NCAD Spotlight: Navigating Ethical Challenges When Working with LGBTQ+ Patients

With regards to ethics, providing addiction treatment for special populations requires special considerations. In particular, working with LGBTQ+ clients who are struggling with their identity and/or sexual orientation in addition to substance use disorder issues can create ethical dilemmas for providers to navigate.

At the upcoming National Conference on Addiction Disorders, Mark McMillan, LMSW, CAADC, a behavioral health and addiction therapist for the Center for Relationship and Sexual Health in Ferndale, Michigan, will provide an overview of ethics for SUD treatment and LGBTQ+ clients. Ahead of that session, he spoke with Addiction Professional about some of the unique ethical dilemmas faced in treating this population, the differences between inappropriate and unethical behaviors, and additional challenges created by COVID-19.

Editor’s note: This interview has been edited for length and clarity.

What are some of the challenges clinicians face when navigating ethical dilemmas specific to working with LGBTQ patients?

When we say ethical dilemmas, we’re talking about making the best choice possible. In a sense, we have a lot of guidelines out there. To be more specific with this presentation, I wanted to shine a light on what you’re asking specifically—ethical dilemmas when treating LGBTQ clients, navigating substance abuse—and one of the biggest challenges is meeting clients where they’re at without comprising things we might not consider, like having a person come out to other staff members when they’re not out, understanding and appropriately navigating a coming-out process for some. Sometimes “forcing” the client to come out to choose the appropriate track and a higher level of care, like intensive outpatient or residential treatment. … I’m in private practice here in Ferndale, Michigan, and I often talk about the luxury of where I can navigate without having to be mindful of other policies in the venue where I’m at. One of the last things I talk about with ethical dilemmas is understanding how we may “force” some clients to become abstinent. I’m a big believer in harm reduction. Especially in this community, a higher number of us—especially our gay and lesbian brothers and sisters—are really navigating challenges with substance abuse based on trauma in their childhood attached to our sexuality. In the sense of saying “I want to get sober or stop using,” it may not be the best approach to say “be abstinent or stop using immediately” without first understanding the full person and where they’re at with regards to coming out, were there challenges with their family support and work, and things like that.

Can you clarify the difference between an inappropriate behavior and an ethics violation? Are all inappropriate behaviors ethics violations and vice versa?

The idea here, inappropriate behavior and ethics violations, we get more into not only policy—starting with policy in the venue, then going to state laws and federal HIPAA requirements. Inappropriate behavior, again, might lean into some of the things I said earlier. We may be forcing people to come out. Another example might be with a transgender client, inappropriately placing them with regards to their gender and how they are presenting. A trans female client who was born male, it might be inappropriate to have that person go through a male track in a residential or IOP program. Another inappropriate behavior, we are talking about three things: how we interpret certain policies, how I may feel I’m doing this for the right reason but really am not, and then we are more aware of policy, but where my own values and morals may lie and I’m not really current with societal changes and opinions, and always, we’re working within the venue and HIPAA policies. Another inappropriate behavior as opposed to an ethics violation may be having a client go to prayer circles or having them be in a spiritual or religious setting without understanding that person’s spirituality or religious beliefs. In the presentation, I talk about religious freedom precedents going on today, the idea of withholding services or valuable mental health services based on the person’s sexuality or gender identity.

There is the example of “I’m not going to make a wedding cake for a gay couple,” but more often, we subtly may guide someone to a certain service within the venue or to other types of programs within the county based on our own beliefs and not what the client is telling us. The last thing I would say is with inappropriate behavior and ethics violations, I’m a big believer in being competent. Ethics say we are experts and competent in the services we are providing. That sense of “come to me and receive services,” if you’re LGBT, and I’m only “friendly” to a certain type of client, this sets up an idea that this type of person who feels they are competent but only [selectively] friendly, they may be making more inappropriate subtle decisions with micro aggressions, not having the person feel validated and putting them through a “system” that doesn’t recognize them for the individual they are.

How has your work been impacted by COVID-19?

Going into a stay-at-home order or lockdown, and not having access to recovery meetings. Any of those 12-Step or recovery groups—I tend to stay away from saying “AA or 12-Step” groups because there are so many other types of groups out there now—where we were meeting in person. Navigating through this, it does a lot for someone not even newly sober or newly clean, even someone long-term. We miss the fellowship. We miss having connections and those moments.

In addition to trying to navigate something we’ve never been through before—a worldwide pandemic—we’re also going back to our roots and feeling newly sober again. We’re trying to connect through video conferences. We’re trying to figure out how it feels to share. ... There was a lot in that sense in a recovery community, where already in the LGBT recovery community, it’s pretty much a rural setting because there are only so many groups around. Now that things have slightly changed, before COVID hit, we were well-known and more “out” in other mainstream groups. I believe certain specialty groups are important, like LGBT or even a trans group. Having that lockdown and not being able to go, for older clients, I’ve heard the term “putting us back in the closet.” There was a lot there to navigate.