The Importance of the Disclosure Interaction for LGBTQ Clients

Addressing LGBTQ issues in treatment

It is important for providers to address LGBTQ issues in treatment. In addition to the customary needs of every patient, the LGBTQ population has several special needs, which include coming out, internalized heterosexism, social support, dating and intimacy for sexual minorities, use of certain drugs and the role of spirituality (Hicks, 2000; Rowan & Faul, 2011). For example, discrimination and internalized heterosexism, or believing the negative stereotypes for being LGBTQ, have been linked to higher rates of substance use (Weber, 2008).

However, before these issues can be identified, the provider must first know the sexual orientation and gender identity of the patient.

Disclosure Distinct from Coming Out

Sexual orientation and gender identity are often hidden characteristics, not visibly apparent. LGBTQ individuals may need to disclose their sexual orientation or gender identity to make this information known. Disclosure is verbal or nonverbal communication of an LGBTQ identity. Disclosure is separate from the coming out process, which many LGBTQ individuals go through when first identifying as LGBTQ. Disclosure can happen at any point in the coming out process, provided the environment supports it. Disclosure may include spoken statements, but can also occur through clothing and appearance. Disclosure can happen on a daily basis in many different contexts, such as at work, at the grocery store, or at the doctor’s office. Every time an LGBTQ person reveals their sexual orientation or gender identity to a new person is known as a disclosure interaction.

Research has shown that the disclosure interaction is an important component of a healthcare interaction. This has been most consistently shown in the medical and nursing literature, where disclosure to healthcare professionals has been studied for decades (e.g., Brotman, Jalbert, & Rowe, 2002; Hitchcock & Wilson 1992). Between 25% and 90% of LGBTQ individuals disclose to their healthcare provider. Research on disclosure in the behavioral healthcare environment has not been as extensive, but inferences can be drawn from the above as well as the psychological (e.g., Frank & Leary, 1991; Mohr & Fassinger, 2003) and behavioral health (e.g., Green & Feinstein, 2012; Matthews & Selvidge, 2005) literature.

Many variables have been found to influence the decision to disclose (Jamison, 2010). These can be divided into patient characteristics, provider characteristics, and healthcare environment. Men disclose more frequently than women, as do those from higher socioeconomic statuses. Individuals aged 30-60 disclose more often than younger or older people. Individuals from more populated areas disclose more frequently than those who live in more rural areas. People who have positive attitudes and beliefs about their LGBTQ identity disclose more often than those with negative views.

In terms of provider characteristics, LGBTQ individuals disclose more frequently to female providers, and to younger providers. If the LGBTQ patient knows or suspects the provider is LGBTQ as well, this facilitates disclosed to more often. The geographic area of the healthcare facility is important; those in more populated areas, and those in known LGBTQ-friendly sections of cities, promote disclosure.

Finally, the context of the health care visit will influence the disclosure interaction; if LGBTQ patients believe their sexual orientation or gender identity is important for their presenting concern, they are more likely to disclose.

The biggest predictor of whether or not disclosure occurs is the perceived anticipated level of acceptance of that disclosure. That is, people who believe their disclosure will be positively received are more likely to disclose. Those who believe their disclosure will be met with a negative reaction are less likely to disclose. This is independent from how they feel about their own sexual orientation or gender identity. As a result, LGBTQ individuals engage in a constant risk-benefit analysis, looking for clues in each new situation as to whether or not it will be safe to disclose. In most cases, physical safety will trump psychological comfort; a person will not disclose to remain physically safe even if he or she is psychologically uncomfortable doing so.

And disclosure is important to the health of LGBTQ individuals. All of the following findings have implications for the LGBTQ individual in substance use disorder treatment. Individuals who report positive disclosure interactions report positive psychological outcomes, such as feeling heard, cared for, and empowered. Negative interactions are associated with feeling embarrassed, ashamed, exposed, vulnerable, ignored, denigrated, terrified, betrayed, and traumatized.

Positive interactions lead to higher levels of trust and openness between the patient and provider. With negative interactions, patients are less likely to communicate other information that may be important to their care. When disclosure is positive, more accurate diagnoses are given, along with better treatment advise, appropriate education, and relevant recommendations.

The opposite is true with negative interactions. Positive interactions are associated with higher adherence to medication and treatment recommendations, along with higher rates of seeking help in the future. Negative interactions are associated with lower adherence to treatment recommendations and individuals are less likely to return for care in the future. Individuals who have positive interactions are more likely to involve their family in their care.

The Disclosure Interaction

Given the relationship between disclosure interactions and health outcomes, it is important to understand this dynamic, complex, multi-dimensional construct. The disclosure interaction has three factors: initiation, communication, and acknowledgement. Initiation refers to how disclosure may be prompted, made difficult, or discouraged. Examples include a question on a form or during an interview, a connection to a presenting concern, or the presence of a support person.

Communication refers to information patients give about their sexual orientation or gender identity, including ways they may keep this information hidden. There are four types of communication arranged along two dimensions: active/passive, and disclosure/non-disclosure. Active disclosure is when a patient makes a direct statement regarding their status. They might state, “I am gay,” or “I am a transgender male.” If indirect information is given without a direct statement, this is passive disclosure.

An example might be if a female patient refers to her partner as “she,” or if a male patient holds hands with his male partner in front of a provider. For bisexual patients, they may state they have relationships with men and women, without stating their sexual orientation. A male transgender individual may passively disclose by saying, “I was born a female.” Passive non-disclosure occurs when the patient avoids giving information about their sexual orientation or gender identity, but does not directly lie about it. A patient who avoids conversation about their partner, or one who sidesteps a question about relationships by stating, “I am not in a relationship,” would be engaging in passive non-disclosure. A transgender patient may avoid questions about their childhood.

Active non-disclosure involves presenting oneself as heterosexual or cisgender. It is lying to protect oneself. A gay patient might say “I am straight” when asked about their sexuality, or substitute opposite-sex pronouns for their same-sex partner. Transgender patients may lie about what sex they were born into.

Acknowledgement refers to the reaction of the provider. It can be positive or negative. Positive acknowledgement includes when a provider shows a genuine sense of support and understanding, or is knowledgeable about LGBTQ issues. Providers engaging in positive interactions also encourage the partner to be there for the patient, and ask questions about the patient’s relationship (“How’s your partner?” “Do you two have children?”, “How long have you been together?” etc.).

There are many negative acknowledgment reactions providers can have. These include getting nervous, asking intrusive questions, and changing their demeanor to become more rigid and steely. Patients report interactions are negative when providers show confusion at their disclosure, or respond with “a certain look on their face.”

Finally, if a patient is using passive disclosure, a negative outcome can occur when the provider does not pick up on the patient’s clues. Interestingly, patients report different feelings about a provider who shows no reaction to their disclosure. Some feel it is positive, because the provider is taking the information in stride, and not reacting in any way. Others feel it is negative, because they cannot tell if their disclosure has been heard. It is safe to assume that showing no reaction can be interpreted different ways.

Most LGBTQ people say that they want to disclose, and that their sexual orientation and gender identity are important to their care. They want this disclosure to be met warmly, and for this information to be folded into their care. The disclosure interaction has important implications for the LGBTQ patient’s care, and providers can do many things to make the interaction a positive one.

To impact the initiation phase of the interaction, providers first need to examine their own biases and beliefs regarding sexual orientation and gender identity. They may need to confront ingrained beliefs from childhood, the media, and personal experiences. To communicate to LGBTQ patients that their disclosure will be welcomed warmly, treatment centers can evaluate decorations and literature in offices and common areas. A poster that depicts a same sex couple, or the presence of a LGBTQ-themed daily meditation book, can communicate a welcoming atmosphere. The presence of a rainbow flag can also indicate a welcoming environment.

Any paperwork that asks for information about gender or relationships should be constructed to be LGBTQ-friendly. For example, giving “transgender” as a choice in addition to “male” and “female” on intake forms. Alternatively, you can ask for gender and leave a blank space for patients to fill in as they define themselves.

During assessment interviews, the language the provider uses is critical. Using open questions is recommended. For example, ask “How do you define your sexual orientation?” instead of assuming the patient is heterosexual unless he or she corrects your heterosexist language. Assuming you know the sexual orientation of the patient because he or she is in an opposite-sex relationship is another common mistake. Many bisexual individuals remain invisible because of this. Ask clients how they define their gender, and which gender pronouns (he/him, she/her, or something else) they prefer.

If what the patient is communicating is unclear to you, ask questions to clarify and gather more information in non-judgmental way. Finally, use the client’s label, not your own. If the patient identifies as “queer,” use this term to apply to him or her and in your documentation instead of assigning another label.

Disclosure Interaction May Affect Recovery

Once communication has occurred, the provider can influence the interaction by how he or she acknowledges this disclosure.
  • Be aware of body language.
  • Do not turn away from the patient or leave the room.
  • Do not avoid eye contact.
  • Recognize the disclosure with an affirming statement.
  • Saying, “Thank you for disclosing to me; it’s important for us to know,” can indicate that the information will be treated with care.
  • Even a simple “That’s great” can affirm the patient.
  • Ask appropriate questions, such as how long the patient has been out, or when did they first identify as transgender. It is inappropriate to ask questions regarding sexual anatomy of a transgender individual.
  • You might ask about the patient’s family of choice, in addition to their family of origin.
  • Incorporate the disclosure into assessment and treatment, reflecting this information in future questions asked or information given.

The disclosure interaction usually happens in the space of a few seconds or a few minutes, but it is a critical exchange. It has a long-lasting impact on how engaged the patient feels in treatment and whether they will follow their recovery management plan.

There are many things providers can do to make the interaction a positive one. This includes examining decoration and forms, changing the language one uses, and making an effort to affirm the patient’s disclosure. Providers should do everything in their power to make the exchange a positive one for their LGBTQ patients, to give them the best chances of success in recovery.

Dr. Jorja Jamison has a PhD in counseling psychology with academic and research interests in lesbian, gay, bisexual, transgender, and queer (LGBTQ) issues, multicultural counseling, and Latina healthcare services. She has given numerous lectures and workshops, including at the American Psychological Association annual conference and the National Conference on Addiction Disorders. Dr. Jamison joined the Hazelden Betty Ford Graduate School of Addiction Studies as assistant professor in August of 2012. She is a licensed psychologist with the state of Minnesota and has worked in private practice. Dr. Jamison specializes in adolescent addiction, vocational issues for recovering individuals, and addiction within the LGBTQ community.

Vol. 20(1) Winter 2015 — Reprinted by permission of Paradigm magazine — • 1-800-522-3784
Read More
Signs of addiction

7 Ways to Tell If Your Loved One Has an Addiction

Identifying addiction in a loved one and talking about it with them. Read More >

Read More
Ask your treatment provider important questions before signing an authorization for treatment

12 Questions to Ask Every Treatment Provider

A checklist for each alcohol and drug treatment program. Read More >

Read More
Bounaries in Addiction Recovery

Self-Care is About Setting Boundaries and Letting Go

Learn how setting boundaries and letting go can help in addiction recovery Read More >