Queer and using substances, a ‘double whammy’: results from a needs assessment of substance use treatment professionals in South Africa

This study explored the training needs of substance use disorder (SUD) treatment practitioners in relation to their readiness in treating queer clients. We conducted a series of semi-structured interviews (N = 7) based in the Western Cape of South Africa. A thematic analysis identified themes related to treatment structures developed for a binary perception of gender, the burden of discrimination borne by queer clients that may impede treatment, and practitioner interest in further training and development. Our findings suggest that SUD treatment practitioners do not feel fully prepared to treat queer clients and are aware of a need for gender-sensitive training in this area. Improvements to practitioner training and readiness could yield benefits for both clients and practitioners within the treatment space.

South Africa contends with a substantial substance use problem and its treatment centres for substance use disorders (SUDs) face challenges related to material support and client accessibility (Myers et al., 2009;Peltzer et al., 2010;Pretorius et al., 2009;Ramlagan et al., 2010). Access barriers such as historical disadvantages (Myers et al., 2009(Myers et al., , 2014, finances (Burnhams et al., 2012;Myers et al., 2010), and rurality (Myers et al., 2011) make up some of the issues at hand, but gender-based barriers to SUD treatment have also been documented (Pretorius et al., 2009). Queer people, whose identities do not conform to predominant cisgender and heterosexual frameworks (Hyde et al., 2019;Robinson, 2016), are at considerable risk of SUD, possibly more than their cisgender and heterosexual counterparts (Glynn & Van den Berg, 2017;Keuroghlian et al., 2015;Kidd et al., 2018), but are rarely described in South African surveillance data. Surveillance data such as that generated by the South African Community Epidemiology Network on Drug Use (SACENDU) tracks demographics, prevalence and treatment enrolment and is a cornerstone to understanding the epidemiology of substance use in South Africa.
With few exceptions , data on queer gender identities are not collected in surveillance data, which limits knowledge on the prevalence and epidemiology of SUD in queer populations (Jobson et al., 2012;Nduna, 2012). This is despite international evidence suggesting that queer people experience an increased prevalence of SUDs (Glynn & Van den Berg, 2017;Kidd et al., 2018). The potentially high prevalence of SUDs in South African queer populations has been noted by various South African researchers (McAdams-Mahmoud et al., 2014;Polders et al., 2008;Stevens, 2012). Although it is scattered and under-examined, these data still reflect conclusions reached by international authors that SUD appears to have a disproportionate prevalence among queer populations (Glynn & Van den Berg, 2017;Newcomb et al., 2019). Queer people develop SUD for diverse reasons, including the high burden of discrimination and interpersonal violence borne by queer populations (McAdams-Mahmoud et al., 2014;Pitoňák, 2017;Polders et al., 2008).
Evidence of a high burden of SUD among queer populations coupled with low surveillance data speak to a problem of missing data (Keuroghlian et al., 2015). South African surveillance data do not account for sexual orientations, but the small amount of data on queer gendered people suggest very low enrolment in treatment . Low enrolment can imply the presence of access barriers and although the reasons for low enrolment can vary (Myers et al., 2010;Pretorius et al., 2009), healthcare practitioners are cited as a particular point of friction for queer healthcare users (Jacobs, 2019;Müller, 2016;Scandurra et al., 2019), due to a combination of discrimination and inadequate training.
Although the identification and address of gender-based gaps and deficiencies in South African healthcare institutions is a national priority (Tirivanhu & Jansen van Rensburg, 2018), there is asyet little focus on healthcare practitioners who treat queer people. This study focuses on South African mental healthcare practitioners working to treat SUD and is aimed at ascertaining their training needs for treating queer clients of a range of genders and sexualities. Emphasis is placed on practitioner needs due to their important position in the treatment process and to address the lack of research on practitioner experiences in this area.

Participants
Seven participants were drawn from a convenience sample of registered mental healthcare professionals working in the Cape Town Metropolitan Area of South Africa. All participants were working in SUD treatment practice at the time of recruitment and the sample consisted of six women and one man. The sample included three psychologists, three social workers, and one registered counsellor. Participants were recruited from a SACENDU register of healthcare practitioners and researchers in the Western Cape area, as well as through e-mail to work addresses.

Interview guide
All participants took part in semi-structured individual interviews with a focus on their training needs for seeing queer clients and treatment experiences with queer clients. In the context of this study, 'queer' clients included anyone receiving treatment who identified as other than cisgender or heterosexual. This is due to previous work (Jacobs, 2019) finding that healthcare practitioners can conflate gender and sexuality in their treatment of clients. Secondary topics included the recognition of, and policies regarding gender issues within their facilities and context-specific issues such as programme materials, and differences between group and individual treatment. All interviews were conducted in English at a time of the participant's choosing. Interviews for this study were conducted and recorded electronically due to travel restrictions imposed by the COVID-19 pandemic.
Examples of open-ended questions that could be asked during interviews include the following: Procedure Participant recruitment occurred electronically through a register of healthcare stakeholders in the Cape Town area with gatekeeper permission, or publicly available work e-mail addresses. Participants were provided with informed consent documentation for both the interview and audio recording of its contents. They were also informed of the purpose of the research and their right to withdrawal. Participants were assured of their confidentiality and that efforts would be made by the researchers to conceal their identities, and the identities of their clients and facilities.

Ethical considerations
Ethical clearance for the study was provided by the Rhodes University Ethical Standards Committee (RUESC) under tracking number 2019-0451-909. Participants were informed in detail about the nature of the study and their participation, and were assured of their right to withdraw consent at any time. The participants were also assured of the confidentiality of their responses and protection of any disclosure involving clients.

Data analysis
The thematic analysis procedure followed Braun and Clarke's (2006) approach while being mindful of common shortcomings associated with adhering to their approach too rigidly (Braun et al., 2016). The conventional process of inductive coding was performed in QSR International's NVivo 12, with the software environment allowing for more efficient sorting of codes and data, and their development into cogent themes. Where codes represent single, relevant units of data, themes are codes connecting to form a consistent topic across multiple sets of data that contribute to the study's aims. Generated themes were reviewed and organised until a final set capable of addressing the research aims was developed. Effective transcription and thick analysis were used in the analysis to make best sense of each participant's words in the context of their work and the wider study.

Results and discussion
All participants noted that gender-sensitive training with the aim of improving knowledge of queer clients would be useful, and that differences in opinion arose over preferred areas of improvement and training approaches. Participant responses revealed challenges that arose in treating queer clients, including a heightened burden of trauma and shame borne by clients, damaged support structures due to discrimination, and practitioners' own anxieties about relating to queer clients. In particular, participants indicated that their knowledge of queer identities was limited, which hampered their ability to understand the lived experiences of queer clients and treat them effectively. Their responses cast light on the gendered structures of SUD treatment that hampered the treatment of queer clients. These included better-known healthcare challenges faced by queer people -such as challenges related to living with a non-binary gender in a cis-normative bureaucratic system (Jacobs, 2021;Meer & Müller, 2017) -as well as challenges specific to SUD treatment (Jacobs, 2019). Issues discussed included how to house queer clients within gender-segregated in-patient facilities, the placement of queer clients into gender-segregated treatment groups, and facilitating therapy with discriminatory families. These issues identified spoke to the often-social nature of SUD treatment, which relies on group therapy and the placement of clients in closer contact with their support structures such as family, religious groups, and their community.
This article presents three of the key themes generated from the study. These three themes were (1) gender binarism in SUD treatment, (2) queer discrimination and substance use, and (3) interest in gender-sensitive training. Findings are presented as quotations with context and discussion directly below. In the pursuit of ethical goals to maintain participant confidentiality, each participant has been assigned a letter designation (Participant A, Participant B, etc.).

Theme 1: gender binarism in SUD treatment
Theme 1 presents evidence on the impact of an SUD treatment structure designed and normed for a two-gender population, and its effects on queer clients and the practitioners who treat them.
We have a specific manual for females, and we have specific literature for females in recovery -for women in recovery . . . we find that when it comes to women, we will then hold a women's-only group if we have enough numbers. At the moment in our treatment programme, we only have two women so then we'll do a co-ed group. (Participant 1, female) Like ninety nine percent of people who actually walk into our doors is male. Maybe not ninety-nine, but, you know, it's a very high percentage. Although we've been keen to actually also do the [programme's] women's sessions, we've never had enough women to actually constitute a group to actually run sessions. (Participant 3, female) We have far fewer women than men and that could put them in a vulnerable place. For example, in group therapy when sharing personal things about abortion or prostitution and they're in a group with men who they could perceive as similar to the people who have abused them. For that reason, we feel it is important to try and create a safer space for women. (Participant 5, female) The reason was comfort. I think the female patients wanted their own group. If memory serves. So the female sex addicts didn't want to be in the group with the male sex addicts. (Participant 2 female) Here, participants describe structures in their facilities that cater to a cis-normative standard. Chiefly, all participants reported working in group treatment settings, highlighting the social nature of SUD treatment programmes. Participants noted that men accounted for the majority of enrolments into their facilities, which is corroborated by surveillance data on client demographics (Hornsby et al., 2022). Women are supported through the availability of training and materials intended to work with 'women's' issues, but these resources may be unused due to low enrolment. Consequently, women are often folded into a default, co-ed treatment group. Participants described the role of gender-specific treatment groups in a protective and context-specific manner. SUD in women can appear alongside gender-based violence, such as heightened rates of intimate partner violence, sexual violence, sex work, and childcare burdens. These topics may warrant discussion as part of the recovery process but may be taboo or traumatising to discuss in a co-ed setting. Although an all-genders programme should be able to treat anyone, the necessity of developing materials and practitioner training aimed at treating women implies that all-gender programmes have shortcomings across different genders. Responses also emphasised the prevalence of men in treatment and the need to form protective spaces for women away from men.
So when one's looking at application forms for programs, or if one is looking at assessment or intake forms, it's the standard sort of tick male/female, you know? There isn't any acceptance or space for people who identify themselves differently. (Participant 3) I think maybe at the beginning of this year, or the end of last year. It's a topic of discussion that's come up like, 'okay, how're we going take this forward?' You know, when we're asking for gender on our assessment form, what space are we going to give there? Because it's the usual male/female thing. (Participant 1, female) But I did notice the other day, one of my worksheets that I need to change -I do a group on love languages, and in my worksheet it says 'he' or 'she'. I forget what it was speaking about in the worksheet, but I clocked that, and I thought 'ooh I need to re-phrase that pronoun or change those pronouns to be more inclusive. (Participant 2, female) The two-gender binary is visible outside of treatment groups too. Medical documentation typically reflects male and female self-identification and is a point of contention for people who identify outside of the binary genders (Cicero et al., 2019;Jacobs, 2021). However, an awareness of these gendered issues is also present among this participant group. Participant 1's facility was in discussions about adjusting their assessment documentation to reflect more diverse gender identities prior to the interview, and Participant 2 recounted a case of changing worksheets to reflect gender-neutral language. These actions point to a desire to better accommodate queer clients and are a positive sign for change.
Due to client demographics generally being aligned to cisgender men and women, practitioners and their facilities tended to operate within the gender binary. Their existing resources, procedures, and training were developed for a two-gender system and this is reflected in ordinary practices such as the formation of treatment groups. This is not unreasonable given the origins of their training and materials. However, shortcomings are revealed in this system of treatment when queer people arrive whose gender expression differ from the two-gender binary, but must still be organised into a two-gender system. Some of these challenges are revealed in the following themes.

Theme 2: queer discrimination and substance use
Theme 2 reports on participants' observations of an increased burden of discrimination faced by queer clients, and its interactions with substance use.
A lot of the clients come with a huge amount of trauma regarding their queerness or lesbian or gay status -whatever they identify with. It's usually a big part of the treatment plan, whether it's trying to help them work through accepting who they are, or trying to help mend family relationships, because you know the family relationships a lot of the time are broken because the person has come out . . . So yes, they're quite complicated cases. Lots of shame -I hate to say this, but sometimes more shame and guilt than someone who doesn't have to go through the experience of having to come out, you know? To open up to their families like, 'oh hey, I'm actually gay, and guess what I have a heroin problem'. So it's almost like a double-whammy in some ways. (Participant 1, female) Parental rejection, parental abandonment, parents not understanding the patient and their gender identity or their sexual orientation, and feeling rejected on that front. Which is quite a big thing, because if that's not accepted, then 'I'm not accepted'. If that is rejected, then, 'I'm rejected'. (Participant 2, female) I also think of family-related matters, because the issues of disorganisation in the family, judgement and acceptance in the family and support structures are also important. That is going to determine a person's ability to deal with the substance use -whether they have a healthy, positive support system that they can lean on. If that support system isn't there, then it's working with the person in identifying and developing a support system. (Participant 3, female) The participants above all noted burdens of discrimination and judgement faced by queer clients. Families were characterised as potential risk factors to a client's recovery when queer discrimination was in effect. This highlights the social nature of SUD treatment compared to many other forms of healthcare; the greater emphasis on social support in SUD treatment extends private disclosure beyond the therapist and into the realms of treatment groups, families, and communities. This is intentional and utilises social networks in a supportive role in the recovery process. However, the discrimination faced by queer people can ostracise them from communities that would normally be supportive. Consequently, practitioners face clients with fewer support structures, or who must mend support structures in the face of both stigmatisation against substance use and stigmatisation against queerness. This cross-cutting stigmatisation speaks to the complex, intersectional nature of discrimination and lived experience. To say nothing of well-studied forms of intersectional discrimination, including socio-economic status, race, ethnicity, and gender; intersectional challenges in healthcare access can arise in unexpected ways when two forms of stigma interact with each other. A system of practice that emphasises self-determination, personal reflection, and an awareness of intersectional issues can reinforce practitioner readiness and understanding (Psychological Society of South Africa, 2017).
A lot of patients we see have a lot of pain from their parental relationships. I mean the patient needs to be discharged right back into that family system. And that's often what they say is: 'Here I'm protected, but I need to go back into the world at some point'. (Participant 2,female) Participant 2 later remarks on some clients' feelings about being discharged from a protective therapeutic environment into a discriminatory familial environment, illustrating a concern for their long-term recovery in the face of discrimination. When the effects of simultaneous stigmatisation for having SUD and being queer are considered together, there is concern over the interlinked effects of both challenges. There is a real possibility that a high burden of discrimination contributed to queer people's substance use as a coping mechanism in the first place. Queer clients who enter treatment in that position may have to traverse a difficult recovery process with a weakened support structure and a heavy burden of shame. All of this occurs in a treatment system not developed to accommodate them and alongside practitioners who feel uncertain about how to care for them. The next theme will elaborate on one key area of SUD treatment that is not fully prepared to meet queer clients: the practitioners.

Theme 3: interest in gender-sensitive training
Theme 3 discusses the extent to which participants expressed interest in further gender-sensitive training, and specific points they raised on the topic of training.
Certainly, I think there is a need for that [gender-sensitive training]. For at least the awareness, the sensitivity, the start of the conversations around that. And then I think making those specific concerns more visible, more mainstream in a sense. (Participant 3, female) There's very little actually, we sort of scratch around for stuff. . . . I had to take the opportunity [to find a training facilitator] for myself and it was extremely helpful, but it wasn't laid down on any level in our training in our community or organisations. There's a need, a huge need, even if it's all final year university social workers getting a module that equips them for understanding. (Participant 5, female) And I think it [queerness] needs to be normalised, and it needs to be seen as not a thing that needs to be fixed, because there's nothing wrong there. And I think there needs to be more discussions around this. It needs to be taken from schools, to varsities, to treatments, to therapies, to CBDs, to talks, to everything. (Participant 6, female) When asked whether gender-sensitive training for the treatment of queer clients in SUD was necessary, all participants answered in the affirmative. Although different participants cited different priority areas, there was unanimity in the need for training. Participants 3 and 6 both noted that queerphobia was a societal ill that was not solely localised to healthcare practitioners and, as such, should also be addressed at the societal level. Participant 5's response to the need for training was accompanied by an anecdote of 'scratching around' and finding knowledgeable people to present informal training to her facility's practitioners. This experience simultaneously reflects the desire for gender-sensitivity training as well as its scarcity.
It's one of the things that I think we have to work on -I actually wrote it down on my piece of paper. The biggest space is our issue around language. What term do you use? What is the correct language? I don't think it's something we have necessarily focussed on. (Participant 1, female) I think your average social worker doesn't know the different identities are in that group. They have a vague idea, but they don't really understand. Among participants, the most highlighted area of improvement was that of the understanding of queer identities and language. This describes a foundational knowledge of queer identities, the ways of respecting queer identities, as well as the underlying reasons for why these behaviours are valuable -that is, queer literacy (Miller, 2016). The participants' responses speak to both a lack of knowledge about queer identities and an accompanying anxiety about using incorrect language. Participant 6 is most specific in their unease, as they recognise that correct forms of addressing and referring to individuals are an important part of being 'respectful', and they see their lack of knowledge as 'bad'. Rather than being something that only impacts clients, a lack of training affects practitioners' confidence and readiness to see their clients and can negatively impact them too. For practitioners who are aware of a need for more knowledge but cannot locate it, this can become a source of anxiety.
Training should be conducted in a manner that allows for processing and discussion of individuals' different attitudes -my experience has been that queer individuals may be confrontational in their approach, defensive to the point of being militant. . .this is not my experience with individual clients as such -in fact, those clients have been generally quite respectful -it has been my experience more so with specific NGO staff that may be working with queer individuals. (Participant 4, female) I wouldn't have a problem with presenting new points of view, but I do have problems with someone who has a specific idea that they think is right. I want people who are experts to do the teaching and for gender, it would not be great to teach it as dogma because that would be highly problematic. It should be about teaching varying points of view and new ideas -then it's better . . . Ideally, training should not be prescriptive, but training that presents new data, new information, new research. Especially so if there are counter-arguments and a presentation of many different theories. (Participant 7,male) The need affirmed by participants for more training was clear, but not without caveats. Some participants provided insights on the manner in which training should be conducted (pedagogy). These perspectives are very valuable, as any training programme would surely fail if it were completely rejected by the interlocutors. Participant 4 recounted their experiences with queer-supportive non-governmental organisations (NGOs) as sometimes being negative due to an inflexible or defensive approach to their work. Their response speaks to the need for training spaces to be spaces where practitioners can make errors and discuss personal attitudes that may be queerphobic. Participant 7 shared a similar sentiment and rejected training that is rigid and prescriptive while favouring training spaces that promoted openness to information and perspectives. Gender and sexuality can be divisive topics that are highly personal to everyone. The process of improving practitioner readiness for treating queer clients should be one of sensitisation, rather than instruction. It is notable that the preferred training space of these participants mirrors a safe, substance use therapy group: an open-minded space that allows people to share new perspectives and treats people's differences fairly.
Limitations of this study include a small sample size and lack of generalisability, as necessitated by the greater relative depth and capabilities inherent to qualitative research. As it stands, there is still an extraordinary amount of missing research in the realm of queer healthcare experiences in South African SUD treatment. Priority avenues include the expansion of surveillance data collection to better support queer identities and provide clarity on the epidemiology of substance use among queer populations, and further investigation into the training needs of SUD treatment practitioners in the treatment of queer clients. Equally lacking in South Africa are accounts from queer people in treatment, which would provide valuable insights into the rationale and characteristics of their substance use, as well as their experiences in treatment. Further research should prioritise the development of improved surveillance data on queer people experiencing SUD to better understand the epidemiology of SUD within queer populations. Improved surveillance data would also contribute to an improved understanding of SUD prevalence among different demographics, and eventually support training interventions that improve practitioner readiness in treating queer people. Based on feedback from participants in this study, priority areas of improvement for training include queer literacy and understanding of queer identities without sacrificing the palatability of training to practitioners.

Conclusion
The mental healthcare practitioners interviewed for this study expressed a need for gender-sensitive training to improve their readiness when treating queer clients with SUD. Although different participants raised different priority areas, there was substantial discussion on the value of improved training. Queer literacy was the most-cited gap, with participants expressing confusion about the array of queer identities, and fear of making errors in social interactions that may harm queer clients. Beyond their training needs, practitioners recognised that queer clients bore a burden of stigma alongside the existing stigma of substance use and this could negatively impact the treatment process. Discriminatory family and community environments were identified as specific points of tension for queer clients, especially considering the social nature of SUD treatment and its dependence on strengthening surrounding social support systems. Perhaps, most crucially, the structure of SUD treatment is designed to support a two-gender binary. When treatment groups are gendered, they are divided along male-female lines. Women may be collected into exclusive groups for protective purposes -to discuss 'womens's issues' in private or shelter them from trauma resulting from gender-based violence. This system may be adequate to address the needs of cisgender men and women, but research has begun to identify its shortcomings when it encounters gender-diverse and sexually diverse clients (Jacobs, 2019).