Sexuality and Gender: Implications for Transgender Populations

Transgender people are at an elevated risk of developing substance use disorders, according to the Center for American Progress. An estimated 20–30 percent of transgender people misuse substances, compared to around 9 percent of the general population in the United States.

Intense stress (especially trauma) is a primary risk factor for developing a substance use disorder. And transgender people typically experience a lot of stress, as Dr. Tammi Furman Dice and her husband, Farley Center therapist Tony Dice, M.S.Ed., explain in their presentation as part of the  Williamsburg Place Lecture Series. Tammi Dice has a Ph.D. in counselor education and supervision and is an associate dean at Old Dominion University in Norfolk, VA.

The stress many transgender people experience arises from relentless discrimination and stigma. Transgender people frequently turn to drugs and alcohol as a way to cope with these challenges. A shocking one third of transgender people attempt to commit suicide.

Gender Identity versus Sexual Orientation

The terminology around transgender people is evolving and can be very confusing for cisgender people (a term used for people whose gender identity matches the sex that they were assigned at birth). Tony starts the lecture by introducing himself as “pansexual” (a person sexually, romantically or emotionally attracted toward people regardless of their sex or gender identity), and by announcing that his pronouns are he, his, and him.

One objective of the lecture is to “promote understanding and use of current terminology.” Another key objective is to describe the differences between gender identities and sexual orientations. Pansexuality is Tony’s sexual orientation, while his pronouns indicate his male gender identity. Gender identity refers to the personal sense of one's own gender while sexual orientation indicates to whom a person is attracted sexually. As Tammi explains, a biological female identifying as a man (gender identity), but attracted to females is heterosexual (orientation), not lesbian—which would imply that such a person is really a female because of his genitalia.

Gender identity is no longer considered to be binary either, with male or female as the only two possibilities. When it comes to the transgender category, most people are familiar with female-to-male or male-to-female transitions, such as Caitlyn Jenner. “That’s what we think about when we hear transgender,” says Tammi. In reality we are talking about a spectrum. Gender identity does not necessarily begin or end with identifying as male or female. Some individuals do not identify with some or all of the aspects of gender assigned to their biological sex.

Genderqueer, also known as non-binary, is a third category for gender identities that are not exclusively masculine or feminine‍—‌identities that are outside the traditional gender binary. Genderqueer people may express a combination of masculinity and femininity, or neither, in their gender expression. Genderqueer individuals may also identify as having two or more genders or no gender, or moving freely between genders (genderfluid).

Transgender Emergence Model

Developing a gender identity is a normal process, but for gender-variant people this process is complicated by a dissonance between cultural expectations and their core sense of self. In her Transgender Emergence Model, family therapist and educator Arlene Istar Lev identified six stages in this process:

  1. Awareness
  2. Seeking information/reaching out
  3. Disclosure to significant others
  4. Exploration (identity and self-labelling)
  5. Exploration (transition issue and possible body modification)
  6. Integration (acceptance and post-transition issues)

Recognizing these stages and thus understanding the transition experience of transgender people better enable the therapist to be an affirming helper. It can also help avoid unintentional micro-aggressions. “Therapists have to be aware of the way they are engaging,” says Tammi. “Workshops like this one are important so that you can become more sensitive and skilled.” Unskilled questions like “What is your real name?” and statements like “You look just like a real man” raise barriers between therapist and client and impede their therapeutic alliance.

Therapists should always remember that the client is the real expert in the room. While it is perfectly appropriate to ask questions, they should be imbued with a certain awareness and avoid minimizing the reality the client is living. As a therapist, “I will meet you where you are,” explains Tony. “Question could be, ‘How would you like me to address you?’ or ‘What are your pronouns?’ to let down potential walls.” Don’t automatically assume the client wants surgery simply because he/she/ze/ey identifies as transgender.

Pronouns Matter

Some genderqueer people prefer to use gender-neutral pronouns. Usage of singular they, their, and them is the most common. Ze, hir, hirs and ey, eir, em  are used as well.

In 2012, a gender-neutral pronoun "hen" was proposed in Sweden. Swedish was the first language to officially add a third-person neutral pronoun for people. "Hen" can be used to describe anyone regardless of their sex or gender identification.

This much language change and variety can be daunting and confusing. Tony and Tammi recommend an affirmative therapy approach: listen to their narrative without judging. Individual clients can express who they are, and the therapist’s role is to affirm it, not to correct it. “You don’t try to change them but affirm and support,” explains Tammi. “As a therapist, you should realize these individuals have likely experienced mass quantities of discrimination outside of your counseling environment. The best approach you can use is to honor who they are.”

As a result of the widespread discrimination and other stressors, substance abuse is disproportionately high in the transgender population. Addiction professionals should not try treating substance use disorders without an understanding of the co-occurring transgender situation. Since the client is likely to have suffered sexual assault and other physical violence, trauma-informed care is also indicated. Frequently, an interdisciplinary approach is required to deal with multiple medical and psychological problems. Proficient therapists reach out and collaborate.

Tammi and Tony Dice finished the lecture with a case study of a patient in an addiction treatment center. On his intake forms Jack indicated that he was a 32-year-old African-American heterosexual male. During treatment, Jack disclosed that he was transgender and wished to use the time in treatment to begin her transition. She requested to be referred to as “Jacky” and wanted to be transferred to the female dormitories. She stated that she had been aware of her transgender status for some time and had been misusing drugs as a way of coping with “living a lie.”

At The Farley Center, addiction treatment addresses all the needs of the patient based on a thorough assessment. Traumatic experiences can alter the way people cope with stress and, in turn, affect recovery. Chronic pain, depression, anxiety, medical conditions, or a non-traditional gender identity need to be addressed in therapy.  Supportive needs vary from individual to individual.

Farley’s multidisciplinary team—which includes an addiction medicine physician, an addiction psychiatrist, psychologists, licensed clinicians, nurses, and patients—collaborates to maximize a comprehensive treatment approach to heal body, mind, and spirit.