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A qualitative study of transgender individuals’ experiences in residential addiction treatment settings:… Lyons, Tara; Shannon, Kate; Pierre, Leslie; Small, Will; Krüsi, Andrea; Kerr, Thomas May 7, 2015

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RESEARCHA qualitative study of tranl,5,BackgroundAlthough the body of research focused on addictiongender identity and gender expression [1]) groups. Thus,treatment experiences among transgender persons haveLyons et al. Substance Abuse Treatment, Prevention, and Policy  (2015) 10:17 DOI 10.1186/s13011-015-0015-4rates of substance use among transgender groups areSciences Mall, Vancouver, BC V6T 1Z3, CanadaFull list of author information is available at the end of the articletreatment processes and outcomes has continued togrow, transgender individuals who use drugs have typic-ally been excluded from such research, or they have beengrouped with those of sexual minority and/or cisgender(individuals whose assigned sex corresponds to theirnot been well documented and the results to date aremixed. While high rates of substance use have been doc-umented among some transgender populations [2,3],other studies have found scant differences in substanceuse patterns among transgender and cisgender groups[4]. Transgender women have been found to be morelikely to report syringe use; however, it has not beenestablished whether this is indicative of the injection ofhormones and/or substance use [4,5]. Further, while* Correspondence: uhri-tk@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada2Department of Medicine, University of British Columbia, 317-2194 HealthAbstractBackground: While considerable research has been undertaken on addiction treatment, the experiences of transgenderindividuals who use drugs are rarely explored in such research, as too often transgender individuals are excluded entirelyor grouped with those of sexual minority groups. Consequently, little is known about the treatment experiences in thispopulation. Thus, we sought to qualitatively investigate the residential addiction treatment experiences of transgenderindividuals who use illicit drugs in a Canadian setting.Methods: In-depth semi-structured interviews were conducted with 34 transgender individuals in Vancouver, Canadabetween June 2012 and May 2013. Participants were recruited from three open prospective cohorts of individuals whouse drugs and an open prospective cohort of sex workers. Theory-driven and data-driven approaches were used toanalyze the data and two transgender researcher assistants aided with the coding and the interpretation of data in aprocess called participatory analysis.Results: Fourteen participants had previous experience of addiction treatment and their experiences varied according towhether their gender identity was accepted in the treatment programs. Three themes emerged from the data thatcharacterized individuals’ experiences in treatment settings: (1) enacted stigma in the forms of social rejection andviolence, (2) transphobia and felt stigma, and (3) “trans friendly” and inclusive treatment. Participants who reported feltand enacted stigma, including violence, left treatment prematurely after isolation and conflicts. In contrast, participantswho felt included and respected in treatment settings reported positive treatment experiences.Conclusions: The study findings demonstrate the importance of fostering respect and inclusivity of gender diverseindividuals in residential treatment settings. These findings illustrate the need for gender-based, anti-stigma policies andprograms to be established within existing addiction treatment programs. Additionally, it is vital to establish transgenderand/or LGBTQ specific treatment programs as recommended by the participants in this study.Keywords: Transgender, Treatment, Enacted stigma, Felt stigma, Inclusion, Indigenous, Drug useexperiences in residentiasettings: stigma and incluTara Lyons1,2, Kate Shannon1,2,3, Leslie Pierre4, Will Small1© 2015 Lyons et al.; licensee BioMed Central.Commons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.Open Accesssgender individuals’addiction treatmentsivityAndrea Krüsi1,2 and Thomas Kerr1,2*This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,Lyons et al. Substance Abuse Treatment, Prevention, and Policy  (2015) 10:17 Page 2 of 6not concrete, transgender persons have reported diffi-culty accessing addiction treatment programs [6] andhealthcare more broadly [7].Barriers to addiction treatment for transgender per-sons are often rooted in stigma and include structuralbarriers (e.g., sex segregated housing) as well as treat-ment provider attitudes. Past research suggests thatmany treatment professionals report stigmatizing atti-tudes towards their LGBTQ clients and also lack know-ledge of LGBTQ-related issues [8,9]. Further, treatmentproviders working with LGBTQ individuals receive littleif any education into the specific treatment needs ofgender and sexual minorities [10,11]. For example, in astudy comparing rural and urban treatment providers inthe US, Eliason and Hughes [9] found an average of1 hour of training on transgender issues among coun-selors in the rural setting, and 2.4 hours in the urbansetting. With limited training and understanding oftransgender populations, treatment providers may con-tribute to barriers to addiction treatment, including stig-matizing attitudes.Stigmas acts as a barrier to health services, includingaddiction treatment, and it is understood as a process bywhich marginalized individuals or groups are labeledwith negative, often stereotypical, characteristics whichcontribute to harmful outcomes (e.g., social exclusion)[12]. Stigmatization is a social process dependent uponpower that nurtures and reproduces social inequalities;consequently there are multiple ways stigma occurs[12-14]. For example, enacted stigma is characterized asincidents of discrimination (e.g., rejection, violence) andfelt stigma refers to an internalization of stigma whichmanifests as the fear of experiencing some form ofenacted stigma [15]. Therefore, there may be complex-ities surrounding experiences of stigma for transgenderpersons in addiction treatment settings.While there is some literature on substance use amongtransgender groups and treatment provider training,studies investigating transgender individuals experiencewith addiction treatment are scarce. Transgender partici-pants in a New York study reported lower satisfactionwith treatment and lower rates of abstinence and treat-ment completion compared to heterosexual, gay and bisex-ual counterparts [16]. In a study of transgender indigenouspeople in Ontario, 71% of the participants who attemptedto obtain addiction treatment services were unable to ac-cess this service [6]. Because transgender persons are regu-larly grouped with sexual minorities in research studiesthere is little available information on the experiences oftransgender individuals in residential treatment settings.Given the known and vast differences between transgenderand sexual minority populations there is a major gap in theliterature examining the treatment experiences of trans-gender populations that we seek to address herein.MethodsBetween June 2012 and May 2013 the first author con-ducted in-depth semi-structured interviews with 34transgender individuals engaged in drug use and/or sexwork. Participants were recruited from three open pro-spective cohorts of individuals who use drugs and anopen prospective cohort of sex workers. In addition,three participants were referred to the study by otherparticipants. Eligibility included a) identifying as a per-son whose gender identity or expression differs fromtheir assigned sex at birth, b) having exchanged sex formoney or having used illicit drugs, c) residing in theGreater Vancouver area, and d) being 14 years of age orolder. The interview guide, which was guided by an ex-tensive literature review on transgender populations andhealth, sex work, substance use, was comprised of tentopics (e.g., addiction treatment, housing, access tohealth services) to capture a range of experience giventhe dearth of literature on the lived experiences of trans-gender persons in the drug use and sex work settingsunder study. The interviews lasted approximately onehour and were conducted at research offices in Vancou-ver, Canada. No participants declined to be interviewedor left the study and participants were paid $20 to com-pensate for their time. All of the interviews were audiorecorded with permission and every participant providedwritten informed consent. This study has received an-nual ethical approval through Providence Health Care/University of British Columbia Research Ethics Boardand pseudonyms are used to protect the identity ofparticipants.AnalysisAll interviews were transcribed verbatim and importedinto ATLAS.ti (version 7), a qualitative data manage-ment software. Theoretical thematic analysis [17] in con-junction with research questions guided the first-levelcoding. Two transgender participants were hired as re-search assistants to conduct the second- and third- levelanalyses with the first author in a process they devel-oped, called participatory analysis. At each participatoryanalysis session the data associated with a first-level code(e.g., stigma) was printed and divided into 2 sections,with one half analyzed independently by each person. Asa second step, the sections were traded between the firstauthor and the research assistant in order for each sec-tion to be analyzed by each person. We validated thecodes, corrected any coding errors, and discussed theor-etical approaches. Codes were separated analytically intosub-codes and new codes were pulled out from the ana-lysis using an inductive approach [18]. The 24 one-on-one analysis sessions, which ranged from 2 to 3 hours,were held at research offices. Using a participatory ana-lysis approach enriched and contextualized the researchLyons et al. Substance Abuse Treatment, Prevention, and Policy  (2015) 10:17 Page 3 of 6findings and provided an opportunity to engage with re-search participants beyond an interview setting.ResultsOf the 34 participants in our study, 14 reported ever at-tending residential treatment and 20 reported never at-tending residential treatment. Of the 14 participants whoattended residential treatment, all had been assigned malesex at birth; however they described their gender identityin different ways and used different pronouns (e.g., she,they). Nine identified as transgender, 4 identified as two-spirit, and 1 reported dressing as a woman in the contextof sex work. Two-spirit is a translation of a NorthernAlgonquin term used to describe an indigenous personwho has feminine and masculine spirits [19]. Two-spirit isa fluid, non-binary term and as such it is used by some in-digenous people to describe their sexual orientation as les-bian, gay, bisexual, or queer [20]. Participants ranged inage from 27 to 47 years of age, with an average age of36.8 years. Thirteen participants identified as Indigenous(First Nations or Métis) and 1 identified as Caucasian. Justover half of the participants (n = 8) reported currentlyusing illicit drugs (e.g., heroin, crystal methamphetamine,cocaine) excluding cannabis, 3 reported only consumingcannabis, and 3 reported no current drug use, but had ahistory of drug use. Seven participants reported attendingmen’s-only treatment facilities, while 4 reported attendingwomen’s-only and 3 reported attending mixed gender fa-cilities. Below we present three themes that characterizedtransgender individuals’ experiences in residential treat-ment settings.Social rejection, harassment, and violence as enactedstigmaParticipants in our study experienced enacted stigma,defined as incidents of discrimination (e.g., rejection,lack of support, denial of service, violence) [15] in treat-ment settings. Those who reported negative encountersdescribed enacted stigma ranging from name-calling toviolence by other residents in treatment settings. For ex-ample, Eva attended a mixed gender treatment facilityand because she was placed within a women’s section,she had limited contact with men. Despite this separ-ation, she experienced harassment by men in the treat-ment setting:I think some men did [make an issue of my gender]to try to be mean to me but, I just wouldn’t have anyof it. I’d be like get lost.Participants also described social rejection and harass-ment. For example, Marion discussed having conflictswith others in treatment about their gender identity andstated, “I just didn’t know where I belonged”. Julia notedbeing targeted by others in the treatment setting, whichresulted in her isolating herself from others and leavingtreatment after a week.I had a lot of support from the staff, but with theother clients, it was really difficult. I mean everybody’stalking in the whole unit about me. …‘cause I’m theonly transgender. … I ended up isolating myself andlocked in my room 24 hours a day. … It’s like thisisn’t dealing with your addiction.Reports of enacted stigma from staff were less com-mon; however, participants discussed staff not under-standing their gender identity. For example, when Juliaarrived at the treatment centre there was confusionabout her gender identity:It was really difficult. I went there and … when I gotthere they had no idea I was transgender. … Theydidn’t know how to deal with it.Casey described conflicts with their treatment counsellor:[My counsellor] said that I wasn’t being true to myselfbecause I was not acting like a normal two-spirited per-son would and I would argue with her like, well notargue, but debate with her, how am I supposed to act.Am I supposed to stay here and pop a hip every time?[She was saying you weren’t feminine enough?]. Yeah, itwas weird. I just didn’t really like talking about it and …she was rude. She was really, really rude. So yeah, I left.Casey’s counselor made comments about how femininethey should be acting and engaged in debates with themabout their gender presentation. This resulted in Caseyfeeling uncomfortable and judged, and subsequently theyleft treatment prematurely.Physical and sexual violence were other forms ofenacted stigma that participants reported. Leah de-scribed her experience in a mixed gender facility:There was a guy that threatened me in there and toldme he was gonna kill me. He was calling me a faggotand it was brought to the staff. … So the staff and meand the guy all sat down and they still kept the guy onthe unit. I left because I felt unsafe there.There were also reports of sexual violence in our study.For example, Riley describes an experience in a men’streatment centre:Buddy’s sitting there constantly walking by and rubbinghis genitals… He’d sit there, rub his cock. He’s like, heyfudge packer come over and sit on my cock.example, Amelia reported that the staff and other clientsment experiences of transgender individuals in a Canad-Lyons et al. Substance Abuse Treatment, Prevention, and Policy  (2015) 10:17 Page 4 of 6This encounter escalated into a physical fight and thestaff attempted to expel Riley from treatment. After ameeting with the director of the facility, the other clientwas removed from the treatment program. The directoralso responded by stating homophobic and transphobiccomments would no longer be tolerated and they wouldbe considered punishable acts. Riley noted the directorof the facility saying, “all the gay men and trans thathave been through here, all you boys made it hard forthem and they’ve all left because of your ignorance”.These two experiences demonstrate the importance ofstaff interventions in violence. Leah continued to feelunsafe after staff intervened and consequently left treat-ment, while Riley had support from staff and continuedon with treatment. As these examples illustrate, partici-pants encountered various forms of enacted stigma fromstaff and other individuals in the treatment setting andmany of the participants who experienced enactedstigma in treatment settings also reported leaving treat-ment prematurely.Transphobia & felt stigmaFelt stigma captures the fear of experiencing some formof enacted stigma, [15] and is another form of stigmathat characterized participants’ treatment experiences.Felt stigma was evidenced in participants’ beliefs thattheir presence was a disturbance to others in treatment.Rachel explained why she had not attended treatment inthe past:It’s kinda hard to go in there as a transgender personbecause all the energy and all the focus would be onthat…Someone will say you’re a diversion from therest of the class.Additionally, Taylor expressed fear of being judged byother individuals in treatment.In the groups I wouldn’t come out and talk aboutcertain things because there were other straightpeople there. But I know that lesbian and gay peopleand trans, if they heard me talk about these otherthings they wouldn’t go ‘oh my god’, but a straightperson would.Felt stigma helps explain how participants internalizedfears of experiencing transphobia in treatment settings.The fear of being a nuisance or diversion from others inthe treatment program resulted in not accessing treat-ment or limiting what they shared in treatment groups.The common threads through the above examples areparticipants’ feelings of being unwelcomed, isolated, andunsafe in residential treatment settings. Participants re-ported not having their treatment needs met as well asian setting. The findings illustrate how stigma works toexclude transgender persons from treatment settings.Specifically, many transgender individuals in our studydid not have their treatment needs met due to enactedand felt stigma In addition, we found that participantswho reported positive treatment experiences had re-ceived treatment within settings that understood andrespected transgender persons. Thus, our findings demon-strate the importance of fostering respect and inclusivityat a women’s only treatment centre “accepted me…theydidn’t judge me”. Additionally, two participants recounted“trans friendly” experiences in indigenous treatment set-tings. Rielle explained what made her treatment experi-ences unique:Their staff was knowledgeable around trans people,the terminology… I was put in on a women’s side as Irequested and when it came time to doing the groupsI was obviously put with the women versus put withthe men. … I did the sweats with the women. I dideverything that the women did, I was included in thatand I wasn’t excluded from that or anything. I shareda room with another female and it was good.Rielle described participating in all aspects of treat-ment as a woman in the indigenous treatment settings.In general, those who remained in treatment and/orrecounted positive treatment experiences reported beingincluded in treatment settings by having their genderidentity respected and being placed with the appropriategender in treatment groups and housing.DiscussionAs part of a larger qualitative study on the experiencesof transgender individuals who use drug and/or engagein sex work, this paper has outlined the addiction treat-prematurely leaving treatment after experiences ofenacted and felt stigma. As one of the researcher assis-tants who conducted the participatory analysis noted:“This leads to us to feeling like we have no right to exist.We are seen as a distraction to other people, as a dis-turbance, which puts others’ needs before our needs”. Incontrast, some participants reported having positive ex-periences in treatment settings, which we turn to next.“Trans friendly” and inclusive treatment experiencesParticipants who reported positive treatment experiencesreported being accepted and having their gender identityrespected by staff and others in treatment settings. Forof gender diverse individuals in residential treatmentsettings.Lyons et al. Substance Abuse Treatment, Prevention, and Policy  (2015) 10:17 Page 5 of 6This study is one of a very small number that exploresthe experiences of transgender individuals in a treatmentsetting. Because transgender populations are often ex-cluded from research or grouped with sexual minorities(e.g., gay men), this study presents a starting point formore in-depth research into how to decrease stigma andtransphobia in addiction treatment. The experiences offelt and enacted stigma in treatment settings are sup-ported by the few studies examining treatment experi-ences of transgender individuals. For example, Senreich[16] found transgender participants in mixed gendertreatment facilities felt lower levels of support and con-nection while in treatment and they were less likely tocomplete the treatment program compared to heterosex-ual, gay and bisexual counterparts. Likewise, in Namaste’s[21] study transgender persons reported feeling isolated attreatment centres. We were unable to locate studies thatillustrated positive treatment experiences for transgenderpersons and therefore our findings may indicate an im-portant direction for future research, and more import-antly directions for program development.Indigenous peoples were vastly overrepresented in ourstudy and this is explained in part by our samplingmethods where participants were sampled from cohortsof people who use drugs and a cohort of sex workers inan area characterized by disenfranchisement and socialinequalities. Indigenous persons are overrepresented inthe local environment due to colonialism and the dis-placement of indigenous people in Canada [22]. Two-spirit people have reported moving to urban areas afterfacing homophobia and transphobia [20,23] and as suchmay be further overrepresented in our urban study set-ting. Historically, two-spirit people were included intheir communities and often they held high social statusand roles in ceremony. Colonialism and the ongoing at-tempts by the state to destroy indigenous peoples andtheir cultures includes practices such as residentialschools, forcibly removing indigenous children fromhomes, displacement of land, and violence [24-26]. Thelegacies of colonization are inseparable from the currenthealth inequities and discrimination which burden manyindigenous peoples [27]; legacies which are evident inour study sample of transgender individuals.There is a debate in the literature regarding whetherspecialized treatment settings should be established forLGBTQ groups or whether treatment staff and programsshould be better tailored to the needs of the LGBTQ in-dividuals across treatment settings [28-30]. In our study,participants advocated for the development of trans-gender and/or LBGT combined treatment programs, re-covery houses, and treatment centres. The desire fortransgender specific treatment programs was driven bywanting a place where participants felt they belongedand where they were supported and accepted. Whilesuch places may take time to develop, changes can bemade to existing programs to ensure an inclusive and asupportive therapeutic environment for transgender in-dividuals, such as hiring transgender staff, transgender-related training of staff, implementing policies to preventdiscrimination and violence, and establishing and model-ing guidelines of respect.Residential treatment programs, transgender specificor otherwise, are not a single solution to substance useamong transgender populations. Treatment programsalone cannot address economic, gender and socio-structural disenfranchisement that burdens many trans-gender persons. To improve the health and treatmentoutcomes of transgender populations, including thosewho use drugs, it is imperative to design and evaluate in-terventions and policies that seek to support participationin the workforce, access to transition-related healthcarefor those interested in transition, and anti-stigma educa-tion and policies (e.g., introducing gender identity educa-tion and polices in schools). One example is Argentina’sGender Identity Law (Law 26,743 24/05/2012) which wasestablished in May 2012 [31]. This law is based on aframework that affirms equity and human rights, the rightto self-defined gender identity, and allows for changes togender, image, or birth name on their identity card andbirth certificates without any requirement of psychiatricevaluation [32]. The law also recommends universalcoverage for transition-related healthcare; however, theimpact of this law, and others like it, remains under-evaluated.There is pronounced heterogeneity of transgenderpopulations and as such the study sample cannot be as-sumed to represent all gender diverse individuals. In par-ticular, it is important to note that the participants weresampled from cohorts of individuals who use drugs anda cohort of sex workers and therefore the findings maynot be generalizable to other transgender populations.Future research would benefit from a focus on youngtransgender persons as they may have unique experi-ences seeking addiction treatment. Additionally, includ-ing two-spirit and transgender participants in the samplemay overshadow the unique experiences of two-spirit in-dividuals. Future research would benefit from two-spiritspecific research conducted by indigenous peoples and/or in accordance with indigenous research methods andethics. Lastly, our data was based on self-report and maybe susceptible to response biases.In conclusion, this study highlights the urgent need toimplement policies and practices to ensure transgenderindividuals experience inclusivity and have their genderidentity respected in treatment settings. Such changesmay improve treatment outcomes, and we suggest evalu-ations of transgender-inclusive policies and treatmentsettings are important areas of future research. Our10. Hellman RE, Stanton M, Lee J, Tytun A, Vachon R. Treatment of homosexualalcoholics in government-funded agencies: provider training and attitudes.Psychiatr Serv. 1989;40(11):1163–8.11. Israelstam S. Knowledge and opinions of alcohol intervention workers inOntario, Canada, regarding issues affecting male gays and lesbians: parts iand ii. Subst Use Misuse. 1988;23(3):227–52.12. Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27:363–85.Lyons et al. Substance Abuse Treatment, Prevention, and Policy  (2015) 10:17 Page 6 of 6study gives examples of how stigma is a socially embed-ded process that contributes to social inequalities, suchas access to treatment programs. Thus, it is vital that inaddition to establishing anti-stigma policies and practiceswithin treatment settings, broader anti-stigma researchand activism is undertaken to combat the discriminationand harassment that many transgender groups are bur-dened with in their daily lives.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsTL, KS, and TK designed the study. TL conducted the interviews. TL and LPconducted the data analysis. TL and TK drafted the manuscript. All authorsprovided critical comments on the first draft of the manuscript and approvedthe final version to be submitted.AcknowledgmentsThe authors thank the study participants for their contribution to the research,the transgender researchers, and current and past researchers and staff. Thestudy was supported by the US National Institutes of Health (R01DA033147).TL and AK are supported by the Canadian Institutes of Health Research. WS issupported by the Michael Smith Foundation for Health Research. KS issupported by a Canada Research Chair in Global Sexual Health and HIV/AIDSand Michael Smith Foundation for Health Research.Author details1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. 2Department ofMedicine, University of British Columbia, 317-2194 Health Sciences Mall,Vancouver, BC V6T 1Z3, Canada. 3School of Population and Public Health,University of British Columbia, 5804 Fairview Avenue, Vancouver, BC V6T 1Z3,Canada. 4Providing Alternatives Counselling & Education Society (PACE), 49W. Cordova St, Vancouver, BC V6B 1C8, Canada. 5Faculty of Health Sciences,Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6, Canada.Received: 13 March 2015 Accepted: 29 April 2015References1. Johnson JR. Cisgender privilege, intersectionality, and the criminalization ofCeCe McDonald: why intercultural communication needs transgenderstudies. J Int Intercultural Commun. 2013;6(2):135–44.2. 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