From: Asking the Right Questions 2: Talking about sexual orientation and gender identity in mental health, counselling, and addiction settings (© 2004 CAMH)
This manual is for all therapists, counsellors, other clinicians, nurses and doctors assessing or treating clients who have substance use and/or mental health concerns.
This manual is a revision of Asking the Right Questions: Talking about Sexual Orientation and Gender Identity during Assessment for Drug and Alcohol Concerns. We have expanded on the earlier version to include mental health issues in the assessment questions.
Substance use and mental health concerns may be related to sexual orientation and/or gender identity issues, particularly those issues relating to societal oppression — to provide effective treatment, therapists and counsellors must know about these issues.
This manual will help therapists/counsellors create an environment where lesbian, gay, bisexual, transgendered, transsexual, two-spirit, intersex, and queer (LGBTTTIQ) clients feel comfortable identifying themselves as such. This will allow therapists/counsellors to:
- best assess the specific needs of LGBTTTIQ clients
- engage these clients in a positive treatment process
- develop specifically tailored treatment plans
- make appropriate referrals.
Why is this manual important?
Many clients are not open about their sexual orientation or gender identity in mainstream treatment/counselling facilities. They may feel uncomfortable or anxious, fearing negative responses or prejudiced attitudes from staff and other clients.
Many clinicians are understanding of sexual orientation and gender identity issues. However, these clinicians may lack a repertoire of appropriate questions to ask about sexual orientation or gender identity, or they may be unaware of why such questions are necessary for clients of substance use and/or mental health services.
Some questions in standard assessments may be upsetting. For example, if a question about “significant others” is phrased in terms of opposite gender, an LGBTTTIQ person may feel uncomfortable.
Traditional assessment items/scales may not be accurate for all clients if the interpretations do not address the specific needs of different sexual orientations or gender identities.
Standard assessment instruments, such as provincially or state-mandated assessment tools, should be supplemented with population-specific questions to better assess the needs of LGBTTTIQ clients and formulate treatment/counselling plans.
Findings from two phases of the ARQ project — General conclusions
The Centre for Addiction and Mental Health conducted a research project through its Rainbow Services (formerly known as LesBiGay Service), asking service providers and clients what should go into the original manual, which focused on substance use — this phase became known as ARQ (Asking the Right Questions). Further research was conducted to revise and expand the manual to also include mental health issues — this phase became known as ARQ2 (see the Appendix for a detailed description of each phase). Here are the general conclusions of the two phases of the project:
Therapists/counsellors should use sensitive and direct questions at assessment to determine the sexual orientation and gender identity of all clients.
LGBTTTIQ people have specific life factors that relate to substance use and/or mental health problems. These factors include:
- the “coming out” process
- gender transition
- societal oppression (e.g., homophobia, biphobia, transphobia)
- threats to socioeconomic security (e.g., housing, employment) because of discrimination
- internalized oppression
- loss of family support
- isolation and alienation
- the predominance of bars in LGBTTTIQ communities
- body image
- “passing”
- concerns with aging
- the impact of HIV and AIDS.
Awareness of clients’ sexual orientation and gender identity is very relevant in effective treatment and counselling. However, many clients are not open about their sexual orientation or gender identity in mainstream treatment facilities — they may be uncomfortable, feeling anxious or afraid of negative responses or homophobic/biphobic/transphobic attitudes of staff and other clients.
Several factors contribute to client self-disclosure:
- feelings of safety
- non-judgmental and non-heterosexist/genderist attitudes of staff and other clients
- advertising of a service in LGBTTTIQ publications and communities
- LGBTTTIQ-positive stickers and posters
- use of non-biased, inclusive language
- confidentiality
- staff who are knowledgeable of LGBTTTIQ-specific issues.
The following factors enhance the experience of services for LGBTTTIQ people:
- availability of specialized programs/services
- composition of treatment/counselling groups based on sexual orientation and gender identity
- anti-discrimination policies
- LGBTTTIQ-positive materials in waiting areas
- access to LGBTTTIQ-positive therapists/counsellors.
Specialized addiction treatment programs and mental health counselling services are helpful and clinically relevant for LGBTTTIQ people. However, therapists/counsellors should not assume that LGBTTTIQ clients must be seen in specialized settings. Clients may prefer an LGBTTTIQ-specific program, if available, but they may also prefer mainstream services (e.g., general treatment programs) or other specialized services based on other aspects of their identity (e.g., aboriginal services, older person’s services, women’s services). At the Centre for Addiction and Mental Health (CAMH), we support the need for LGBTTTIQ-specialized services while making efforts to build capacity in mainstream services.
LGBTTTIQ is a common acronym for lesbian, gay, bisexual, transsexual, transgendered, two-spirit, intersex and queer individuals/communities. This acronym may or may not be used in a particular community. For example, in some places, the acronym LGBT (for lesbian, gay, bisexual and transgendered/transsexual) may be more common. We have included this longer acronym to be more inclusive of the diversity within these communities.
A significant other is a life partner, domestic partner, lover, boyfriend, or girlfriend. It is often equivalent to the term “spouse” for LGBTTTIQ people.
Sexual minorities include people who identify as LGBTTTIQ.
A gay boy/man is someone whose primary sexual orientation is toward other boys/men.
A lesbian is a girl/woman whose primary sexual orientation is toward other girls/women.
A bisexual person is someone whose sexual orientation is toward men and women.
A transgendered person is someone who does not conform to society’s gender norms of masculine/feminine.
A transsexual is a person who has an intense and sometimes long-term experience of being the sex opposite to his or her birth-assigned sex. Specifically, a female-to-male transsexual (transman) is assigned a female sex at birth, but feels like a male and identifies as a (transsexual) boy/man. A male-to-female transsexual (transwoman) is assigned a male sex at birth, but feels like a female and identifies as a (transsexual) girl/woman.
Trans and transpeople are non-clinical terms that usually include transsexual, transgendered and other gender-variant people.
Two-spirit is an English word used by First Nation and other indigenous peoples for those in their cultures who are gay or lesbian, are intersex, transsexual, transgendered or have multiple gender identities.
Intersex is the term that has recently replaced “hermaphrodite.” Intersex people possess some blend of male and female physical sex characteristics (see also www.isna.org).
Queer is a term that has traditionally been used as a derogatory and offensive word for LGBTTTIQ people. Many have reclaimed this word and use it proudly to describe their identity.
Sexual orientation is how someone thinks of oneself in terms of one’s emotional, romantic or sexual attraction, desire or affection for another person.
Genderism is the assumption that all people must conform to society’s gender norms and, specifically, the binary construct of only two genders (male and female). Genderism does not include or allow for people to be intersex, transgendered, transsexual, or genderqueer (see Gender identity for a discussion of gender).
In Asking the Right Questions 2: