work with youth of any background, especially youth who are gay or lesbian or from an ethnic

minority background. Young gay males in particular may be subjected to harassment at home or

school, and they are prone to alcohol use, dropping out of school, running away, and getting

involved in sex for drugs or money (Ku et al., 1992; Rotheram-Borus et al., 1995; Savin-

Williams, 1994). Many young gay male streetworkers abuse amphetamines, "tweaking" to have a

sexual experience, and may exchange sex for drugs.

In general, gay men, lesbians, bisexuals, and transgender people are wary of the medical

establishment and may resist seeking health care, distrust the advice given, or question the

treatment plan suggested if the provider displays evidence of homophobia or heterosexism.

Transgender individuals

Some substance abuse treatment clients are transgender. The following definitions have been

provided to clarify the confusion some providers may feel when working with transgender

clients (CSAT, in press [b]).

Transgender people are a diverse group of individuals who cross or transcend culturally defined

categories of gender. They can include the following:

Male-to-female (MTF) and female-to-male (FTM) transsexuals--those who desire or



have had hormone therapy or sex reassignment surgery

Cross-dressers or transvestites--those who desire to wear clothing associated with



another sex

Transgenderists--those who live in the gender role associated with another sex without



desiring sex reassignment surgery

Bigender persons--those who identify as both man and woman



Drag queens and kings--usually gay men and lesbian women who "do drag" and dress up



in, respectively, women's and men's clothing

Female and male impersonators--males who impersonate women and females who



impersonate men, usually for entertainment

Gender identification is different from sexual orientation. Gender identity refers to a person's

basic conviction of being male, female, or transgender. Sexual orientation refers to sexual

attraction to others (men, women, or transgender persons). For example, many cross-dressers are

heterosexual men who have active sexual relationships with women. Many homosexual men,

although historically considered effeminate, identify strongly as men and appear very masculine.

Substance use plays a significant role in the high HIV prevalence in MTF transgender

individuals (Longshore et al., 1993, 1998). One study that investigated 519 transgender

individuals in San Francisco found high rates of substance abuse among both MTF and FTM

individuals (Clements et al., 1998). The study reported that 55 percent of the MTF sample

indicated they had been in substance abuse treatment at some time during their lifetime. The

study also found that HIV prevalence was significantly higher among MTF individuals (35

percent) than FTM individuals (2 percent), and among the MTF individuals, HIV prevalence for

African Americans was 61 percent. Although the HIV prevalence rate was low in the FTM