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The Importance of Queer and Trans-Affirming Mental Health and Substance Use Support

Historically, LGBTQ people have not been made to feel comfortable to talk about their lives and experiences while accessing support in health care and social service settings. To this day, many people suffer from abuse, bullying, harassment and discrimination because they are LGBTQ-identified. This certainly also happens in health care settings. Existing services are not designed with LGBTQ people in mind and health care providers are not receiving the proper training to meet the needs of this population. In response, Faith and Tim started Pieces to Pathways (P2P), a peer-based harm reduction program for queer and trans folks.

P2P started as a conversation between Faith and Tim, two friends who met in recovery. The two got sober with the support of 12-Step programs,[1] and this lived experience as sober queer and trans people combined with their histories of grassroots community development inspired the development of the program.

Faith and Tim, who are vocal about their own experiences with addiction and recovery, would regularly get friends or mutual acquaintances sent their way when they struggled with substance use. They would meet with these individuals, often in coffee shops, to discuss their stories and share what had worked for them to get sober and stay sober. When it came time to make a referral to social or health services that were queer and trans affirming, Faith and Tim discovered that there were very few places they felt comfortable referring people to.

In the summer of 2014, Faith and Tim started P2P and in December 2014, they were successful in securing government funding from the Toronto Central LHIN (Local Health Integration Network) to conduct a community based needs assessment. By the end of March 2015, a full literature review analyzing 115 peer-reviewed articles was conducted, 28 different social service providers were interviewed, 640 LGBTQ youth were surveyed, and 5 focus groups were facilitated with 48 participants. The findings, compiled into a final report, echoed Faith and Tim’s experiences:

  • 65% of survey respondents said that provider and/or client orientation towards their LGBTQ identity negatively impacted their service use experiences.
  • Past year substance use prevalence rates among queer/trans youth in Toronto ranged from 1.19 to 57.2 times higher than those of the general Canadian population.
  • 37% of survey respondents would like to or were actively trying to reduce or eliminate their alcohol use.
  • 44% of survey respondents would like to or were actively trying to reduce or eliminate their drug use.

Many queer and trans youth use alcohol and drugs to cope with the daily oppression they face in their lives and many use substances just to survive. When this population thinks they might have a problem with their use, they are unsure if existing services will be able to meet their needs as an LGBTQ person. When this population actually goes to get help and access services, 2 out of 3 have a negative experience because of their queer and trans identity. Survey respondents reported not feeling safe disclosing their identity, not being accepted for their identity, and being actively mistreated by health care providers. This results in an unfortunate situation where queer and trans folks must either access services that may be harmful to them, or completely disengage with services altogether.

To respond to these realities, P2P was envisioned as a peer based program – with all frontline staff being queer and trans identified and having their own lived experiences with substance use and recovery, however defined by each individual. In this model, lived experience is used both as an intervention strategy and as a tool to build community for people that are facing similar struggles. The program is currently housed at Breakaway Addiction Services[2] and, as a harm reduction program, offers 1-to-1 support through case management, hosts 3 community drop-in nights and co-facilitates dialectical behavioural therapy (DBT) groups.[3]

Throughout P2P’s work, the access needs for gender variant individuals in health care settings have been made clear.

Top three needs

All-gender bathrooms, inclusive in-take forms, and respect for an individual’s pronouns.

When these needs are not met, patients/clients report feeling like they are not respected or understood for who they are, which can result in them discontinuing treatment or not accessing health care in the future.

10 Tips for Engaging and Supporting LGBTQ Youth

  1. If you don’t know or understand a particular concept, “Google It” or ask a colleague.
  2. Avoid making assumptions about peoples’ gender, sex and sexual orientation.
  3. If you’re unsure about a person’s pronouns, ask them.
  4. If facilitating a group environment, incorporate a “pronoun go-around” and also ask if participants have any access needs.
  5. If you make a mistake, it’s okay. Apologize and make it right next time.
  6. Show that you support the LGBTQ community.
  7. Know your limitations in supporting someone and if necessary, refer to a colleague or another organization.
  8. Stay up to date and keep yourself informed about historical and contemporary LGBTQ issues. If you have learned something, share it with others.
  9. Ask the person what they want, what they need and how they want their experiences defined.
  10. Understand that not all queer and trans youth have the same experiences.

 

[1] 12-Step programs are community based supports where individuals who identify as addicts and alcoholics meet to mutually support one another.

[2] Located in the Parkdale area of Toronto

[3] The drop-in spaces include an abstinence night on Monday, a harm reduction space for racialized youth on Tuesdays and a harm reduction night on Thursdays. P2P regularly works with many addiction, harm reduction and mental health service providers in Toronto by providing LGBTQ and harm reduction advocacy, education and training. Once a month, P2P hosts a community harm reduction kit making event that is open to everyone, where participants can make safer use kits for crack use, injection drug use, crystal use and partying, as well as kits for injecting hormones and safer sex practices. P2P regularly attends drop-ins of partnering organizations and parties to do harm reduction outreach and to hand out kits.

 

Decolonizing Gender, Sexuality & Mental Health

How has trauma inflicted upon my people through Residential Schools and the Sixties Scoop impacted our views around gender and sexuality? How has religion changed how we view relationships? How has language extraction impacted the ways we talk about gender and sex? These are questions I ask myself when I think about why Indigenous people have disproportionately high rates of sexually transmitted infections, including HIV/AIDS. Indigenous communities can also be very transphobic and homophobic, due to the impacts of colonialism and the pervasiveness of homophobia and transphobia elsewhere in society.

The biggest underlying issue that is affecting us is stigma and how that continues to impact the mental health of Indigenous people across Canada.

I am a Saulteaux-Cree First Nations person who identifies as Two Spirit, Queer and Trans. I grew up in an urbanized community, and spent a big part of my life within the Friendship Centre movement surrounded by other Indigenous people. I feel a great deal of privilege being trans and queer while growing up in an urban community because I have had a significant amount of access to resources and space to explore my identity compared to my Two Spirit & Indigenous LGBTQ+ friends in the North.

I have access to knowledge and information that has allowed me to expand my knowledge on sexuality and gender. I have had access to spaces that are affirming for my identity and I know where to meet other LGBTQ+ people. I have choices in which communities I choose to spend my time with. I know how to access Hormonal Transition Therapy and know that my transitioning costs can be covered under Indian Status. I have been able to learn and advocate more about sexuality and gender without the fear of being outed. Because of my access to my resources, I’m not afraid to be myself. Because of feeling comfortable with my identity, I am comfortable with my body and exploring and learning how to talk about sexual health. It’s also been easier for me to destigmatize my own views around sexuality and gender and to even pursue a career in sexual health. I have learned how to navigate the health system with ease because of this. I know where to go to for a routine sexual health check-up, and I wouldn’t be afraid if I was diagnosed with an STI. I know what contraception methods are available to me under Indian status and how to get Plan B for cheap. I know how to access counselling services for sexual assault, and also where and how to access an abortion if I ever need one. I have had access to a basic understanding of sexual health because of the public school curriculums I have been a part of. I think these are things that many of us take for granted.

For the past year and a half, I’ve been working alongside many different Indigenous communities to broaden their understanding of sexual health, gender and sexuality. I’ve also worked with many Indigenous youth leaders who do the same work. Storytelling and sharing circles, where participants sit in a circle to share stories without interruption, are ways that Indigenous people share knowledge with each other and have become foundational to my work. It is important for me to put time into listening to the various experiences that Indigenous people go through when it comes to sexual health, sexuality and gender. It was through this process I learned more concretely about how the violent history of colonialism has impacted many Indigenous people across Canada, and how many Indigenous people still hold stigma around sexual health, sexuality and gender. I have met many Indigenous people who have shared their stories with me and they have allowed me to share pieces of them with others for the purpose of starting these conversations.

The stories I have heard many times in multiple different ways from various people have had the same theme: ​fear​.​ ​From fear around coming out to their families and communities due to homophobia and transphobia, to fear of being gossiped about in a small community after being spotted by a community member at the sexual health clinic. Another person shared how an HIV/AIDs service provider breached confidentiality of a client’s HIV status, and how it impacted their life. The most dangerous part of these stories is stigma and how it silences people and results in negative mental health impacts for those experiencing these incidents.

Indigenous people who identify as Two Spirit and LGBTQ+, as well as Indigenous people post-diagnosis, are more likely to experience suicidal thoughts at some point in their lives. Conversations around sexual health, sexuality and gender can be difficult for many Indigenous people because these words have potential to hold a lot of power, and also possess a history of trauma. This is because of the legacies that systems like Residential School and the Sixties Scoop have created.

Indian Residential Schools were government-sponsored Christian-based schools to assimilate Indigenous children into European culture. Many children were forcibly taken from their families to attend and were punished for speaking their native language or practicing their culture. The educational curriculum was inadequate, and many Indigenous children were sexually abused throughout Residential School.

The Sixties Scoop was a government-run practice of forcibly taking Indigenous children throughout the sixties and placing them into foster homes and adoption. Being separated from your community, culture and language is traumatizing for Indigenous children, and we have seen the effects that these systems have created for Indigenous people currently. When Indigenous children were separated from their culture and language, they were also separated from teachings around the fluidity of gender and their roles and because many Indigenous people now strongly believe within the Christian faith, it has also stigmatized our views around sexuality. It was through these systems that talking about sexual health, sexuality and gender has become shameful to talk about, as well as traumatic.

How then do we approach the stigma of sexual health, sexuality and gender? I have learned through my work that storytelling and sharing circles are a very powerful way for Indigenous people to share their stories of misconception, pain, trauma and stigma while also reconnecting to culture. Sharing circles have potential to be healing and can take a trauma-informed approach. They are a crucial way to help Indigenous people learn and unpack the ways that we view gender and sexuality, and to help destigmatize conversations about healthy sexuality, sexual health and harm reduction. It’s through these conversations that we will begin to turn shame into resilience.

LGBTQ Life: First visit to the doc

You’re visiting a walk in clinic for the first time. The receptionist loudly asks, “What is the reason for your visit?” Panicked, you glance around the room: you were already worried about running into somebody that you know, and now you’re worried that everybody will know why you’re here. “I want an STI check”, you reply. He hands you an intake form.

The form asks, “Are you sexually active? Y/N” You mark yes, though you aren’t sure that the form is asking about the kind of sex that you’re having. Only three options are provided for sexual orientation: heterosexual/homosexual/bisexual. None of those terms work for you, and you don’t know how to respond. You stare around the room. There are posters on the walls, but none of the people on the posters look like you.

When you see the doctor, she immediately begins going through your intake form. “You last saw a doctor seven years ago? Don’t you realize the importance of regular medical care? You need to see a doctor every two years at the very minimum!” She doesn’t ask why it’s been that long: if she had, you could have told her that your last doctor had been the same one that your parents go to. That you never told him about your sexual orientation because you were worried about what he would say and who he would tell. Eventually you just stopped going.

She continues. “I see here that you’re sexually active. What kind of birth control are you using?” When you tell her that you aren’t using any birth control, her eyes widen: “Aren’t you aware of the risk of pregnancy? Are you sure that a pregnancy hasn’t already occurred?” When she sees your response to the question about sexual orientation she pauses: “Oh, I couldn’t tell! Well, I guess we don’t need to worry about the birth control, then.”

She finishes going through the intake form, and tells you to lie down on the exam table for your physical. By now, you don’t want to see the doctor. You haven’t had any symptoms of an STI, anyways, so you think you’re probably fine. But you’re already in the paper gown, and you feel too awkward telling her that you want to leave. As she does the exam, she says, “You know, I have a bisexual cousin and we were always so jealous of her. Twice the dates! But she always had been greedy.” You want to tell her that what she’s saying is oppressive, but by now you feel like you can’t say anything at all.

Finally the appointment is over. As you leave, you mutter to yourself, “I am NEVER going back.”

TAKE TWO

You’re visiting a sexual health clinic for the first time. You’re nervous about running into somebody you know—from what you’ve heard, everybody goes to this clinic—but glad to be in a space with such a good reputation.

You look down at the intake form that the receptionist handed you. The form asks for the name on your health card, but there is also a separate question asking, “Do you go by another name?”  You’re relieved. You haven’t used the name on your health card in years, and hate having to answer to it. It’s good to know that you won’t have to correct anybody here. The form asks for your pronoun, your gender, your sexual orientation. Each question includes a long list of options as well as an “other” box: you’re glad that you could write anything in. Once you’ve filled out the form, you look around the clinic. The space is colourful and friendly, and there are posters on the walls. You see a positive space poster, and a couple of posters advertising LGBTQ groups in the area. Flyers on a table provide information about other available community resources.

When you’re called in for your appointment, the doctor uses the name that you had asked to be called. She tells you about herself and the clinic, emphasizing that they are LGBTQ-positive. She confirms the information that you had provided on your intake form, but doesn’t assume what that information means. She asks you about your relationships, sexual activity, and the protection that you’re using. You watch the doctor closely, trying to see if she’s judging you, but her friendly attitude doesn’t change. Based on the information that you’ve provided, she recommends some tests and asks what you think. You tell her that you would also like to be tested for HIV. She agrees, explaining that a positive test would be recorded, and asks if you would like a referral to an anonymous clinic. When you tell her that you’re comfortable being tested where you are, she reassures you that all of the tests you’ve agreed on can be performed onsite. You’re relieved that you don’t need to go anywhere else: based on past experience, you know that not all healthcare environments are so friendly. As the doctor performs your exam, she tells you what she is doing and checks in to see if you’re comfortable. Considering the fact that you’re at a doctor’s office, you really are.

Before leaving the clinic, you fill out a feedback form: “This was great! The most LGBTQ-positive clinic I’ve ever been to!”

Which version do you want your visit to look like? What else makes for a good/bad experience? Let us know in the comments below!