Engaging Transgender Substance Users in Substance Use Treatment

Jean Oggins, Ph.D.
Box 426856
San Francisco
CA. 94142
(415) 225 1506

Jeanna Eichenbaum, M.S.W.
Walden House
520 Townsend Street
San Francisco, CA 94103

Citation:  http://www.symposion.com/ijt/ijtvo06no02_03.htm

• Abstract
• Keywords
• Introduction
• Walden House and the Transgender Recovery Program
• Challenges Transgendered Substance Users Face
• The TRP Program: Keys to Effective Work with Transgender Substance Users
• Transgender Staff
• Acceptance of Transgender Clients as Women and Individuals
• Sensitivity training for Clients and Staff
• Development of Peer Support
• Development of Community Ties
• Summary and Comparison with other Programs
• Suggestions for Follow-up
• Appendix
• References

Abstract

This article describes the Transgender Recovery Program, a residential substance use treatment program for male-to-female transgender women receiving substance use treatment and mental health services at San Francisco’s Walden House. With an 81% success rate in retaining clients in its first nine months, the program provides male-to-female transgender women with transgender staff and support groups, helps transgender clients build ties among themselves and with other agency clients, and helps transgender women re-enter the community by building a network of employers and landlords who are friendly toward transgender individuals. The program also provides sensitivity training and education about transgender issues for clients, staff, and community agencies, as well as conducting outreach in the community. Elements of program success include affirming transgender people as women and individuals, developing peer support, and expanding clients’ social and vocational horizons.

Keywords: transgender, substance use treatment, recovery, peer counseling.

Introduction

Male-to-female (MtF) transgender women who use drugs or alcohol present substance use treatment providers with unique challenges. As biologically-born males who view themselves as females, MtF women may or may not also dress as women, use cosmetics, take estrogen to increase breast size, or undergo surgery (including sexual reassignment surgery) to physically alter their hair, voices or bodies or change their sex from male to female. Often MtF women have experienced rejection and discrimination from others (including family) who cannot accept a male’s identification as female. MtF women may leave communities of origin for urban areas perceived to be more tolerant but may feel isolated generally. In order to provide treatment that lets MtF women feel safe, an understanding of the population and a commitment to meeting their needs is required (Israel and Tarver, 1997). This article describes a substance use treatment program for MtF women and suggests that key elements in retaining transgender clients in treatment include affirming their identities as women, providing transgender staff, and helping transgender clients build ties with one another, other agency clients, and community employers and providers.

Walden House and the Transgender Recovery Program

Walden House offers low-cost substance use treatment—including detoxification, short-term and long-term residential treatment, and day treatment—to indigent people throughout California. It offers medical and mental health services; legal, educational and vocational services; and transitional satellite housing to clients who have finished treatment and are re-entering the community. The program is structured as a modified therapeutic community that emphasizes family, and also clients taking on increasing responsibility within the program and the community over time. The Transgender Recovery Program (TRP) described here is located within one of the agency’s several facilities: 20 of the 112 beds in Walden House are set aside for transgender clients.

The Transgender Recovery Program (TRP) is part of an intervention to prevent drug abuse, hormone abuse, and HIV among high-risk transgender women, including sex workers. The TRP program serves MtF transgenders, providing treatment for substance use (e.g., for cocaine, heroin or polydrug use) and mental health (e.g., anxiety or depression) in a residential treatment therapeutic community. The program does not serve female-to-male transgenders, who are at less risk from drug use and prostitution (Clements-Nolle et al., 2001).

The first 16 clients of the TRP were as follows: nine African-Americans, three Hispanic-Americans, two Asian-Americans / Pacific Islanders and two European-Americans. Seven came from jail, four from homeless shelters, or the streets, and five had apartments. At treatment entry, all but one person reported being unemployed or disabled. On average, clients have a high school education (SD = 2.04) and are 38 (SD = 7.94, Range: 23 to 52 years old). At treatment entry, half (n = 8) reported no substance use in the past 30 days (four had come directly from jail), seven reported being polydrug users and one reported using only one drug. With respect to drugs reportedly used in the past 30 days, about one-third of clients noted using amphetamines or marijuana; and one-quarter had used alcohol, one quarter had used cocaine, and one-quarter had used heroin. About one-third each of clients rated their health as excellent/very good, good or fair respectively.

Thirteen of these sixteen clients (81%) have stayed in treatment, of these, three have stayed six months or longer and are preparing to re-enter the community. Two clients left the program at re-entry, when health or mental health problems led to referrals to other agencies. The 81% completion rate of the TRP compares favorably to a 60% completion rate for a typical Walden House six-month residential treatment program. Retention in treatment is important because longer periods of treatment improve chances of stopping or reducing drug or alcohol use (Simpson et al. 1999; Shwartz et al., 1997).

Challenges Transgendered Substance Users Face

Depression, substance use, and sex work

White and Townsend (1998) define transgender people as having “persistent and distressing discomfort with their assigned gender.” Identifying with a gender that differs from one’s biological gender and the negative reactions of other people to this identification can make depression a common problem. In a sample of 392 San Francisco MtF women (of whom 32% were sex workers), 62% were depressed, one-third had tried to commit suicide and one-fifth had been hospitalized for mental health problems, 35% were also HIV-positive (Clements-Nolle et al., 2001). A study of prostitutes (including transgendered prostitutes) in Washington D.C. found that 42% met criteria for post-traumatic stress disorder (Valera et al., 2001).

For the transgender person, drugs and alcohol may meet various needs. As children or youth, MtF individuals may feel different from other males—for example, in liking to cross-dress or play with girls (Mason-Schrock, 1996). Discouraged from those behaviors, some may later use alcohol or drugs as distraction from a sense of inauthenticity as males (Mason-Schrock, 1996). Substance use can also lower inhibitions and make it easier to cross-dress and look for sex (Bockting, Robinson and Rosser, 1998). Furthermore, experiences of harassment and discrimination may affect mental health (see Garnets, Hereks and Levy (1992) on effects of harassment on gay men and lesbians) and contribute to use of drugs and alcohol. Lombardi et al. (in press) found that 60% of a transgender sample had experienced harassment or violence and 37% had experienced economic discrimination. Among youth, cross-gendered youth are especially likely to be abused because they do not meet cultural ideals for gender roles (Savin-Williams, 1994); these youth also tend to have high levels of substance use (Kreiss and Patterson, 1997).

Encountering rejection from family or at school, transgender teens may drop out of school, leave home, and end up on the streets, where they may use alcohol or drugs. One study (Clements et al. 1999) found that transgenders reported low self-esteem and lack of education and job opportunities. When transgendered people present as women, they face negative reactions from employers and this is one reason for their chronic underemployment and unemployment (Gagne and Tewksbury, 1998). With few job opportunities, some MtF women turn to prostitution. Clients’ favorable sexual responses may boost MtF women’s self-esteem and sense of value as women (Boles and Elifson, 1994), and work in the sex industry can pay for expensive cosmetic and sex reassignment surgery that enhance a MtF woman’s image and increase her income (Pang et al., 1994). The body may be envisioned as a work in progress, with surgery hoped for or planned—something that may keep transgender people involved in prostitution. Weinberg et al. (1999) found that MtF sex workers, who tended to have regular working schedules, sometimes reported that estrogen interfered with sexual response (see Baldwin and Baldwin, 1997) and tended to feel dissatisfied with the work. Yet MtF sex workers were less likely than female sex workers to think about quitting prostitution within a year.

In order to cope with long hours and the stress of street life, transgender sex workers may turn to methamphetamines (Nemoto et al., 1999), marijuana, cocaine (San Francisco Department of Public Health, 1999), and alcohol (Weinberg et al, 1999), since sex workers may solicit clients at bars. Transgender sex workers tend to draw men who like a mix of sexual characteristics or deny they are having sex with a genetic male. Weinberg et al. (1999) found that 60% of the sex workers in their study sometimes or always refused to disclose their gender, 15% feared client violence if they learned the sex worker was male. At transgender bars, MtF women had less reason to worry, since clients tended to know sex workers were MtF woman, and bars tended to be free of police.

Transgender women may be at risk for HIV in several ways. Clements-Nolle et al. (2001) reported that 20% of MtF women in their study had used non-hormonal intravenous drugs in the past six months, almost half of these having shared syringes or backloaded. Among transgender women, sex workers may be especially likely to be intravenous drug users (Reback and Lombardi, 1999), with some paid extra to inject with clients (Nemoto et al., 1999). Other HIV risk factors for MtF women include sharing needles to inject hormones or silicone (Bockting et al., 1998) or practicing receptive anal sex (Weinberg et al., 1999). MtF sex workers may also tend to have multiple partners, use condoms inconsistently, exchange sex for drugs, or have steady partners who use drugs (Nemoto et al., 1999). MtF women may feel vulnerable to multiple HIV risk factors, anxious about sexual experimentation or the death of friends, afraid that HIV compounds the stigma of being transgendered, concerned that HIV could interfere with sexual reassignment surgery, or worried that time to achieve a satisfying life is running out (Bockting et al., 1998).

Although transgender clients may recognize a need for drug treatment (including residential treatment), they may have experienced insensitivity or discrimination in previous treatment episodes (San Francisco Department of Public Health AIDS Office, 1997). Some seeking help may have been verbally and physically abused by clients and staff, asked to wear men’s clothes, or required to shower and sleep in men’s areas where they may fear sexual advances similar to those that may have been experienced in men’s quarters in prison (Stephens et al., 1999). MtF women who have not lived in heterogeneous communities for several years may generally worry about abuse similar to that met in families or communities.

Issues for transgendered women in substance use treatment

Provider respect and sensitivity are crucial if transgender substance users are to feel comfortable about entering treatment and staying in it long enough to make progress in recovery from substance abuse (Clements et al. 1999; Moriarty et al., 1998). Respect for diverse individual experiences is key (Lombardi and van Servellen, 2000; Lombardi, 2001): providers should not force clients to disclose their transgender status, should let them define their own gender and address them by that gender, and should allow for complexity of experience. For example, although three-quarters of the MtF women in the Clements-Nolle et al. (2001) study had sex with males, 69% of the MtF group identified as heterosexual, insofar as they perceived themselves to be women attracted to men. Providers should not assume that MtF women identify with gay men, or that they have sex only with men. Generally, an effective therapist will let a transgender person explore her identity free of labels, considering the implications of that identity on various aspects of her life (Hendricks, 2001). Indeed, transgender clients may prefer that transgender staff develop and implement programs and train other providers in sensitivity and care (Clements-Nolle et al., 1999).

Furthermore, transgender women often rely on make-up and feminine clothing to establish and maintain a female gender role and identity. However, substance use treatment programs frequently encourage plain dress and little make-up to help clients focus on internal changes and avoid romantic distractions. Amending program rules and allowing MtF women access to cosmetics and women’s clothing can reduce barriers to treatment—alleviating unnecessary emotional stress so that MtF women can focus on their recovery, and reducing other clients’ confusion about the MtF women’s gender assignment. However, clients still need to learn that provocative dress is not appropriate for people in a recovery program. Both MtF and female staff can help MtF women find ways to use dress and make-up as part of a new way to be in the world as women.

Providers should be aware that transgender clients may have unique issues in dealing with self-esteem and family, feeling victimized, establishing legal identities as women, getting medical care (e.g., obtaining hormones and sex reassignment surgery, which may not be covered by health insurance), or finding and keeping jobs, including changing gender on the job (Lombardi and van Servellen, 2000). Many clients entering substance use treatment feel they have limited vocational options due to poor work histories, little education, or few job skills. MtF women may also encounter a general lack of understanding and fear in the community, such that they come to believe that sex work is the only option for employment. Providers may need to build new networks of providers who are friendly to transgender people and can help them obtain housing, health care, and employment without discrimination (Lombardi and van Servellen, 2000).

Former sex workers may also have unique needs. MtF women may have been sexually abused, may be vulnerable to abuse generally, and may be suicidal. Staff may need to make crisis interventions, as well as helping people develop an active support network and deal with stress (Hendricks, 2001). Even when they have not been sexually victimized, MtF women may feel conflicted about sexual experimentation during adolescence. As adults, former sex workers used to receiving endorsement of their female identity from men may value physical attractiveness and external validation from men. Helping MtF women develop an internal sense of worth is key. Professional MtF staff can be important role models, showing clients other viable ways to live and work.

Furthermore, while working as prostitutes, MtF women have competed for clients, and may have difficulty feeling close to each other. Encouraged by transgender and other staff, MtF women can build supportive friendships. In support groups with transgender staff and clients, a client can also receive validation for her MtF experience, seeing that she is not alone. She can see how role models tell stories that legitimate life as a transgender person, can tell her own story as she receives affirmation and guidance through the positive nonverbal behavior and questions of other people, and is likely to appreciate their tact in not questioning her story’s logic or truth (Mason-Schrock, 1996).

Recruiting new clients to a transgender substance use treatment program can be a challenge. MtF women at risk from prostitution, addiction, or homelessness may be most effectively recruited into treatment at five kinds of sites:

1. bars and clubs frequented by transgender women, including sex workers,

2. the streets, where outreach workers may also be able to locate MtF sex workers,

3. the criminal justice system and jail, including lawyers, drug court, parole, probation, and other parties, where women may also have the chance to leave jail for treatment

4. detoxification centers, where clients often need long term, intensive treatment,

5. homeless shelters, which MtF women may be especially likely to use in urban areas.

These sites may also allow efforts in harm reduction that promote safer sex and drug practices.

The TRP Program: Keys to Effective Work with Transgender Substance Users

To understand how the TRP program conducts treatment and outreach to address varied issues in the lives of MtF women, hour-long semistructured interviews were conducted with two of the MtF staff of the Transgender Recovery Program, five of the thirteen MtF clients recruited by staff for interviews, and the building’s male house manager. Two clients had been in the program for six months, two for two months, and one client was new. Interviews, conducted in private and with informed consent, asked how people came to the program, what they liked about the program and what they would change; and their views of the program; including peer staff, peer support groups, living quarters, relation to other clients, sensitivity training, and vocational services. Interviews were not audiotaped; the interviewer took notes. She also observed a two-hour case group of five MtF clients and listened to a taped client focus group on vocational issues. The description of the TRP program that follows is based on these interviews and observations.

The TRP program has five key components that seem to make it effective: (1) transgender staff, (2) acceptance of transgender clients as women and individuals, (3) sensitivity training for clients and staff, (4) development of peer support, and (5) development of community ties. These are discussed below. (For client case studies, please see the Appendix.)

Transgender Staff

A key part of the TRP program is providing strong, capable MtF staff, including both a licensed clinical social worker and a drug and alcohol counselor who has been through drug treatment herself. Able to empathize with clients’ feelings about establishing a transgender identity and about difficulties maintaining it in daily life, MtF staff can help give clients insight about transgender issues and model ways that MtF women can achieve satisfying lives without recourse to substance use. Transgender staff can also speak up for MtF clients, helping them feel safe at the agency. With respect to non-transgender staff, clients, and community, MtF staff provide sensitivity training about transgender issues, build ties with community agencies that provide services for MtF women and can provide referrals for new clients.

Transgender staff at Walden House fulfill several functions that help them provide effective treatment. These include therapy, counseling, role models and acting as advocates. The MtF licensed social worker, who has an advanced degree and professional training as a therapist, meets with clients for therapy weekly. Clients value her sensitivity, knowledge and insight, which help them accept her working with them to evaluate life choices with honesty and realism. Clients also value insights about substance use recovery that are offered by the drug and alcohol counselor, who has gone through treatment at Walden House herself. She meets with clients individually and in groups, where she discusses day-to-day concerns and discipline; MtF women appreciate her understanding when clients feel misunderstood by other clients or staff. While recognizing the importance of affirming people’s transgender identity, staff do not focus on those issues at the expense of understanding issues about substance use, mental health and recovery. They balance their work in these areas, moving back and forth between them, to help clients effectively. Additionally, MtF clients may see other therapists in or outside the agency, such as those providing required counseling on gender identity before sex reassignment surgery.

MtF staff may be especially aware of some issues that can impact treatment, hormone use, for example. A client said that hormones brought her down but that methamphetamines raised her spirits, and that the hormones contributed to water retention, while speed dehydrated her, thus putting stress on her liver. Some women hoped to get surgery so as not to have to depend on hormones. The MtF counselor, who previously had to stop taking hormones in a Christian drug treatment program and had been very depressed then, said that treatment staff are aware of “highs and lows” involved in getting back on hormones and monitor clients carefully.

Some clients say these staff are the first professional transgenders they have known—offering a view of life options other than prostitution or dealing drugs, such as: education and professional careers (including those helping transgender women), steady romantic relationships, friends and connections in the community, or life as a woman post-surgery. With two clinical staff, MtF clients have two different role models and so can choose whom they talk to and what they talk to them about.

Clients and staff also agree that the presence of MtF staff shows that Walden House is committed to providing a safe environment in which MtF clients feel comfortable and thus are willing to stay in treatment to become drug-free and sober. The therapist and counselor stand up for transgender clients when other clients express prejudice; they point out that problems are due to individual issues and not “transgender issues.” They show clients that the presence of transgender staff and clients is normal, and than transgender clients are making recovery a priority like everyone else. One client remembered that a male staff person made an abrupt remark to her and then apologized profusely. The client thought he might have worried about negative reports to MtF staff and behaved more respectfully as a result. Another client noted that respect for MtF staff led to similar respect for MtF clients. Notions that MtF women are flirtatious, manipulative, or only interested in money are further challenged when clients see MtF women work hard in recovery or as helpful Big Sisters. (Each new client is assigned an MtF Big Sister who greets her when she arrives, shows her around, helps her find meetings and meet people, and gives her a welcome pack that includes a good hairbrush and fancy soaps, giving MtF women an immediate sense of affirmation and belonging.). When MtF are accepted as they are, they can more easily address their drug issues, “I don’t have an identity problem,” one client said, “I have an addiction crisis and just want the same treatment as everyone else.”

Acceptance of Transgender Clients as Women and Individuals

A second key component of the TRP program is its acceptance of transgender clients as women. In the past, rejection or abuse experienced in expressing a female identity may have exacerbated some MtF women’s drug use and made them wary of seeking help. However, Walden House shows MtF clients that they are welcomed, perceived, and valued as women. Housed among women (including sharing women’s bathrooms), MtF women can also draw on program funds for makeup or clothing, can wear women’s clothes, are referred to as women, and have access to hormones and counseling for surgery to maintain a female appearance. To educate transgender women and help them assess values, the program social worker also brings in speakers on transgender issues and is designing a transgender curriculum to cover such topics as hormone use, surgery and gender confirmation treatment, relationships and dating, professional development and job search, safer sex, and building self-esteem.

MtF clients who have felt rejected or ugly discover they are affirmed and attractive; they have fun and want to stay. They also have a relatively peaceful environment in which to focus on their recovery. At the same time, some MtF clients may still have more “masculine” appearances, behavior, interests, and job skills, or may see “transgender” as an identity that is unique. Expectations that transgendered individuals will behave stereotypically as women (e.g., letting men run the show) or fit into a homogeneous transgender community are likely to be misplaced. As with any client, it is important to see transgender clients as individuals.

Sensitivity training for Clients and Staff

Not only are transgender clients treated as women at TRP, but in sensitivity training, MtF staff try to increase staff and client awareness about the ways that transgender clients think about gender and themselves. Staff also discuss the right of a person to treatment free from harassment, whatever their gender. Staff involved in intake, treatment, or vocational development receive an hour of training in transgender issues during basic clinical training, and can receive two further hours of more in-depth training. Clients and staff also receive training about transgender issues during several workshops and all-day events held as part of an ongoing educational process. As in any treatment program, client turnover can be frequent. The program’s social worker meets with new clients to provide sensitivity training every two weeks. New clients may already know MtF clients from prison or the streets, and may have negative stereotypes. While noting that preconceptions may hold for some MtF women, she adds that MtF women vary widely as individuals and that drug treatment clients are more alike than different.

Examples of exercises and workshops

In sensitivity training for clients and staff, vignettes help when discussing issues that transgender clients and peers might experience in treatment, and what recovery might mean to a MtF woman. One vignette describes a person who thought drug treatment would be a safe place to begin changing gender, but found that other clients had trouble accepting that change. The client also had issues about sexual molestation, cocaine use, lack of education, and anger. Questions used with the vignette concerned were, “What gender identity does this client have? What are some of the issues that you, as the client’s counselor, would want to focus on? Why do you think it is difficult for some people to accept transgender people? Do you feel this person is entitled to get help to become drug-free and sober? Why?” The last question is key, the program social worker says, showing that “the bottom line is that everyone here has a potentially fatal disease” and has a right to recovery, without ostracism.

A second vignette focuses on likable aspects and the individuality of one MtF woman who has had a difficult life. A heroin addict, who was beaten and raped as a prostitute, and cuts herself to “relieve tension,” she was admitted to treatment from jail. She moved to San Francisco from a Midwest town in the 10th grade of high school. She has a good sense of humor, likes to paint, and hopes to connect with a former lover, another MtF woman, after they become sober. Questions after the story ask, “What is a male-to-female transgender woman? What are this client’s risk factors for HIV? Is there anything about this client that surprises you? Why do you think the client left the place she grew up? What do you like best about this client?"

In another exercise, the social worker writes “transgender” on the blackboard and asks clients to say what words come to mind. Answers might include “confused,” “courageous,” or “complex.” Clients then break into groups to discuss their own experiences of being “confused,” “courageous,” or any of the other qualities written on the board—an experience that shows clients that they are similar, which helps MtF women feel accepted in a wider community—a new and healing experience for some. In another exercise, the social worker asks clients what it means to live in a therapeutic community “family,” and shares her own thoughts, “Family means there’s enough love to contain the difficult stuff that’s going to come up in relationship.” On occasion, the TRP program devotes a whole day to transgender training, with all staff required to attend. Clients find staff supportive and willing to learn, strengthening trust in Walden House. Of course, developing a program sensitive to transgender clients takes time. Although Walden House has welcomed and advocated for transgender clients for years, staff found that when TRP was first implemented, clients expressed a general cultural phobia about people changing gender. Furthermore, in spite of private bathroom stalls for toilets and showers, some women still avoided using bathrooms at the same time as MtF transgenders; some MtF clients had had sex change operations, however, others still had facial hair and male genitalia. The program’s social worker quickly decided to educate clients about transgender issues, and scheduled a meeting for the whole building, including all staff. In a role she does not often take as a therapist (but which raised her credibility among drug treatment clients), she talked about her own life as an MtF woman. In educating clients, she tried to show the broad range of issues affecting transgendered women and asked clients to consider when they too had felt like outsiders, whether because of ethnicity, drugs, sexuality or other reasons. As transgender and other clients spoke of depression, anxiety, suicidality, homelessness, unemployment or other conditions that led them to turn to drugs, clients had a chance to see that they were more alike than different. MtF women felt greater acceptance, and over time, women living in women’s housing have also come to accept MtF clients’ presence there.

Furthermore, early on, some staff, who had not worked with transgendered clients and were receiving sensitivity training, were so concerned that the MtF women feel supported that other clients felt uncomfortable. Early transgender support groups had also tended to focus on comfort in the house. As more MtF women entered the program, however, their presence was viewed as being more the norm, and staff and clients came to appreciate each person’s personality and needs.

Development of Peer Support

Ties between clients develop not only through sensitivity training but also in formal and informal groups. Transgender clients are assigned a MtF Big Sister to whom they can turn for help and advice, and also meet with MtF staff in groups of five to six clients for two hours each week and in transgender support groups once a week. MtF clients in the small program get to know and value each other. When a client talks about leaving the program, the others press her to stay. In sharing views, clients give each other new ways to see and handle life.

Examples from a peer support group

In support groups, MtF women can discuss topics about which transgender individuals may have unique perspectives. Due to discomfort about gender, transgender people may have a difficult time talking about sex (Bockting et al., 1998)—an obstacle to discussing safer sex. However, in a case meeting where the drug and alcohol counselor introduced the topic of relationships, clients did discuss sex, including whether hormones reduced or increased sexual interest, whether oral sex put one at risk for HIV, and how testing for HIV might change one’s life. A common concern was finding a lover. Clients talked about disclosing MtF identities to apparently heterosexual male lovers who then reacted negatively because they then questioned their own sexual identities. The women didn’t know if the men were in denial about their interest in men or couldn’t read cues about MtF identity. Sometimes demoralized by partners’ responses, MtF women wondered if they would find a partner who understood and cared about them. Some thought that having a sex change might improve their situation. The drug and alcohol counselor, who has had sexual reassignment surgery, lets clients know that surgery itself will not help people deal with being transgendered, but that these are issues to be worked on in treatment. In the peer support group, clients also voiced their concerns about leaving the safety of treatment to re-enter the community, even though clients re-entering the community remain in Walden House satellite housing for several months, and are encouraged to build ties with outside transgender support groups.

Building ties with non-transgender peers

Not only do transgender clients develop friendships with each other, but they also learn to find fun ways to socialize with non-transgender clients: for example, a dance hosted by drag queens proved a great success. They also participate in support groups with non-transgender clients. Yet developing ties may take time. A staff person said it was not uncommon for non-transgendered clients to ask transgender women why they had decided to change genders and how they had done this, or to air prejudices. A transgender woman found that early in the TRP program if an MtF woman had problems with other clients it was “like front page news.” Yet staff keep things from being blown out of proportion, noting that issues may be individual and may not reflect on the fact that a person is transgendered—something that has helped MtF women deal with comments from other people. Sometimes clients discuss differences among themselves, sometimes an issue is brought to staff or a group. Clients who find it too difficult to cope with transgenders are told they can go to another facility. However, staff said that general acceptance of MtF women in the building persuades most clients to adapt.

Transgender women may also have to work through their own biases, including views that people who are nice are sexually attracted to MtF women. Transgender women described accommodations they had made at the agency, including changing clothes that staff found too provocative, requesting work assignments that kept them out of range of male clients who were attracted to them, and seeking outside support groups for sex workers in order to express anger about victimization by men that other clients found too difficult to handle in support groups. With transgender sensitivity training firmly in place, clients have generally come to accept the MtF women in their midst. Living in the therapeutic community teaches transgender women that they are not a hidden society, but in many ways are like others. For other clients, program acceptance of transgender clients sends a message of comfort: everyone has a place. After treatment, clients should have a new support network with whom to talk and have fun—people who know the client as someone in recovery and support her recovery.

Development of Community Ties

Help with work, housing, and support

Preparing to re-enter the community after drug treatment poses other challenges. For some TRP clients, it may be hard to imagine doing any work other than sex work. MtF staff serve as role models and offer advice on how to find new ways of working and living. For example, in a focus group, the social worker suggested that clients did not disclose their transgender identity to employers on a first interview but to wait until a second interview, when the employer already has a favorable impression and gender can be discussed in the course of providing paperwork. Clients who are worried about returning to live in a low-income neighborhood, where loneliness might lead them back into sex work, are encouraged to attend outside transgender support groups, where they can meet others who are not on drugs but live happily in the community. Staff also urge clients to consider a wider set of job options. They can do more than work in adult bookstores selling sexually explicit material; they can find work where they are not subject to harassment, and can become involved in transgender activism.

Walden House also provides work experience (as part of the phase of re-entering the community), and actively seeks employers and landlords who seem friendly to transgender people and unlikely to discriminate against them—something that should help the MtF women maintain their recovery. The program has compiled a rolodex with ample contacts for transgender clients and a book with names and phone numbers of friendly employers and landlords. Clients also appreciate that staff from the Walden House vocational program have come to TRP, told them the office is “ready for them” and helped clients feel at ease. English language classes, computer classes, and workshops on resumes and interviewing are also viewed as helpful. Furthermore, outpatient recovery services are available for clients who leave treatment early, and the program is seeking mentors who share the same language and race as the client and can provide support in person or by phone.

Outreach

Outreach poses other challenges. To help community providers better understand the difficulties transgender women experience, the program social worker lectures to agencies, hospitals and transgender groups. She discusses transgender issues, and differences between gender and sexual identity that might cause confusion about MtF women. To increase referrals to Walden House, the social worker has also built ties with agencies that offer services to transgenders, including substance use treatment agencies, correctional facilities, a clinic that provides hormones, and agencies offering support groups for MtF women or former sex workers.

In trying to bring MtF women into treatment, staff have found that people who are in jail, are homeless, or suffering from acute effects of addiction seem most receptive to recovery services. Addicts may be most open to changes necessary for substance use treatment when they are desperate and have nothing to lose by entering a recovery program. In contrast, bars and the streets have not tended to yield new clients. MtF sex workers soliciting clients for the purpose of paying rent or buying drugs or food may find outreach workers annoying and intrusive. Yet some may still listen when TRP staff discuss how to reduce HIV risk or drug use.

Example of program outreach

The social worker recruits clients to Walden House through monthly visits to the county jail and letters to inmates. Clients referred from jail tend to come with the benefit of some abstinence from substance use while there. The drug and alcohol counselor also responds promptly to calls from referring agencies, so that a potential client meets Walden House transgender staff immediately. This is important because clients may fear that non-transgender people will not understand them or will discriminate against them. Staff describe the TRP program and conduct brief health and mental health screening to make sure the person is stable enough for residential treatment and has some motivation to recover. Knowing that MtF women have few resources, staff admit most into the program relatively quickly. Transgender staff are involved in the agency’s two-week orientation for new clients “from day one.”

Some clients also come to the agency because they hear good reports from others. Some clients in turn attend outside transgender support groups or a church not far from an area frequented by sex workers. Holding programs of interest to transgender women at these locations might help introduce MtF women to the TRP program. Other ways to bring transgender clients to services are described elsewhere (Bockting et al., 1998).

Summary and Comparison with other Programs

In drug treatment, a key question is how to retain clients long enough to make progress in recovery. The Transgender Recovery Program has retained 13 of 16 clients (81%) for up to six months in treatment and has attracted new clients through word of mouth. Writing on transgender views of desirable and effective HIV prevention services, Bockting et al. (1998) note three elements of a successful intervention: affirmation of transgender identity, peer education and community involvement. Walden House seems to succeed in retaining clients for similar reasons. It accepts transgender clients as women and helps them feel safe, allowing them to focus on recovery. Peer staff also effectively help the women deal with emotional and practical issues. Furthermore, the program builds community among MtF women and other clients, and seeks community members willing to provide services, jobs and housing for MtF women. HIV prevention programs for transgenders have also succeeded thanks to transgender sensitivity training (e.g., Warren, 1999), transgender-specific curricula (e.g., Reback and Lombardi, 1999), peer educators (e.g., Bockting et al., 1999), peer support groups (e.g., Hein and Kirk, 1999; Reback and Lombardi, 1999), community involvement (e.g., Bockting et al., 1999), and street outreach (e.g., Warren, 1999). However, treatment (especially outpatient and residential substance use treatment) sensitive to transgender issues remains in short supply (Warren, 1999). Given high rates of drug use and HIV among transgender women (Clements-Nolle et al., 2001) much more remains to be done in this area.

Suggestions for Follow-up

As the TRP program expands, new challenges remain. As in many drug treatment programs, in the facility where the TRP is housed, two-thirds of the clients are men. With MtF women living in women’s quarters, the building has even fewer biologically-born women than is typical in treatment facilities. Indeed, MtF women sometimes constitute half of the clients in women’s support groups. The manager of TRP is now expanding the program to other buildings, noting that some transgender women focus mainly on their relations with men, and can benefit from getting to know a wider range of women well. Another challenge is to attract enough MtF women to each new site so they feel a sense of group identity and support. Scheduling MtF staff across these sites or finding new MtF staff poses another challenge. Walden House is also developing a curriculum on needs of transgender substance users, including such issues as the interaction of drugs and hormones and effects on mood and health. Staff also ask how providers can best be educated about views held by many transgender women, including views that sexual reassignment surgery can enhance mental health rather than harming it (see Franzini and Casinelli, 1986). The challenges of developing a transgender program, recruiting clients, and integrating them into the community might be even greater in areas less tolerant of transgender issues than San Francisco.

In any transgender program, success in retaining and treating clients is likely to be greatest where agencies respect client wishes to live as women and receive services from other transgender women, in an environment that is safe but challenges clients to expand social and vocational horizons. Implementation of new substance use treatment programs for MtF transgender individuals will not only provide an important service for a group at heightened risk of mental health problems and HIV, but also add to an understanding of ways in which transgender individuals are much like others in treatment or are special and unique.

Appendix

Case studies are presented to give an idea of the TRP program’s diverse clientele.

Judy

For years Judy was “married” to a gay man and worked as a mechanic. Judy started drinking to deal with ridicule from other people of her as an MtF woman. Using amphetamines to stay alert when she drank, she found that life “became more fun,” and speed helped her stay thin. When Judy and her husband broke up, she became homeless and later went to jail for drug possession and stealing a car. Judy says if she had something important to look forward to, drugs “wouldn’t be such a big deal,” and she wouldn’t be using her mechanical skill to steal cars. In prison Judy was given a chance to leave jail and enter treatment. Although she sometimes imagines leaving treatment and using drugs again, she is touched when other clients ask her to stay, “I’m thinking, let me try and complete this. I might get something I never knew existed.”

Used to living with only her husband, Judy sometimes feels overwhelmed by the busy therapeutic community. She feels pressure to spend all her time socializing with “the (MtF) girls” when she might want to talk with “the boys” or be alone—options that Judy’s counselor reinforces in support group as good for Judy’s recovery. Yet Judy is glad that therapeutic community helps clients see transgender people as women. In contrast, “in jail, no way.”

Issues about gender identity do arise sometimes. Although Judy “feels O.K. being like a man,” she worries that her voice is too deep and that she might be seen as being like a man. She was heartened when her MtF therapist said, “That’s not the first thing people notice.” Judy has also learned to make quick witty replies when other clients tell her she looks like a man. Judy also defended herself when a person in her MtF support group commented, “You look too feminine to be a car thief!” “But I do it in a feminine way,” Judy replied, “I’m calm and put on my makeup in the car, and I’ve learned how to use a key without breaking windows.” Judy wants to return to work as a mechanic but thinks it would be hard to break into a male-dominated workplace as an MtF woman, especially when local mechanics already know her as a man. Afraid to be turned down for work based on her looks, without any consideration of her skills, Judy sometimes considers selling drugs. Yet she finds therapy helpful, renewing her hope of working again in “this normally working, spinning world.”

Carla

Carla, a Latina MtF woman, used to work at a restaurant and took care of her aging parents. Carla began using methamphetamines to cope with her stressful schedule. When her parents died, the drugs also helped her feel less lonely and “love others more” as she embarked on a more adventurous love life. As Carla began losing jobs due to drugs, she wanted to enter treatment. Yet the gentle soft-spoken woman was afraid clients might not take her seriously as a transgendered person or might subject her to verbal abuse similar to that she had experienced in all-boys’ schools for 11 years. Carla had also started using hormones to increase her breast size, and did not want to share a bathroom with men, some of whom had been in jail.

When a friend told Carla about the TRP program at Walden House, she jumped at the chance to go there. She feels accepted by women in the program and enjoys program trips to the beach, picnics, or camping. And in her transgender support group she sees she is not alone:

We all played with dolls and had teas. We were all afraid to go to school. We were abused. We were prostitutes because we had no other way to survive. We come from different countries and different states, but we all have the same feelings. We get more depressed than other people do because we’re on hormones and we have been marginal people all our lives. I don’t feel lonely anymore.

Sometimes Carla cannot understand why she has been given such a difficult life to lead. Yet she doesn’t want to have a sex-change operation so as not to offend God, “God is always correct, he must have made us for a reason, some feelings of love.” Still searching for an answer, she reflects, “The most important thing is the person first and then the sex life preference. The key is to be correct. The counselor clears all our doubts with perfect answers, showing us good behaviors as a transgender. If I am correct, others will be correct, and I can live my life.”

Pat

A spiritual woman, Pat looks for the positive in life, and used methamphetamines to escape negative feelings she had about prostitution. She found it especially difficult to deal with apparently heterosexual lovers who resented having to question their sexuality and so projected hatred of their sexuality onto MtF women instead, making them feel “worthless, ugly and rotten.” Treatment helps Pat release her feelings and appreciate herself as she soaks in the affirmation and love she finds in recovery. Accepting both her masculine and feminine identities, Pat does not want to change her sex but seeks understanding that she is unique as a transgender person, “A unicorn has a horn. If you saw the horn off, it’s only another horse, and there are a lot of horses. But I’m rare.”

References

Baldwin, J. D. and Baldwin, J. I. (1997) Gender differences in sexual interest. Archives of Sexual Behavior, 26: 181–210.

Bockting, W. O., Robinson, B. E., and Rosser, B. R. (1998) Transgender HIV prevention: A qualitative needs assessment. AIDS Care, 10: 505–525.

Bockting, W. O., Rosser, B. R. S., and Coleman, E. (1999) Transgender HIV prevention: Community involvement and empowerment. International Journal of Transgenderism, 3(1+2), www.symposion.com/ijt/hiv_risk/bockting.htm.

Boles, J. and Elifson, K. W. (1994) The social organization of transvestite prostitution and AIDS. Social Science and Medicine, 39: 85–93.

Clements, K., Wilkinson, W., Kitano, K., and Marx, R. (1999) HIV prevention and health service needs of the transgender community in San Francisco. International Journal of Transgenderism, 3(1+2): www.symposion.com/ijt/hiv_risk/clements.htm.

Clements-Nolle, K., Marx, R., Guzman, R., and Katz, M. (2001) HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications for public health intervention. American Journal of Public Health, 91: 915–921.

Franzini, l. R. and Casinelli, D. L. (1986) Health professionals’ factual knowledge and changing attitudes towards transsexuals. Social Science and Medicine, 22: 535–539.

Gagne, P. and Tewksbury, R. (1998) Conformity pressures and gender resistance among transgendered individuals. Social Problems, 45: 81–102.

Garnets, L., Herek, G. M., and Levy, B. (1992) Violence and victimization of lesbian and gay men: Mental health consequences. In G. M. Herek and K. T. Berrill (Eds.), Hate crimes: Confronting violence against lesbians and gay men, Newbury Park: Sage.

Hein, D. and Kirk, M. (1999) Education and soul searching: The Enterprise HIV Prevention Group. International Journal of Transgenderism, 3(1+2): www.symposion.com/ijt/hiv_risk/hein.htm.

Hendricks, M. L. (2001) Clinical issues in work with transgender individuals. Exchange: Psychology and AIDS, 30: 3–27. American Psychological Association.

Israel, G. E. and Tarver, D. E. II. (1997) Transgender care: Recommended guidelines, practical information, and personal accounts, Philadelphia: Temple University Press.

Kreiss, J. L. and Patterson, D. L. (1997) Psychosocial issues in primary care of lesbian, gay, bisexual, and transgender youth. Journal of Pediatric Health Care, 11: 266–274.

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

Lombardi, E. L. (2001) Enhancing transgender health care. American Journal of Public Health, 91: 869–872.

Lombardi, E.L., Wilchins, R.A., Priesing, D., and Malouf, D. (in press) Gender violence: Transgender experiences with violence and discrimination. The Journal of Homosexuality.

Mason-Schrock, D. (1996) Transsexuals’ narrative construction of the “true self.” Social Psychology Quarterly, 59:176–192.

Moriarty, H. J., Thiagalingam, A., and Hill, P. D. (1998) Audit of service to a minority client group. Male to female transsexuals. International Journal of STD and AIDS, 9: 238–240.

Nemoto, T., Luke, D., Mamo, L., Ching, A., and Patria, J. (1999) HIV risk behaviours among male-to-female transgenders in comparison with homosexual or bisexual males and heterosexual females. AIDS Care, 11: 297–312.

Pang, H., Pugh, K., and Catalan, J. (1994) Gender identity disorder and HIV disease. International Journal of STD and AIDS, 5: 130–132.

Reback, C. and Lombardi, E. L. (1999) A community-based harm reduction program for male-to-female transgenders at risk for HIV infection. The International Journal of Transgenderism, 3 (1+2): www.symposion.com/ijt/hiv_risk/reback.htm.

San Francisco Department of Public Health, AIDS Office (1997) HIV prevention and health service needs of the transgender community in San Francisco: Reports from eleven focus groups, San Francisco, CA, San Francisco Department of Public Health.

San Francisco Department of Public Health (1999) The Transgender Community Health Project: Descriptive results, San Francisco, CA, San Francisco Department of Public Health.

Savin-Williams, R. C. (1994) Verbal and physical abuse as stressors in the lives of lesbian, gay male, and bisexual youths: Associations with school problems, running away, substance abuse, prostitution, and suicide. Journal of Consulting and Clinical Psychology, 62: 261–269.

Shwartz, M., Mulvey, K. P., Woods, D., Brannigan, P., and Plough, A. (1997) Length of stay as an outcome in an era of managed care. An empirical study. Journal of Substance Abuse Treatment, 14: 11–18.

Simpson, D. D., Joe, G. W., Fletcher, B. W., Hubbard, R. L., and Anglin, M. D. (1999) A national evaluation of treatment outcomes for cocaine dependence. Archives of General Psychiatry, 56: 507–514.

Stephens, T., Cozza, S. and Braithewaite, R. L. (1999) Transsexual orientation in HIV risk behaviors in an adult male prison. International Journal of STD and AIDS, 10: 28–31.

Valera, R. J., Sawyer, R. G., and Schiraldi, G. R. (2001) Perceived health needs of inner-city street prostitutes: A preliminary study. American Journal of Health Behavior, 25: 50–59.

Warren, B. E. (1999) Sex, truth and videotape: HIV prevention at the Gender Identity Project in New York City. International Journal of Transgenderism, 3(1+2): www.symposion.com/ijt/hiv_risk/warren.htm.

Weinberg, M. S., Shaver, F. M., and Williams, C. J. (1999) Gendered sex work in the San Francisco Tenderloin. Archives of Sexual Behavior, 28: 503–521.

White, J. C. and Townsend, M. H. (1998) Transgender medicine: Issues and definitions. Journal of the Gay and Lesbian Medical Association, 2: 1–3.

Correspondence to Jean Oggins.