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Unfamiliarity Breeds Contempt 

OK so why this. There is as far as I can find no research concerning the attitude of counselors concerning transgender clients. while this covers only one segment I feel it is fairly  safe to bet this is reasonably representative of most counselors. The material in text books I currently have is spotty, brief, and often inaccurate. One text book I currently have quotes material from over thirty years ago

Attitudes of substance abuse counselors toward transgender clients?

Substance abuse counselors exert considerable power and influence over their clients, and their attitudes may significantly affect clients’ chances of recovery (Miller & Rolhiick, 1991). It is therefore crucial for substance abuse counselors to understand their transgender clients and accept them as individuals and not as a stereotype of some group. An effective counseling relationship requires that cultural competence is a core value. The client exists as part of an interlocking system and to leaves part of that system unrecognized or discounted lessens the chance of success.  What are the factors that contribute to change? The effective relationship with the client is one of the keys to any therapeutic relationship.

 The Relative Contributions of Four Factors to Change in Psychotherapy

This is the result of a Meta study concerning therapeutic outcomes. I am drawing a conclusion that the numbers hold true in substance abuse counseling.

 40% - Extratherapeutic Factors:  Clients and their Environments. These are the resources the client already has before they see the counselor such as client’s motivation and energy, support from family and others, and the fact that clients often improve on their own before they even engage in counseling.

 30% - The Therapeutic Relationship:   It appears that Carl Rogers was correct when he suggested that an empathic relationship, as perceived by the client, is, in and of itself, therapeutic.

 15% - Therapeutic Techniques:  This includes the specific techniques employed by the counselor such as behavior modification, awareness of feelings, and cognitive restructuring.

 15% - Expectancy, Hope, and Placebo:  As Jerome Frank and others have argued, the client’s expectations, beliefs, and faith in therapy and in the therapist appear to be therapeutic factors. (Miller, S.D., Duncan, B.L., Hubble, M.A. 1997. Escape from Babel)

Research data related to AOD (alcohol and other drugs) use patterns of transgender persons is scant (or nonexistent). However, because they are believed to experience even greater stigma, violence, and marginalization (Lombardi & van Servellen, 2000; Meyer et al., 2000) than are lesbians and gay men, it seems reasonable to assume that those that are transgender are as likely to use and abuse AODs. There does not appear to be any research into this but it is clear from anecdotal evidence that this is a problem. To intervene effectively with transgendered individuals, information about, and sensitivity to, the unique risks and concerns of this group is essential.

Only a small body of AOD research has focused on lesbians and/or on gay men and I can find none concerning transgender women or men. Although lesbians, gay men, bisexual and transgender persons share some common concerns, primarily those related to stigma and discrimination, as many differences exist within these populations as exist between them and the heterosexual population. There is one distinction that seems to escape most researchers and that is the fact that to be Lesbian, Gay, and Bisexual are sexual orientations; being transgender is not. As such, while there are similarities, there are profound differences as well.

 Sexual orientation and gender identity are not the causes of substance abuse, but appear to be related to societal reactions to LGBT people.  This includes such behaviors as the stigma associated with belonging to an often despised minority (Kettelhack, 1999) or the stress of daily living associated with this identity such as needing to hide the identity to keep a job or experiencing harassment or discrimination (McKiman & Peterson,1998)

Risk factors for substance abuse associated with being transgendered 

bulletGreater likelihood of loss of family support
bulletLack of social support system
bulletBalancing multiple roles and responsibilities e.g. the transperson may work male and live at home as female.
bulletNon-acceptance of self or internalized transphobia. Internalized transphobia refers to the acceptance of negative societal stereotypes and attitudes about T* people, and can result in lower self-esteem and lack of feelings of self-worth.
bulletFinding a sober peer group, finding a peer group at all
bulletNot enough recovering peers
bulletFinding places to socialize ( e.g. gay bars are usually accepting)

 The following is excerpted from a study Substance Use and Abuse in Lesbian, Gay, Bisexual and Transgender Populations Tonda L. Hughes1;3 and Michele Eliason (2002).   I have separated out the transgender specific material along with adding additional material.

As training programs and continuing education forums are increasingly addressing the needs of diverse clients, those clients who are transgender, T* may be omitted or ignored for many reasons. Trainers may have limited knowledge of these issues, the most likely cause, or think of diversity strictly in terms of racial and cultural difference.

Methodology of the study

An adaptation of Gregory Herek’s Attitudes Toward Lesbians and Gays (ATLG) http://psychology.ucdavis.edu/rainbow/html/atlg.html  was administered. The short version of this survey contained five items regarding lesbians and five items regarding gay men, and was chosen to keep the administration time as brief as possible. The author of the current study added five items on bisexuality and five items on transgender in the same style and format as the ATLG items. The final scale had 20 items: five each concerning lesbians, gay men, bisexual people, and transgendered people. All of the items were rated on a nine-point scale whereby one indicated strongly disagree and nine indicated strongly agree. (Tonda et al., 2002)


          After approval by the institution’s human subjects review board in March of 2000, questionnaires were sent to the directors of community- and hospital-based substance

abuse treatment agencies in Iowa. A total of 1000 questionnaires were mailed, and 242 were returned completed. (Tonda et al., 2002)

Demographic/personal information

        “Exactly half of the sample reported that they had no instruction at all about LGB issues in their formal educational programs, and 80% had no instruction about transgender issues. Of those who had some formal education on LGB issues, 60% had 5 hours or less of instruction. Ninety percent (90%) of those who had some formal education regarding transgender issues reported five or fewer hours of training (mean = 0.9 h)”. (Tonda et al., 2002)

Table 1 depicts the responses regarding familiarity with LGBT clients and issues, and shows a considerable lack of knowledge. In general, the respondents were more familiar with issues concerning lesbians and gay men than they were with issues concerning bisexual or trans­gendered people”. (Tonda et al., 2002

Table 1

(percents and mean scores) (N= 242) 


Unfamiliar (%)











Gay Men












Specific issues




Substance abuse prevalence




Relationship issues




Coming-out process




Gay-bashing/hate crimes




Domestic partnership laws




Legal issues, e.g., power of attorney




Coping strategies




Appropriate terminology












Internalized homophobia




Family issues




Legal protection





          When asked to report what their religious faith had to say about LGBT people, 19% reported that “they are sinful and immoral,” 41% reported that “they are to be accepted as people but their behavior condemned,” and 40% indicated that “they are to be accepted completely.” (Tonda et al., 2002).

Table 2 shows the results of the separate attitude questions regarding LGBT people. Note that respondents were most negative about transgendered people, followed by bisexuals, then gay men, and were the least negative about lesbians; however, the mean scores for all four groups were relatively low, suggesting a fairly high level of tolerance and/or acceptance. (Tonda et al., 2002)

Table 2

Counselors’ attitudes towards sexual/gender identity groups (N= 242)


Positive (%)

Ambivalent (%)

Negative (%)









Gay men
























 Finally, negative attitudes about transgendered people were associated with religious beliefs, educational level, and type of religion. These four variables accounted for 42% of the variance in the scores regarding attitudes toward transgendered people. (Tonda et al., 2002)

“Since religious beliefs were a factor in the negative attitudes toward all four groups, they were examined more closely. Table 3 shows the mean attitude scores for each sex/gender identity group based on which of the three religious ideologies the respondent endorsed. In all four cases, there is no significant difference in attitude scores between believing that homosexuality is sinful and immoral and believing the “love the sinner, hate the sin” viewpoint. However, there was a significant difference between the former two views and the complete acceptance viewpoint.” (Tonda et al., 2002) 

Table 3

Counselors’ attitudes towards LGBT individuals by three variations of religious beliefs: mean scores for each sexual/gender identity group

Belief                                                           Higher scores indicate more negative attitudes.



Gay men



LGBT people are sinful and immoral





“Love the sinner, hate the sin”





Acceptance of LGBT people and their behavior






        This study suggested that generally, substance abuse counselors lack knowledge about LGBT people’s issues and are most ignorant concerning transgender issues, but that many have tolerant or accepting attitudes. However, the 44% of the sample with distinctly negative or ambivalent attitudes can potentially influence an entire agency. Counselors with negative attitudes may view gender variance rather than the addiction as the problem or they may attempt to treat T* clients the same way as heterosexual clients, rendering the gender orientation and societal stigma invisible and unacknowledged

Respondents in this study had some familiarity with “homophobia,” a term that refers to negative attitudes about people who are LGB, (this study leaves out transphobia).  However, they were not very familiar with the term “internalized homophobia” (48% were unfamiliar with it).  The logical conclusion would be that “internalized transphobia” is a subject of greater ignorance. Many experts suggest that LGB people assimilate societal negative stereotypes to some extent, which if not countered by positive role models or accurate information, can lead to feelings of low self-worth, shame, and guilt (Allen & Oleson, 1999; Shidlo, 1994). My personal experience would indicate that there is a much greater sense of isolation among those that are transgendered, and that there are fewer role models available.

 Some T*’s cope, or more correctly, do not cope with negative emotions with the use of alcohol or drugs.  Therefore, it is crucial that substance abuse counselors assess T* clients for internalized transphobia and incorporate these issues into the treatment process. It might be helpful for substance abuse counselors to learn about some of the “coming-out” models in the psychological literature that describe some of the stages or psychological states that a T* person might experience. For example, identity confusion is a common early stage, where the individual may feel totally isolated (I am the only one).  The individual may only, thanks to popular media, have a negative stereotypical understanding. The lack of positive modeling has a large effect. Fears about rejection from family or friends, or fears of loss of job, family, or children are prevalent at this stage and may lead to increased alcohol and drug use. Less is known about the identity development of transgender people, but in my own experience dealing with the community it very well may be even more difficult than achieving sexual identity. (See Appendix.)

The rendering of one’s life as invisible as or less than that of a non-trans person can have devastating effects on mental health and well-being and contribute to substance abuse. If this invisibility extends to substance abuse treatment, treatment outcomes are compromised. Being treated like everyone else is often a detriment to recovery for clients from all minority groups (Center for Substance Abuse Treatment, 1999), because equal treatment generally means being placed in a program designed for and by white, heterosexual, middle class men. (Tonda et al., 2002)

Nearly half of the sample was unfamiliar with the coping strategies used to manage gender identity issues. These are important in developing a relapse prevention plan. There are many forms of “identity management” that a T* persons may use. For example, some lead double lives, being transgendered at home, but gendered at work or within families. Double lives require considerable effort to hide a significant part of one’s life from others. However, even those who are “out” or open about their gender have to face daily experiences of being different. Both the closet and the open life are stressful and may contribute to substance abuse. It is important for substance abuse counselors to assess the coping methods T* clients and help them identify healthy methods to replace the use of alcohol or drugs as coping mechanisms. (Tonda et al., 2002)

Over half of the sample was unfamiliar with the family issues that face many LGBT clients. There are issues with both families of origin and families of choice (Weston, 1991). “Coming-out” or revealing one’s gender orientation to others can be traumatic in many families of origin. T* people face possible rejection from the very people, (families) and institutions e.g. churches, who are supposed to offer unconditional love and support. They often form strong emotional bonds with peers to replace the lost family support. Family members, however defined by the individual, must be included in the treatment process.


Sandra Stewart’s

Transgender Stages


  1. Children during the first stage realize that they are incongruent with the expectations of their culture concerning their gender or sexual identity. We must all have Love/positive regard to be a complete person; we also need Love/positive regard to be able to love our selves. As we grow up we encounter conditions of worth that are reinforced by parents, peers, and the media. We are given rewards when we meet those expectations and punishments when we transgress, thus establishing conditions of worth. Rogers (1961) calls this “conditional positive regard”.


  1. In stage two the conditional positive self regard/Love  We like ourselves only if we have met the conditions and standards expected of us by others, rather than if we are realizing our own potential. Since the “standards” are created without regard to the needs of the individual, it is impossible to meet them and therefore have a positive sense of self. inability to change the environment and  alter the conditions of worth, leads to the construction of a pseudoself to fit in.


  1. In stage three individuals tend to appear to conform to the Societal Norms. And some do not progress beyond this point, there is however a cost. The relationship between the I am and the should be and the presence of the Constructed is incongruity. This between the real self and the ideal self and the discontinuity that is the pseudoself. The greater the gap between the I am and the should be and the stronger the construct the greater the incongruity and the greater the misery. “That self which he losing hope wills to be is a self which he is not (for to will to be that self which one truly is, is indeed the opposite of losing hope)” (Kierkegaard, 1863).


  1. Those individuals who move to stage four begin a radical shift from dependence on others view of them to a relocation of the authority to within them selves, they chose to start being who they are. For this to truly occur the individual must move away from acceptance of cultural norms. 


  1. In the fifth stage the individual is still forming their own sense of self but start to move from self preoccupation and dependence on the view of others and they tend to start considering serving others.


  1. Those who progress to the sixth stage are rare, they are more focused on loving others and self-preoccupation becomes a thing of the past. They can fully express who they are with out fear. They make every effort to help others not only directly but in fostering in them a similar commitment and comfort with how they are.


Based on James Fowler (1981) Stages of faith Consciousness

Kierkegaard, S. (1863). The Sickness Unto Death.

Rogers, C. R. (1961).  On becoming a person.  Boston:  Houghton Mifflin.


Allen, D. J., & Oleson, T. (1999). Shame and internalized homophobia in gay men. Journal of Homosexuality, 37 (3), 33—43.

Center for Substance Abuse Treatment. (1999). Cultural issues in substance abuse treatment. Rockville, MD: Public Health Service, USDHHS (Publ. No. 99-3278).

Ketteihack, G. (1999). Vastly more than that: stories of lesbians and gay men in recovery Center City, MN: Hazelden.

Lombardi, E.L. & Van Servellen, G. (2000). Building culturally sensitive substance use prevention and treatment programs for transgendered populations. Journal of Substance Abuse Treatment, 19, 291–296.

McKiman, D.J. & Peterson, P.L. (1988). Stress, expectancies, and vulnerability to substance abuse: A test of a model among homosexual men. Journal of Abnormal Psychology, 97(4), 461–466.

McKirnan, D. J., & Peterson, P. L. (1989). Alcohol and drug use among homosexual men and women: epidemi­ology and population characteristics. Addictive Behaviors, 14, 545—553.

Meyer, I., Silenzio, V., Wolfe, D., & Dunn, P. (2000). Introduction and background. In L. Dean, I. H. Myer, K. Robinson, R.L. Sell et al. (Eds.). Lesbian, gay, bisexual, and transgender health: Findings and concerns (pp. 4–5). Center for Lesbian, Gay, Bisexual and Transgender Health, Columbia University’s Joseph L. Mailman School of Public Health and the Gay and Lesbian Medical Association.

Miller, S.D., Duncan, B.L., Hubble, M.A. (1997). Escape from Babel: Toward a unifying language for psychotherapy practice. New York: W.W. Norton & Co. down loaded 4/14/04


Miller, W. R., & Roilnick, S. (1991). Motivational interviewing: preparing people to change addictive behavior. New York: Guilford

Shidlo, A. (1994). Internalized homophobia: conceptual and empirical issues in measurement. In: B. Greene, & G. M. Herek (Eds.), Lesbian and gay psychology (pp. 176—205). Thousand Oaks, CA: Sage.

Tonda L. Hughes1;3 and Michele Eliason2 Substance Use and Abuse in Lesbian, Gay, Bisexual and Transgender Populations The Journal of Primary Prevention, Vol. 22, No. 3, Spring 2002

   Weston, K. (1991). Families we choose. New York: Columbia Univ. Press.


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