While this section has used the term ‘gender and sexual diverse’ to describe people who identify as lesbian, gay, bisexual, asexual, trans, non-binary, queer, or intersex, or who are attracted to same sex/genders that differ from heterosexual or cisgender norms, we acknowledge there is no all-inclusive term. Our intention in utilising this term is to describe the evidence regarding co-occurring conditions in relation to people who identify as gender and sexual diverse.
Overall, there is a lack of research examining co-occurring AOD and mental health conditions among people who identify as gender and sexual diverse in Australia [1717]. The research that does exist suggests that AOD and mental health conditions are between three and six times more prevalent among people who identify as sexual or gender diverse than the general Australian population [1653, 1718]. There is also evidence that people who identify as sexual or gender diverse are between two and nine times more likely to experience co-occurring AOD and mental disorders than those who identify as heterosexual or cisgender (i.e., a person whose gender identity corresponds to their biological sex) [1719–1724]. They are also at increased risk of experiencing suicidal ideation and suicide attempts, and multiple disorders [1718, 1720, 1723]. Although comparative research is lacking, it is important to note that there may be differences between groups who do not identify as heterosexual or cisgender [1719]. For example, women who identify as bisexual report more co-occurring conditions than other sexual diverse and heterosexual people (e.g., 38% of bisexual women compared to 12% of heterosexual women and 25% of lesbian women [1725]).
Although there is considerably less research examining co-occurring conditions among people who identify as gender diverse, one recent review found higher rates of depression, anxiety, AOD use, self-harm, and suicidal ideation among people identifying as gender diverse compared to those who identified as cisgender, and highlighted adolescence as a particularly vulnerable period [1726]. Research has also found that medical gender reassignment may be insufficient to improve functioning and mental health outcomes among trans youth; those who experienced poorer mental health outcomes and functioning before reassignment continued to experience similar problems post-reassignment [1727]. Of note, people who identify as gender diverse may experience significant barriers to accessing and engaging in treatment due to gender segregation within many treatment facilities (e.g., housing, treatment sessions), which were designed to treat cisgender people [1728].
Fundamentally, treatment for people who identify as gender and sexual diverse is the same as for any other client group and should focus on the specific needs of the client [1729]. People who identify as gender and sexual diverse represent a diverse group of people from varying backgrounds; thus, like all other clients, a holistic view should be adopted considering all aspects of their presentation. People who identify as gender and sexual diverse often experience stigma, internal pressure, adverse childhood events, feelings of shame, isolation, guilt, being lied to, and loss of social support among other things, all increasing the risk of mental health and AOD problems [1725, 1730, 1731]. As such, co-occurring conditions among people who identify as gender and sexual diverse are likely to be a consequence of being in a minority group within the community, rather than being same sex attracted.
Key principles for inclusive service response when working with people who identify as gender and sexual diverse include [1723, 1732]:
- Freedom from discrimination: Ensuring there are no direct or indirect discriminatory practices (e.g., appropriate use of culturally sensitive language; auditing intake processes, including language, to ensure they are inclusive of people who identify as gender and sexual diverse).
- Affirmation: Encouraging and celebrating diversity, sexual and gender identity (e.g., providing an accepting and affirming approach to the client’s sexual or gender identity; ensuring staff are aware of gender and sexual diverse support services; affirmation of non-traditional family networks; assisting the client develop strategies for dealing with stigma, discrimination, and stress).
- Access and equity: Ensuring people who identify as gender and sexual diverse can access care and incorporating organisational processes that can adapt service delivery to improve outcomes (e.g., providing a welcoming, non-judgemental, and respectful environment; providing appropriate education and training for staff; ensuring there is a high regard for confidentiality around personal information).
- Visibility: Regular participation in community and inclusion events, and committing to inclusive practice (e.g., presence of gender and sexual diverse staff and positive gender and sexual diverse role models; surveying your workforce to assess whether they experience inclusivity at work).
- Co-design: Ongoing engagement with people who identify as gender and sexual diverse as well as community stakeholders, to improve experience of services and treatment outcomes (e.g., partner with gender and sexual diverse organisations to gain expertise on content and to increase access to gender and sexual diverse communities; ensure the workforce reflects diversity and the broader society).
- Recognition and acknowledgement of the principles of the Ottawa Charter: In particular, that health promotion is a process of increasing a person’s capacity to manage and improve their health.
AOD workers are encouraged to access additional resources provided in the ACON and NADA inclusivity guidelines: www.nada.org.au/resources/aod-lgbtiq-inclusive-guidelines-for-treatment-providers/.
Discussing sexuality and related issues requires a sensitive approach and, depending on the issues raised, may lead to the AOD worker assisting with safety, support, accommodation, and harm reduction. Asking people about their sexual identity is vital to informing the needs of AOD clients. People who identify as gender and sexual diverse are often missing from routinely collected data within health services – both at an individual and service level, which means sexual and gender-specific health issues may not be adequately represented or reflected in discussions regarding funding or resource allocation [1733]. While the purpose for questioning people about their sexual and gender diversity is important, it is equally important that workers consider and use professional judgement; for example [1732, 1734]:
- Ask clients open ended questions (i.e., who/what/when/where/why/how) to assist in rapport building, and practice with role play, for example:
- How do you identify sexually (provide options as prompts, such as lesbian, gay, heterosexual, bisexual and so on)?
- What gender do you identify with?
- What are your pronouns (she/her, he/him, they/their, something else)?
- When speaking with you or referring to you with others, what name would you like me to use?
- How comfortable is the person with their sexuality and with talking about it with others?
- Have they told family/friends? How have these people reacted (or how might they)?
- Is it their decision to tell someone or are they being forced?
- How much support do they have?
- Are they financially, physically, or emotionally independent?
Engagement is fundamentally important as well as confidentiality issues. AOD workers should also be aware that, for some clients (especially young clients), issues surrounding sexual and gender identity may be a principal concern and may require increased attention during treatment. Several treatments have been evaluated among people who identify as sexual or gender diverse, though none have been evaluated extensively. These include:
- Effective Skills to Empower Effective Men (ESTEEM): a 10-session CBT-based intervention focusing on improving coping strategies and reducing minority stress processes. An RCT conducted among young gay and bisexual men with depression or anxiety co-occurring with harmful alcohol use found that ESTEEM reduced depressive symptoms, alcohol use problems, and improved sexual health behaviours, relative to a wait list control [1735].
- Empowering Queer Identities in Psychotherapy (EQuIP): based on modules from ESTEEM, EQuIP also comprises 10 sessions focused on minority stressors such as the impact of gender norms on relationships, the intersection of sexism with other forms of oppression, and exposure to harassment. An RCT conducted among sexual diverse women with co-occurring depression or anxiety and heavy alcohol use found that those randomised to receive EQuIP demonstrated greater reductions in anxiety and depression, as well as the amount of problems associated with alcohol use, compared to a wait-list control [1736].
- Seeking Safety: a CBT-based intervention for co-occurring PTSD and AOD use (discussed in Chapter B7). A single pilot study conducted among transgender women found 12 sessions of Seeking Safety was associated with reductions in PTSD symptoms and the severity of AOD use [1737].