individuals, they commonly reported engaging in many of the same HIV risk behaviors as the
Counseling transgender individuals who are HIV positive and in substance abuse treatment can
involve many different issues. Some of these issues are obvious: lack of family and social
supports, isolation, low self-esteem, and internalized transphobia, to name a few. Some issues are
not so obvious; for example, transgender clients currently undergoing hormone therapy often
experience emotional and physical changes that can make treatment for substance abuse more
difficult and relapse more likely. Although medically managed hormone treatment should not be
interrupted, both the clinician and client must be aware that estrogen and testosterone therapies
are mind- and mood-altering substances, particularly when incorrectly taken. Improper
administration of estrogen mimics the premenstrual symptoms of nontranssexual women, which
can have a deleterious effect on recovery (CSAT, in press [b]). These premenstrual symptoms
can trigger or exacerbate Post Acute Withdrawal Syndrome, which is believed to be the leading
cause of relapse.
Additional relapse triggers or clinical issues may include the following: (1) inability to find,
engage in, or maintain gainful employment due to employer prejudice against transgender
individuals; (2) lack of formal education or training because the client was forced to leave school
or home before completing his or her education; (3) the fact that HIV-positive transgender clients
may be denied sex reassignment surgery due to their HIV status, even if they are asymptomatic
and healthy; and (4) the general lack of substance-free role models and widespread social support
for transgender individuals.
Clinicians, particularly those in rural areas, may have had little experience in treating transgender
clients. Figure 7-5 lists some guidelines that clinicians may find helpful in working with this
population. Some resources providers may also find helpful include the Lambda Center in
Washington, D.C. (202-965-8434), which provides behavioral healthcare programs for
transgender clients and others with HIV/AIDS and substance abuse problems, and the Center
Gender Identity Project in New York City (212-620-7310), which provides HIV/AIDS and
substance abuse counseling and referral services exclusively for transgender clients.
Women
The needs of women have always represented a unique challenge to health care and substance
abuse treatment systems. Traditionally, these challenges have not been well met and are being
exacerbated by the growing number of substance-abusing women infected with HIV. The
diseases of substance abuse and HIV/AIDS present differently in women than in men and
progress at different rates for a variety of reasons, including the fact that women usually present
later in the HIV/AIDS disease process than men.
Gender-specific services for women should include the following:
Medical and substance abuse treatment that is accessible, available, and incorporates
o General health (including reproductive health) and wellness across the life span
o Mental health counseling (particularly for PTSD)
