Table 2 Recommendations from N = 23 LGBTQ+ people with lived experience on the provision of LGBTQ+-affirming SU treatment and services
Policies | • Develop and clearly document SOGI-related non-discrimination policies, including guidelines on disciplinary actions for staff and peers who mistreat LGBTQ+ clients with tiered responses based on severity of mistreatment (e.g., name-calling vs. sexual assault). • Develop policies on the routinization of peers sharing names and pronouns as part of introductions. • Include LGBTQ+ people in the development of non-discrimination and staff vetting policies by forming community advisory boards and meeting with LGBTQ+ people with lived experiences in addiction and SU treatment and other services. |
LGBTQ+-Specific Services | • Where possible, create LGBTQ+-only SU treatment programs. If not possible, offer LGBTQ+-specific groups within larger SU treatment programs and ensure that programs are broadly inclusive of LGBTQ+ clients beyond specific groups. |
Staff Hiring | • Where possible in the context of anti-LGBTQ+ legislation, hire openly LGBTQ+ (or explicitly LGBTQ+-allied) staff at all levels, from support staff to behavioral health providers to medical doctors. • Vet staff during hiring and onboarding processes for LGBTQ+-affirming views and practices. |
Intake Forms and Processes | • Intake forms should include questions about the name participants go by, pronouns, gender identity, and sexual orientation, with options for open-ended responses as well as pre-written response options beyond “male” and “female”; “straight”, “lesbian”, “gay”, and “bisexual”. • Responses to SOGI intake questions should be voluntary, recognizing the potentially sensitive nature of such questions. |
Provision of Affirming Treatment | • Staff should share their pronouns and ask clients to do so within group and individual treatment sessions. Sharing and asking about pronouns should be a routine component of care. • Staff should guide patients in exploring the connection between addiction, SOGI-related trauma, discrimination, and stigma, while also recognizing that identifying as LGBTQ+ does not always lead to trauma or negative health outcomes. • Staff should view LGBTQ+ clients holistically (including accounting for unique experiences based on racial, ethnic, and other salient identities) rather than only focusing on SOGI. |
Staff Training | • Staff should receive LGBTQ+ sensitivity training that accounts for fear and anxiety about working with LGBTQ+ clients. Training content should guide staff in how to avoid making SOGI-related assumptions about clients based on the gender of clients’ partners, how to respectfully ask clients about SOGI, education on SOGI-related language and terminology (what does the LGBTQ+ acronym stand for; slang terms), information about LGBTQ+ communities (e.g., chosen family; importance of LGBTQ+-affirming social spaces), and guidelines for working with transgender and gender diverse clients (e.g., normalize sharing and asking about pronouns and correct names). • Staff should receive training in how to intervene when LGBTQ+ clients experience discrimination, stigma, or aggression from other clients. • Staff training should use an intersectional lens to teach staff how to effectively work with clients with intersecting marginalized identities (such as LGBTQ+ people of color). • Trainings should occur regularly (e.g., at least once a year) and should be interactive and individualized based on staff role (e.g., medical doctors, mental health providers, receptionists). • People who identify as LGBTQ+ should deliver staff trainings. |
Visual Cues of an Affirming Environment | • Display rainbow flags; LGBTQ+-specific brochures, signs, and banners (e.g., posters with LGBTQ+ couples and transgender and non-binary people related to SU treatment with motivational messages); and videos with scenarios about SU that include racially diverse LGBTQ+ characters. • Ensure that programs are affirming beyond visual cues (e.g., educating the public on LGBTQ+ issues, hosting LGBTQ+ events, and connecting transgender people with affirming services such as hormone replacement therapy and name change clinics). |
Gender-Affirming Program Structures | • Ensure that programs are safe spaces for transgender and non-binary people, e.g., by offering single-stall gender-neutral bathrooms or by allowing people to use the bathroom aligned with their gender; and by offering gender-neutral living arrangements or housing people based on their gender. |