Purpose

1. Adolescent client responses to sexual orientation questions in the GAIN: What can we learn, what can we do Gillian LeichtlingRMC Research CorporationJoint Meeting on Adolescent Treatment EffectivenessDecember 14-16, 2010

2. Purpose • Utilize data from adolescent treatment assessments to explore: • What questions should be asked about sexual orientation when youth are assessed for treatment? • How can clients’ responses to sexual orientation questions be used to inform the treatment provided to them?

3. Sample • Dataset of youth attending federally-funded adolescent treatment programs across the U.S. that use the Global Appraisal of Individual Needs (GAIN) biopsychosocial treatment assessment. • As of 2008, the GAIN includes items addressing sexual orientation along three key dimensions: behavior, identity, and attraction. • Sexual behavior items are part of the required set of assessment questions for CSAT adolescent treatment grantees. • Identity and attraction items are optional. Some grantee agencies choose to use the items while others do not. • Study includes assessment data for youth who were asked all 3 sexual orientation questions (N = 2,342).

4. Sexual Orientation Items in the GAIN • Behavior • During the past 12 months, did you…have sex with a male partner?Have sex with a female partner? • Identity • Which of the following labels best fits how you would describe your sexual orientation identity? Nonsexual or asexual/ heterosexual or straight/ homosexual, gay, or lesbian/ bisexual/ questioning or curious/ not sure • Attraction • Do you currently have significant sexual or romantic attractions mostly to...the opposite sex/ the same sex/ both males and females/ neither males or females/ not sure?

5. Why Ask 3 Questions about Sexual Orientation? • Incongruence between differing aspects of sexual orientation is not uncommon. E.g., youth may report: • Same-sex sexual experiences with no LGBQ identity • Same-sex identity with no same-sex experiences • Same-sex attraction with no same-sex experiences • Asking only 1 question may fail to identify LGBQ youth. • Incongruent responses to the 3 questions may indicate internal struggles around identity formation or integration.

6. LGB Disclosure Rates by Gender • Percentage of youth in sample classifed as LGB based on responses to GAIN items: 6.9% (161/ 2,329*). • Variation in disclosure rates by gender: • Male disclosure rates extremely low (1.7%) compared to females (18.8%). • Male disclosure rate low compared to male LGB disclosure rates in adolescent general population surveys (conducted anonymously) • Female disclosure rate higher than in adolescent general population surveys. Note that in surveys conducted to date, lesbian/bi females report higher substance use than heterosexual females (Marshal et al., 2008). Could explain overrepresentation in treatment. *13 removed from original sample of 2,342 due to possible response errors.

7. LGB Disclosure Rates by Race/Ethnicity • Variation in disclosure rates by race/ethnicity: • African-American clients had lowest disclosure rates (4.6%) while those in Mixed/Multiracial and Other categories had highest (11.8%; 12.5%). Note: A longitudinal study showed delayed identity integration (e.g., participation in gay social activities, disclosure to others) for African-American LGB youth (Rosario et al., 2004).

8. Why Disclosure Matters for Treatment • High rates of victimization, suicide risk; potential family support issues; other issues critical to address in treatment • Impact of shame, isolation, deception on treatment progress • Disclosure rates could indicate level of internal comfort; could also indicate level of comfort created by the treatment agency. • Older studies show engagement and compliance may be higher when clients perceive providers as gay-affirmative (Paul et al 1991, O’Hanlan et al 1997, Liddle 1997).

9. Enhancing Disclosure Rates • Steps counselors can take to increase disclosure rates and create a positive recovery environment for LGBTQ clients: • Ask about LGB behavior, identity, and attraction. Opens door for the topic and shows counselor comfort in discussing. • Stay open to learning different/additional information as treatment progresses. • Respond to homophobia expressed by clients. Negative experiences with other group treatment participants can interfere with services. • Agency-wide practices important: policies, staff training, presentation as LGBT-friendly, e.g., display of LGBT-friendly posters/brochures, inclusion of LGBTQ in service literature. (Center for Substance Abuse Treatment, 2001)

10. Incongruent Responses to Behavior, Identity, and Attraction items • Examination of the degree of concordance in youth responses to GAIN items across the 3 dimensions was conducted to explore the following questions: • Do the CSAT-required behavioral items adequately identify LGBQ youth at baseline assessment or are the additional questions on identity/attraction necessary? • Are incongruent responses an indicator of earlier stage of identity development?

11. Comparing Responses to 3 GAIN Items • Overall LGB disclosure rates: 6.9% (161/ 2,329)*. • Looking only at the required behavior question, LGB disclosure rates were lower: 4.5% (104/2329) • More than 1/3 of LGB youth were not identified by behavior question alone *Including Questioning or Not Sure youth with no other LGB dimensions would add 13 youth, for a disclosure rate of 7.4% (174/2,329)

12. Is Age a Factor in Incongruent Responses? • LGB youth whose behavior, identity, and attraction were aligned (concordance across 3 dimensions) were older than youth with incongruent responses.

13. What Can “Incongruence” Tell Us? • Internal and external barriers (e.g., internalized homophobia, lack of support, victimization) may delay some youth from developing a consistent LGB identity (Carragher & Rivers, 2002; Rosario et al., 2001). • Identity integration process and substance use trajectory may be linked– more research needed. • Bisexual youth may experience more cognitive dissonance than gay/lesbian youth and may take a longer period of time to form and integrate their sexual identity (Rosario et al., 2001). • Bisexual youth (especially bisexual females) report particularly elevated substance abuse risk (Marshall et al., 2008; Corliss et al., 2010).

14. What Can We Do If Incongruence or Possible Internal Struggles are Identified? • Discussion: • Can we ask questions from a different angle to re-open the topic obliquely?E.g., family support, close friendships, experience with harassment. • Are there community resources we can offer? E.g., discussion group for questioning youth, counselor with expertise, gay/straight social group such as Gay-Straight Alliance • What other issues are important to discuss and particularly relevant to treatment progress?E.g., impact of multiple identities (such as ethnic/cultural identities), relationship between feelings of shame and substance use, social environment and support network, safety.

15. Conclusions • If providers ask only the CSAT-required behavior questions and do not include the optional sexual orientation questions (particularly the identity question), they may fail to identify more than a third of LGB youth. • Questions at assessment may under-identify males and African Americans. • Considerations: • Providers can take steps to increase youth comfort in disclosing and discussing sexual orientation. • Incongruent responses raise red flag about potential internal discomfort. • Addressing internal challenges (e.g., shame, suicidal ideation) and external challenges (e.g., victimization, family censure) relevant to treatment effectiveness for LGB youth.

16. References • Carragher, D.J., Rivers, I. (2002). Trying to Hide: A Cross-National Study of Growing Up for Non-Identified Gay and Bisexual Male Youth. Clinical Child Psychology and Psychiatry, 7:3, 1359–1045. • Center for Substance Abuse Treatment. (2001). A provider's introduction to substance abuse treatment for lesbian, gay, bisexual, and transgender individuals. Rockville, MD: U.S. Department of Health and Human Services. • Corliss H.L., Rosario, M., Wypij, D., Wylie, S.A., Frazier, A.L., Austin, S.B. (2010) Sexual orientation and drug use in a longitudinal cohort study of U.S. adolescents. Addictive Behaviors, 35(5), 517-21. • Lesbian, Gay, and Bisexual (LGB) Youth Sexual Orientation Measurement Work Group. Measuring Sexual Orientation of Young People in Health Research. San Francisco, CA: Gay and Lesbian Medical Association, 2003.

17. References (continued) • Marshal, M.P., Friedman, M.S., Stall, R., King, K.M., Miles, J., Gold, M.A., Bukstein, O.G., Morse, J.Q. (2008). Sexual orientation and adolescent substance use: a meta-analysis and methodological review. Addiction. 103(4), 546-56. • Pathela, P., Blank, S., Sell, R.L., Schillinger, J.A. (2006) The importance of both sexual behavior and identity. American Journal of Public Health, 96(5). • Rosario, M., Schrimshaw, E.W., Hunter, J. (2004). Ethnic/racial differences in the coming-out process of lesbian, gay, and bisexual youths: a comparison of sexual identity development over time. Cultural Diversity and Ethnic Minority Psychology. 10(3), 215-28. • Rosario, M., Schrimshaw, E.W., Hunter, J., Braun, L. (2006). Sexual identity development among lesbian, gay, and bisexual youths: consistency and change over time. Journal of Sex Research.

18. Questions? • Gillian LeichtlingRMC Researchgleichtling@rmccorp.com503.223.8248