groups to give any credence to those expounding this method of reducing HIV/AIDS. The value

of sex and procreation in many cultures makes it difficult for someone from outside the client's

culture, especially someone of a different gender, to tell people to not have sex or to have sex

only with a condom.

Finally, it is important that the counselor recognize that much of what is asked of clients and

their families is personal and private. Questions related to sex, dying, and substance abuse are

not usual topics of conversation, and when asking these questions, the counselor crosses many

boundaries. It often is considered disrespectful (and offensive to certain cultural values) to ask

questions about these specific areas. One wise way to broach these subjects with clients,

especially clients who are significantly older than the provider or from a more traditional culture,

is to simply apologize

The most practical advice is for providers to (1) maintain an open mind, (2) use cultural

consultants for training and support, and (3) when in doubt, defer to the concepts of health and

stability over pathology and dysfunction.

Figure 7-4 presents the LEARN model developed by Berlin and Fowkes, an excellent cross-

cultural communication tool that can be useful in all client encounters, especially with clients

who are culturally different from the provider and who have HIV/AIDS and substance abuse

disorders.

Special Populations

Gay, lesbian, bisexual, and transgender populations

Providers wishing to serve the needs of particular ethnic or cultural groups have learned that

communities must be understood, respected, and consulted in order to make effective

interventions; this also holds true when working with gay men, lesbians, and bisexual men and

women. This population is defined not by traditionally understood cultural and ethnic minority

criteria, but by having a sexual orientation that differs from that of the majority. Transgender

people also form a unique population, often linked to gay men, lesbians, and bisexuals, although

they differ from the majority by gender identification rather than sexual orientation.

Until recently, there has been no solid agreement about the amount of substances used or the

incidence of substance abuse in the gay, lesbian, bisexual, or transgender populations. Most

studies (Beatty, 1983; Diamond and Wilsnack, 1978; Lewis et al., 1982; Lohrenz et al.,

1978; McKirman and Peterson, 1989; Mosbacher, 1988; Pillard, 1989; Saghir and Robins, 1973),

reports (Fifield et al., 1975;Lesbian and Gay Substance Abuse Planning Group, 1991), reviews

of surveys (Morales and Graves, 1983; Weinberg and Williams, 1974) and the experiences of

most clinicians working with gay men and lesbians (Cabaj, 1989; Finnegan and McNally, 1987)

have estimated an incidence of substance abuse of all types at approximately 30 percent, with

ranges of 28 to 35 percent (contrasting with an incidence of 10 to 12 percent for the general

population). The CDC's biannual report on HIV/AIDS clearly indicates a subgroup of gay and

male bisexual injection drug users, and one of the routes of HIV infection for lesbians is via