In this way, the responses of agencies surveyed by SAMHSA would be moremeaningful to LGBT clients looking for treatment resources.

Directions for Future Research

The literature examining the substance user treatment needs of LGBT individuals is still inits infancy. A more systematic review of the literature (and a critique of the research designs)would help researchers, clinicians, and other stakeholders to assess the generalizability ofthe findings and the power of the conclusions cited here. In addition, our study raises severalrelated research questions worthy of further exploration.

The Need for LGBT-Specific Treatment Services

Although substance user treatment programs do exist that are specifically designed forLGBT individuals (e.g., Neisen, 1997), we do not yet know whether such specific ser-vices are more or less effective than general services offered by providers sensitive to theneeds and concerns of LGBT individuals. (For example, Rankow (1995) suggested that

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medical providers, at least, should not overemphasize an individual’s LGBT orientationwhen providing treatment.) We do know that various forms of stigma can interfere withtreatment seeking (Corrigan, 2004). It is possible that some LGBT individuals will avoidseeking treatment from an “LGBT” substance user treatment program for fear of beingdoubly stigmatized. Research findings demonstrating that specialized treatment servicesare indeed more effective would thus be important for the field. Conversely, studies show-ing that LGBT-affirmative treatment programs are sufficient to meet the treatment needs ofat least some LGBT individuals would make the limited access to LGBT-specific treatmentprograms less alarming.

LGBT-Specific Programming

Assuming that we find that LGBT-specific programming is superior to generalized treatmentservices for at least some LGBT clients, future research will still need to clarify and explorewhat, exactly, a “specialized” LGBT service or program should look like. For example,what kinds of training and experience should the treatment provider(s) and support staffhave? What issues and concerns should be addressed in the treatment? What resources andreferral information should be available? Does the sexual orientation or gender identity ofthe treatment provider(s) matter?

Research in the medical field has already begun to look at some of these questions.For example, one study demonstrated that lesbian women want health care providers whohave a positive attitude toward their partners and who are sensitive to social issues ofconcern to lesbians (Saulnier, 1999). Although some studies have demonstrated that LGBTindividuals prefer LGBT treatment providers (Colcher, 1982; Driscoll, 1982), others havefound that for many lesbian women, the provider’s sexual orientation is less importantthan his/her training, experience, and level of understanding of lesbians (Saulnier, 2002).More information about these criteria in the substance use and misuse field, coupled withtreatment outcomes research, would help us to determine which sorts of interventions wouldbe most effective for which LGBT substance using clients.

The Experience of LGBT Individuals in Substance User Treatment

Finally, it would be very helpful to study LGBT individuals receiving substance user treat-ment services to learn more about their experience of the services provided. Of particularinterest would be whether the clients themselves felt that they needed “LGBT-specific”services, whether they felt comfortable and safe being “out” in their treatment programs,and whether they experienced their treatment providers as “non-discriminating” and“accepting” of them.

Examination of LGBT within Group Differences

Although LGBT individuals share some common experiences (e.g., oppression, sexual mi-nority status), there may also be important within-group differences that have implicationsfor individuals’ risk for substance use–related problems and their responsiveness to treat-ment. For example, Drabble, Midanik, and Trocki (2005) looked at the prevalence of absti-nence, drinking, “heavier” drinking, alcohol use–related problems, alcohol dependence, andhelp-seeking among homosexual and bisexual women and men compared with heterosex-uals. Although their study found few significant differences among men by sexual orienta-tion, both lesbians and bisexual women had lower abstention rates and significantly greaterodds of reporting alcohol use–related social consequences, alcohol dependence, and past

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help-seeking for an alcohol problem. The authors concluded that alcohol dependence andalcohol use–related consequences differ by sexual orientation, particularly among women(Drabble et al., 2005). Still other studies have found no statistically significant differencesin alcohol consumption and drinking patterns between heterosexual and lesbian/bisexualwomen (Saulnier and Miller, 1997; Bloomfield, 1993), suggesting that there may be im-portant gender differences within the LGBT community. Finally, more research needs to bedone on the specific treatment needs of bisexual and transgender individuals.

From Research to Practice: Incorporating Research Findings into LGBT-Specific

Treatment

A final issue that bears mentioning is that the research conducted in the area of LGBT-specific treatment must be translated into practice in order to best meet the needs of LGBTclients. As with all research findings, there is the concern that conclusions reached in the“ivory tower” of academia may not easily be transferred into clinical practice in the variety ofsubstance user treatment programs that exist. With regard to this area of research, ways ofensuring that such translation occurs may include dissemination of findings in a varietyof journals and bulletins, in-service trainings at substance user clinics, and other effortsto raise clinicians’ awareness of the specific issues that LGBT individuals may face intreatment. Changing intake forms to query about sexual orientation, gender identity, ordomestic partnerships may send the message to clients that LGBT identity is important intreatment and may provide clinicians with valuable information for a client’s treatment plan.Treatment matching, or pairing LGBT clients with providers trained in addressing LGBTissues, may be one way of addressing client needs. Ultimately, treatment programs maycreate a culture in which sexual orientation or gender identity are recognized as factors thatare potentially as important to the client as ethnicity, spirituality, socioeconomic status, andother demographic variables that are commonly considered to be influential in treatmentdevelopment and outcome.

Conclusion

Although we set out to determine what kinds of services are currently being offered to LGBTsubstance users, our study raised more questions than it answered regarding the status ofLGBT-specific substance user services. The discrepancy between agencies’ reports andactual services provided indicates a need for definitional guidelines regarding specializedtreatment services. As these services continue to be developed, it is essential to translateresearch into the actual practice of agencies in the community. We hope that the findings ofour study, especially the gulf identified between services reported and the actual practicesof agencies, will encourage more objective definitions of “specialized services” providednot just for LGBT individuals, but for other populations as well.

Ultimately, an improved understanding of the factors related to substance misuse amongLGBT individuals will strengthen our ability to treat all clients, regardless of sexual orien-tation or gender identity.

Acknowledgments

The authors thank Erikka Becker, Sarah Carson, Lindsay Gibson, Tom Kelley, Tory Kimp-ton, Cary Markin, Laura Morris, Kristen Schneider, and Kelly Simmons for their datacollection efforts.

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RESUME

La recherche sur la toxicomanie a demontre que l’orientation sexuelle du client influenceles resultats du traitement. Par consequent, un grand nombre de programmes pour toxico-manes offrent des services specialises pour les lesbiennes, les homosexuels, les bisexuels etles transsexuels (LHBT). Dans une recherche recente des listes de traitement du HAMSA,11,8 pour cent (N = 911) des programmes pour toxicomanes (y compris traitement a domi-cile, soins en consultation externe, et hospitalisation partielle) aux Etats-Unis d’Ameriqueet a Puerto Rico ont indique qu’ils offrent des services specialises pour clients LHBT.Neanmoins, un sondage par telephone que nous avons dirige en 2003–2004 revele que 70,8pour cent de ces programmes “LHBT” ne se different pas des services offerts au grand pub-lic, et ce n’est que 7,4 pour cent des programmes qui peuvent identifier un service adapteaux besoins des clients LHBT. Notre recherche se porte sur une discussion des implicationsdes individus LHBT qui cherchent des soins; on note les limites de l’etude et identifie lesdirections d’une recherche a l’avenir.

RESUMEN

La investigacion sobre el abuso de drogas ha demostrado que la orientacion sexual delcliente influye en el resultado del tratamiento. Por consiguiente, muchos programas quetratan el abuso de sustancias ofrecen servicios a lesbianas, gays, bisexuales y transexuales(LGBT). En una reciente busqueda de listados de tratamientos de SAMHSA, se comproboque el 11.8% (N: 911) de los programas de abuso (incluyendo los domiciliarios, los deconsulta externa y las hospitalizaciones parciales) en los Estados Unidos y Puerto Rico,ofrecıan servicios especiales a los clientes “LGBT.” Sin embargo, una encuesta telefonicaconducida en 2003–2004 revelo que el 70.8% de estos programas LBGT no diferıan delos servicios ofrecidos a la poblacion en general, y que solo un 7.4% revelaban un servicioespecialmente preparado para las necesidades de los clientes de LGBT. Se discuten aquılas implicaciones para los individuos LGBT que buscan estos servicios, se observan laslimitaciones del estudio y se identifican nuevas direcciones de investigacion.

THE AUTHORS

Brian N. Cochran, Ph.D., is currently an assistant profes-sor of clinical psychology at the University of Montana.His research program investigates the health correlates ofbeing part of a stigmatized group, with an emphasis onLGBT individuals. Previous research studies have exam-ined stigma within the context of adolescent homeless-ness, help-seeking behavior, and substance abuse treat-ment. He is also pursuing research related to the devel-opment of individually tailored approaches for treatingsubstance use disorders. Representative publications ap-pear in the American Journal of Public Health, Journalof Homosexuality, and the Journal of Substance AbuseTreatment.

Specialized Services for LGBT Individuals 173

K. Michelle Peavy, B.S., is currently a doctoral studentin clinical psychology at the University of Montana. Herprimary research interests are in methamphetamine useand treatment, and sexual minority substance users. She isalso developing instruments to study the pathways throughwhich individuals develop substance use disorders andhow substance use history relates to treatment outcome.

Jennifer S. Robohm, Ph.D., is the Director of the Univer-sity of Montana Clinical Psychology Center and a clinicalpsychologist in private practice. Her clinical and researchinterests include the impact of sexual victimization andsubstance use on treatment for LGBT individuals.

Glossary

Explicit Attitudes: beliefs that individuals endorse with conscious awareness of the beliefbeing measured; for example, endorsing the item “I am uncomfortable around peoplewhose ethnic background is different from my own” would be indicating an explicitattitude.

Gender Identity: an individual’s identification as male, female, or neither (e.g., androgy-nous); one’s gender identity may or may not correspond with the biological sex thatone is born with (see transgender).

Implicit Attitudes: beliefs that exist at an automatic, uncontrolled level; these beliefs may betapped with research methodologies that do not clearly indicate what attitude or beliefis being examined.

LGBT: an acronym referring to lesbian, gay, bisexual, and transgender individuals.Sexual Minorities: often used interchangeably with LGBT, this term refers to people who

are in the “minority,” statistically speaking, with regard to their sexual orientation.Specialized Services: this term refers to treatment programs or groups that are specifically

geared toward working with a particular population or group of people who share acharacteristic (e.g., sexual orientation).

Transgender: a term describing individuals whose behaviors or inner experiences reflect agender identity that is different from their biological sex.

174 Cochran et al.

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