Research indicates that addiction occurs at an approximate rate of 30% in the Lesbian-Gay-Bisexual-Transgender-Queer/Questioning (LGBTQ) community. This is primarily due to social stigma that still exists for LGBTQ people in society. Traditionally, gender is defined as either “male” or “female” and is referred to as the binary gender system. There are numerous nonbinary identities that fall outside of the traditional binary identities of male and female. While not an all-inclusive list, some of these identities include intergender, bigender, genderfluid, genderqueer, agender, neutrois, gender nonconforming, etc. (Matsuno, 2019).

Research also indicates that LGBTQ people struggling with substance use benefit from participating in programs that target and provide LGBTQ/gender affirming care.  Substance use and other co-occurring mental health issues are primarily a result from social stigma, experienced violence, harassment, and rejection, and not specifically based on a person’s gender identity (Harrison et al., 2012: Hendricks & Testa, 2012).

The following recommendations are provided to support gender affirming care in consideration of substance use and co-occurring disorders treatment: 

1. Cultural Competence, in the form of awareness, knowledge, and skills (Sue, 2001). This would include seeking out gender affirming trainings, supervision, and the therapist/counselor working to become more aware of personally held misconceptions about LGBTQ+ and nonbinary people.
2. Empower the Client: Many nonbinary people feel invisible in their identity, so empowering them through nonbinary gender affirming care gives them the opportunity to be seen and feel validated (Matsuno, 2019). Asking clients how they identify and what pronouns they use are a good first step in empowering them and relaying the message that they are in a safe space. Staff should mirror the client’s language, which expresses a message of understanding (Matsuno, 2019).
3. Using Gender-Neutral Pronouns: In addition to empowering nonbinary gender clients by asking how they identify and what pronouns they use, it is recommended that clinicians and staff practice using preferred pronouns by actively engaging with clients and using their preferred pronouns in meetings, consultation with others, and in documentation (Matsuno, 2019). As an example, it may be difficult for people to adjust to using singular they/them; however, the more a person practices the easier it becomes, and the potential for making mistakes decreases (Matsuno, 2019). When mistakes are made it is important to acknowledge the mistake and move on without making it a big deal, which potentially might create an embarrassing situation for the client.
4. Using Gender-Neutral Language: Similar to using gender neutral pronouns, it is recommended that staff use gender neutral language as much as possible, thereby establishing an environment that avoids misgendering clients and helps create a welcoming atmosphere (Austin & Craig, 2015). Rather than she/her/woman, or he/him/man, staff might use gender neutral terms such as person or client, whereby avoiding a situation in which a person is misgendered (Matsuno, 2019).
5. Case Conceptualization: Through the lens of minority stress theory, clinical staff have the opportunity to identify and address external and internal stressors as they relate to the mental health care for nonbinary clients (Hendricks & Testa, 2012). While it is important not to assume the impacts of one’s experience as it relates to their identity, it does foster an opportunity to develop a therapeutic alliance that is curious and respectful, whereby acknowledging and honoring in a client-centered way.
6. Externalizing and Rejecting Negative Messages: Understanding how negative messages are internalized helps clinical staff be able to address mental health needs of nonbinary clients. When clinically appropriate, presenting nonbinary clients with education about the minority stress model and helping them consider how it may or may not be influencing their problems, and reasons for presenting for treatment (Matsuno, 2019).
7. Navigating Disclosure: Helping nonbinary clients navigate the process of coming out and disclosing their identity is a very helpful way to explore the risks and benefits, and balancing disclosure versus nondisclosure (Matsuno, 2019). Additionally, helping nonbinary clients develop coping strategies that prepare them to manage potential negative reactions to their disclosure (Matsuno, 2019).
8. Relational Systems: Encouraging nonbinary clients to involve supportive family, friends, and family of choice in their treatment helps create a support network that enables them to behave congruently as they implement change and live in their respective social environments.
9. Agency Level Policies: As a result of the enactment of California’s 2012 Gender Nondiscrimination Act, agencies should assess and implement policies that support adherence to the law and foster gender affirmative care. While not an all-inclusive list, such policies should address agency hiring practices, counselor-client assignments, housing for transgender and nonbinary clients while in treatment, procedures for collecting urine samples for the purpose of drug testing, and designation of gender inclusive bathrooms (Matsuno, 2019).

While there is a dearth of research available as it relates to nonbinary gender affirming care, the recommendations listed above go a long way to foster a treatment environment that is safe for clients that identify outside the traditional binary system and address treatment considerations to support gender affirming care for nonbinary clients.

New Bridge Foundation® believes in providing all of our clients an accepting and safe environment in which to begin their recovery journey. We are convinced of the necessity to provide gender affirming care and specialized services for those in the LGBTQ+ community.

For more information, please call 800 785-2400 or 510 548-7270.