Comparison of Government and Non-Government Alcohol and Other Drug (AOD) Treatment Service Delivery for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community ISUM_A_1271430 TFJATS_StdSerif-800.cls February 6, 2017 15:44 Trim Info: 8.5in × 11in ISUM #1271430, VOL 0, ISS 0 Comparison of Government and Non-Government Alcohol and Other Drug (AOD) Treatment Service Delivery for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community Amy B. Mullens, Jane Fischer, Mary Stewart, Kathryn Kenny, Shane Garvey, and Joseph Debattista QUERY SHEET This page lists questions we have about your paper. The numbers displayed at left can be found in the text of the paper for reference. In addition, please review your paper as a whole for correctness. Q1. Au: Please provide the department for affiliation d. Q2. Au: Do you mean Mullins, Staunton, et al. 2009 or Mullins, Young, et al., 2009 here? Q3. Au: A declaration of interest statement reporting no conflict of interest has been inserted. Please confirm whether the statement is correct. Q4. Au: Please provide all author names, including first initials, for Hayes et al. 2004. Q5. Au: Please provide the volume number and the page range in ref. Strodl et al., 2015. Q6. Au: Please provide a complete reference in APA 6th edition style for Thorpy et al. 2008. TABLE OF CONTENTS LISTING The table of contents for the journal will list your paper exactly as it appears below: Comparison of Government and Non-Government Alcohol and Other Drug (AOD) Treatment Service Delivery for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community Amy B. Mullens, Jane Fischer, Mary Stewart, Kathryn Kenny, Shane Garvey, and Joseph Debattista ISUM_A_1271430 TFJATS_StdSerif-800.cls February 6, 2017 15:44 Trim Info: 8.5in × 11in SUBSTANCE USE & MISUSE , VOL. , NO. , – http://dx.doi.org/./.. ORIGINAL ARTICLE Comparison of Government and Non-Government Alcohol and Other Drug (AOD) Treatment Service Delivery for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community Amy B. Mullensa , b, Jane Fischerc , d, Mary Stewartc, Kathryn Kennye, Shane Garveyf, and Joseph Debattistag a Sexual Health & HIV Service, Metro North Hospital and Health Service, Brisbane, Australia; b School of Psychology and Counselling, University of Southern Queensland, Ipswich, Australia; c Alcohol and Other Drug Service, Metro North Hospital & Health Service, Brisbane, Australia; d Flinders University, Adelaide, Australia; e DRUG ARM Australasia, Brisbane, Australia; f QLD AIDS Council (formerly QLD Association for HealthyQ1 Communities); g Metro North Public Health Unit, Metro North Hospital and Health Service, Brisbane, Australia. KEYWORDS Alcohol and other drug services; attitudes; knowledge; policy; health workers; non-government organizations; LGBT; faith-based organizations ABSTRACT Background: Lesbian, gay, bisexual, and transgender (LGBT) populations are more likely to misuse alcohol and other drugs (AOD), compared to the general population. However, LGBT engagement with AOD treatment is often precluded by insensitivity and misunderstanding of LGBT issues. These treatment barriers may be a consequence of either worker attitudes, organizational factors or a com- bination of both. Few studies have compared service context as an impediment to AOD treatment. Objectives: This pilot study sought to examine and compare staff attitudes, knowledge and awareness of LGBT issues in two state-wide AOD services within Australia. One organization was a government service, whilst the other was faith based. Methods: A cross-sectional study of a convenience sample (N = 130) of workers employed in a state-wide government AOD service (n = 65), and a state-wide non-government service (n = 65) was conducted. Participants self-completed a questionnaire com- prising tools previously used to assess staff attitudes, knowledge and awareness of LGBT issues. Results: Few significant differences in attitudes and awareness of LGBT issues between government and non-government respondents were found. Nearly all respondents were supportive of LGBT persons irrespective of organizational context, with a small number of negative views. Although most respon- dents demonstrated awareness of organizational policies and practices relating to LGBT clients, many were “unsure” or “neutral” of what these might be. Conclusion: It is confirming that the majority of staff report appropriate attitudes towards LGBT clients. Findings suggest that organizations need to con- tinue to take leadership to strengthen organizational training and capacity to deliver LGBT friendly AOD treatment practices. Studies involving lesbian, gay, bisexual and transgen- der (LGBT) populations in developed countries report higher rates of substance misuse compared to their heterosexual counterparts (Green & Feinstein, 2012; Leonard et al., 2012; Pollock et al., 2012; Roxburgh,5 Lea, de Wit, & Degenhardt, 2016). A number of factors contribute to these higher rates of misuse (Herdt, 1997; Mullens, Young, Dunne, & Norton, 2011a; 2011b). Alco- hol, stimulants, and cannabis use have been historically embedded within gay subcultures (Mullens et al., 2011b;10 Prestage et al., 2007; Prestage et al., 2015), particularly in association with sexual contact (Bourne, Reid, Hickson, Torres-Rueda, & Weatherburn, 2015; Halkitis & Parsons, 2002; Rajasingham et al., 2012), sexually “adventurous” practices (Semple et al., 2009) and enhanced sexual15 experiences (Green & Halkitis, 2006; Mullens, Young, Hamernick, & Dunne, 2009). Reinforcing the role of alcohol within LGBT communities, licensed or sexual CONTACT Joseph Debattista Joseph.Debattista@health.qld.gov.au Metro North Public Health Unit, Bryden Street, Brisbane, QLD , Australia. venues continue to be places where lesbians and gay men have felt comfortable socializing together without fear of 20 stigma from the wider society (Jones-Webb et al., 2013; Mullens, Staunton, Debattista, Hamernick, & Gill, 2009). LGBT people also experience unique challenges related to discrimination and stigma (Pachankis et al., 2014), vic- timization (Collier, van Beusekom, Bos, & Sandfort, 2013) 25 and physical abuse (Goldbach et al., 2014; Ignatavicius, 2013) that can negatively affect psychological well-being (see Flentje, Livingston, Roly, & Sorensen, 2015), and for which some persons use substances to help cope (Mullens et al., 2009; Williamson, 2000). It is well established that Q2 30 some of the most powerful institutions in society have his- torically rejected homosexuality, including various reli- gions, health systems and the media (Meyer, 2013). LGBT persons commonly face a number of specific dif- ficulties (see Leonard et al., 2012). Some of these include 35 social stigmatization, rejection from families, minority ©  Taylor & Francis Group, LLC http://dx.doi.org/10.1080/10826084.2016.1271430 mailto:Joseph.Debattista@health.qld.gov.au ISUM_A_1271430 TFJATS_StdSerif-800.cls February 6, 2017 15:44 Trim Info: 8.5in × 11in 2 A. B. MULLENS ET AL. stress and homophobic abuse (Barrett et al.,1995; Bon- tempto & D’Augelli, 2002; Kelly et al., 2015; Strodl et al., 2015; Thorpy et al., 2008), which has also been associ- ated with an increased risk of psychological and substance40 use disorders (Chakraborty et al., 2011; Lyons & Hosk- ing, 2014; Wright et al., 2000). This is exacerbated by barriers to accessing mental health and substance treat- ment services (Cochran & Cauce, 2006; Kaufman et al., 1997; Staunton, 2007). Experiencing anti-LGBT discrim-45 ination has also been associated with increased frequency of unprotected sex (Jarama et al., 2005). To be effective, treatment must focus on and address cultural variables that influence onset, maintenance and relapse risk (Branstrom & van der Star, 2013; Flentje et al.,50 2015; Lombardi & van Servellan, 2000), including spe- cific LGBT issues. However, there has been an histori- cal reluctance by alcohol and other drug (AOD) services to include sexuality within standard assessment tools, thereby underestimating the number of LGBT clients uti-55 lizing those services (Centre for Substance Abuse Treat- ment, 2001). This lack of recognition of LGBT clients within services can create indifference and inhibit cul- tural and organizational change to servicing the needs of this community. Negative or ambivalent attitudes towards60 sexual diversity among some AOD counselors, and lack of sufficient inclusion of LGBT-specific issues, may also impact upon an LGBT individual’s treatment (Eliason, 2000; Talley, 2013). Compounding challenges to LGBT access and engage-65 ment with AOD treatment services there is a large vari- ation amongst LGBT individuals, and unique issues and processes regarding coming out, gender identity and stigma may also impact upon treatment (Lemoire & Chen, 2005). As a result of these specific issues, LGBT70 people may have unique treatment needs and these can be overlooked in more traditional AOD treatment programs (see Eliason & Hughes, 2004; Lombardi & van Servel- lan, 2000). Consequently, failure to take sexual orientation and identity sufficiently into consideration may also have75 a significant negative impact on the success of treatment (Hershberger & D’Augelli, 2000; Talley, 2013). Previous studies have suggested a range of strategies to enhance an LGBT individual’s access to health services. Initiatives should involve education of staff on LGBT80 issues (Cochran, Peavy, & Cauce, 2007), establishment of specialist services for LGBT in place of generalist ser- vices (Senreich, 2010), inclusion of sexual orientation and more flexible gender options on intake forms (Eliason & Hughes, 2004), and the development by services of LGBT-85 sensitive policies and programs (Leonard et al., 2008). Spector and Pinto (2011) recommend counselors and clinicians working in the alcohol and drug sector improve awareness and understanding of how dominant cultural beliefs and counter transference can impact the therapeu- 90 tic relationship and treatment, for example substance use and HIV prevention. There is limited information, to date, available regarding the effectiveness of LGBT awareness training (e.g., Flavin, 1997; Hayes et al, 2004) or LGBT- tailored treatment approaches (e.g., Green & Feinstein, 95 2012; Matthews et al., 2014). Initial studies within health contexts have demonstrated positive impacts regarding LGBT staff training (Hardacker et al., 2014; Kalinoski et al., 2013); however, data regarding secondary impacts upon client engagement and clinical outcomes are limited. 100 It is well established in the general clinical and coun- seling literature, that clients who feel accepted and under- stood, and are receiving “more culturally sensitive health care” (Lombardi & van Servellen, 2000, p. 295) are more likely to engage with therapy and experience enhanced 105 treatment outcomes (Kelly et al., 2015; Talley, 2013). Thus, the purpose of this study was to better understand over- all staff attitudes and knowledge, and awareness of LGBT issues, across two state-wide alcohol and drug services within Australia - a government agency and a faith based 110 nongovernment agency. Specifically we sought to advance the following research questions: What are AOD treat- ment staff attitudes toward LGBT clients, familiarity with LGBT issues, and awareness of organizational LGBT poli- cies?; and Do staff at governmental and nongovernmental 115 AOD treatment services differ on LGBT attitudes, famil- iarity and awareness of organizational policies? Further, we sought to examine whether staff members of a reli- gious affiliated organization may be more or less informed regarding LGBT issues than staff members of a govern- 120 ment funded service; and the possible impact of religious affiliation on service delivery and staff attitudes (Hatzen- buehler, 2014; Meyer, 2013; White & Whiters, 2005). Method Survey instrument 125 A survey was developed adapting and adopting a number of existing survey instruments that have previously been utilized to assess staff and organizational attitudes towards LGBT persons (Eliason, 2000; Gay and Lesbian Health Victoria, 2013; Herek, 1984). The survey was divided into 130 four domains designed to measure staff: attitudes, expe- rience/knowledge/familiarity, demographics and aware- ness of organization policies and procedures. In total, the survey included 62 questions. Items for the Staff Attitudes section were adapted from 135 Herek’s Attitudes Towards Lesbians and Gays (ATLG; Herek, 1984), with an additional 10 items modified and added to include specific attitudes regarding bisexual and transgender persons in the measurement tool; and ISUM_A_1271430 TFJATS_StdSerif-800.cls February 6, 2017 15:44 Trim Info: 8.5in × 11in SUBSTANCE USE & MISUSE 3 reviewed for acceptability among a focus group of AOD140 professionals with experience in LGBT issues. Ques- tion responses used a 9-point Likert scale ranging from Strongly Disagree to Strongly Agree. Examples of ques- tions used include: “Lesbians just can’t fit into our soci- ety,” “Male homosexuality is a natural expression of sexu-145 ality in man,” and “God made man and woman: anything else is abnormal.” Questions in the “Attitudes” section were grouped regarding attitudes specifically regarding: gay, lesbians, bisexual and transgender people, to summa- rize views AOD staff may hold regarding one or more of150 these subgroups. An additional question asked about the respondent’s religious denomination or personal spiritual beliefs related to LGBT people. Along with reporting the mean response to individual items, a summary score was also calculated, with a possible score range from 20–180.155 Cronbach α was 0.488 for the twenty items. The Experience/Knowledge/Familiarity section included questions about the respondent’s levels of comfort and familiarity with each of the four populations and knowledge of common issues for LGBT people.160 Questions were drawn from a literature review of issues identified to influence substance use treatment for LGBT people (e.g., Center for Substance Abuse Treatment [CSAT], 2001; Eliason & Hughers, 2004; Staunton, 2007). Responses used a 4 point Likert scale ranging from Not165 at all Familiar to Very Familiar. Along with reporting the mean response to individual items, a familiarity-term summary score was calculated, with a possible score range from 4 to 16. Cronbach α was 0.698 for the four items.170 Respondents were also asked about training or educa- tion focusing on issues relevant to LBGT persons. Exam- ples of questions include: “How familiar are you with the term: transgender persons?,” “How familiar are you with the issue of: coming-out process?,” and “How familiar are175 you with the issue of: heterosexism?.” Along with report- ing the mean response to individual items, a familiarity- issues summary score was calculated, with a possible score range from 13 to 52. Cronbach α was 0.921 for the 13 items.180 The Organization Policies and Procedures section utilized the Sexuality & Gender Identity Organiza- tional Audit produced by the Queensland Association of Healthy Communities (now the Queensland AIDS Council), which was originally derived from the Gay185 and Lesbian Health Victoria Sexual Diversity Health Ser- vices Audit (Gay and Lesbian Health Victoria, 2013). This section included 14 statements concerning organi- zational policies, procedures and staff competencies using a 5 point Likert scale ranging from Strongly Disagree to190 Strongly Agree. Examples of statements were: “Your ser- vice displays pamphlets and posters with positive images,” “Your intake forms include gender-neutral options along- side standard terms,” and “Staff have had equity, diversity or awareness training which includes working with LGBT 195 people.” Along with reporting the mean response to indi- vidual items, a summary score was also calculated, with a possible score range from 0 to 96. Cronbach α was 0.929 for 24 items. Staff demographics included age, gender, sexual ori- 200 entation, childhood and current residence (to determine if respondents were from metropolitan, regional or rural areas), level of education, and number of years’ experience in AOD. A pilot study with 20 respondents was conducted at 205 a government AOD service in a metropolitan site (Bris- bane, Australia) to determine the readability and accept- ability of the survey, and minor adjustments were made accordingly. Participants and recruitment 210 For this pilot study, two state-wide AOD organizations— the state-wide government Alcohol and Drug Service operated by Queensland Health with district based pro- grams dispersed across the State, and a non-government AOD service, DrugARM Australasia, with community 215 programs across Queensland and in adjacent states, par- ticipated in the recruitment of staff. DrugARM Australasia is a not-for-profit organization founded upon Christian values and principles, with a stated aim to reducing harms associated with alcohol and 220 other drug use. DrugARM (Drug Awareness, Rehabili- tation and Management) provides education, awareness, prevention, rehabilitation, street outreach and support programs targeting individuals, families and communi- ties throughout New South Wales and Queensland and 225 South Australia. Following ethical approval, each Health Service Dis- trict in Queensland was approached and permission sought for paper based surveys to be distributed to all government AOD units (both hospital and community 230 based) within each of 15 health service districts. Sur- veys were forwarded to each AOD unit by mail, and then distributed to individual staff for anonymous self- completion. A total of approximately 300 government clinical and administrative staff were approached. 235 The same survey was converted to an electronic for- mat on Survey Monkey and the link distributed to all staff and volunteers of the non-government AOD agency, Dru- gARM. Approximately 150 non-government staff across 16 sites were approached. 240 A total of 65 AOD government staff from 15 Health Service Districts across Queensland (response rate 21.7%) completed the questionnaire over a one month period. ISUM_A_1271430 TFJATS_StdSerif-800.cls February 6, 2017 15:44 Trim Info: 8.5in × 11in 4 A. B. MULLENS ET AL. From the city of Brisbane, 35 surveys were completed with the remaining 30 completed by workers employed245 in regional and rural areas. Through DrugARM a total of 65 staff from 16 sites completed the questionnaire (response rate 43.3%). These included staff working in the National Office (Brisbane), the New South Wales State Office (Sydney), and vari-250 ous counseling, support and treatment programs. Two respondents were student volunteers. Data analysis Data were analyzed using SPSS19. Data (overall findings and aggregated by service type) were analyzed, with per-255 centages of respondents who Strongly Agree/Agree and Strongly Disagree/Disagree or Very Familiar/Familiar and Slightly Familiar/Not Familiar calculated. Using the numerical Likert scale, mean values were calculated for each response for both government and non-government260 respondents, which allowed a direct statistical compari- son between government and non-government staff. Ethics clearance This project received ethics clearance from The Prince Charles Hospital HREC, Metro North Hospital and265 Health Service; HREC/12/QPCH/55 Results Demographics Table 1 provides a summary of self-reported partici- pant characteristics based on site, regarding age, sex-270 ual orientation, region of residence (e.g., urban, regional, rural), and percentage of respondents reporting having had received “some training” or formal education focus- ing on issues relevant to LGBT clients. Table . Demographic characteristics by organization. Demographic characteristics Govt. n =  Non-govt. n =  Age (average, range) ; range – ; range – Gender Female .% .% Male .% .% Sexual orientation Heterosexual .% .% Homosexual .% .% “Other” .% .% Residence Large urban area .% .% Small regional city .% .% Small town .% .% Rural area .% .% Among government service respondents, the majority 275 of respondents had worked in a health service profession for over 10 years (62.9%). The main occupation of gov- ernment respondents was nursing (41.5%), psychology (15.4%) and social work (13.8%). The remaining positions evenly spread over a variety of roles including clinician, 280 manager, aboriginal health worker, counselor, adminis- tration officer, needle and syringe program worker, and mental health worker. This staff composition is generally reflective of the composition of roles within this govern- ment service. 285 Among NGO respondents, approximately a third had worked in drug and alcohol services for 1 to 5 years (33.9%) and 18.8% for 5 to 10 years. A third (33.1%) of NGO participants identified as “volunteers” with the remaining positions divided between non-clinical roles 290 (38.1%), education and training roles (13.1%) and clinical roles (15%), which is generally reflective of the composi- tion of roles within this service. Comparison of government and non-government services 295 There was a significant difference in the median age of government and non-government respondents (43 years vs. 32 years). Non-government respondents were more likely to be female, and most respondents in both organi- zations identified as heterosexual (9.2% and 6.5% of the 300 government and non-government sample, respectively, identified as homosexual; with inclusion of 7.7% and 6.5% identifying as “other” from each service, respectively). These estimates are higher than population estimates (Gates, 2011). Education levels were similar, but with a 305 higher level of postgraduate qualifications within the gov- ernment cohort. This may reflect the younger age and higher number of volunteers within the non-government sector. A greater proportion of non-government respondents 310 (75.4%) resided in large urban areas than government (47.7%) with far fewer residing and working in rural areas (<10% of non-government respondents compared to 29.2% of government respondents). There was a greater dispersion of government respondents across regional 315 and rural areas. Almost a third of the nongovernment respondents were volunteers, a sub-set were non-clinical (38.1%) or engaged in education and training. Fewer non-government respondents compared to government respondents were clinical staff (15% vs. 70.7%). Gov- 320 ernment clinical respondents comprised nurses (41.5%), social workers (13.8%) and psychologists (15.4%). Twice as many government workers than non-government workers reported some training on issues relevant to LGBT clients. 325 ISUM_A_1271430 TFJATS_StdSerif-800.cls February 6, 2017 15:44 Trim Info: 8.5in × 11in SUBSTANCE USE & MISUSE 5 Table . Comparison of government and non-government respondents’ attitudes to LGBT clients. Meana  = strongly agree and  = strongly disagree Attitudes toward LGBT clients Govt. n =  Non-govt. n =  Mean difference Total n =  Sig. difference (.) Attitudes summary score . . . . t() = . p = . %CI:-.–. Lesbians just can’t fit into our society . (.) . (.) . . (.) n/s State laws regulating private, consenting lesbian behavior should be loosened . (.) . (.) . . (.) n/s Female sexuality is a sin . (.) . (.) . . (.) n/s Female homosexuality …what society makes of it can be a problem . (.) . (.) . . (.) n/s Lesbians are sick . (.) . (.) . . (.) n/s Male homosexuals are disgusting . (.) . (.) . . (.) n/s Male homosexuality is a perversion . (.) . (.) . . (.) n/s Male homosexuality is a natural expression of sexuality in man . (.) . (.) . . (.) n/s Homosexual behavior between two men is just plain wrong . (.) . (.) . . (.) n/s Male homosexuality is merely a different kind of lifestyle that should not be condemned . (.) . (.) . . (.) n/s Bisexuals are sick . (.) . (.) . . (.) n/s All people are probably born bisexual . (.) . (.) . . (.) n/s There is no place in the moral fabric of society of bisexuality . (.) . (.) . . (.) n/s Bisexuality is merely one of many normal variants of human sexuality . (.) . (.) . . (.) n/s There should be stricter laws regulating bisexual behavior . (.) . (.) . . (.) n/s Transgender people are sick . (.) . (.) . . (.) n/s Laws that regulate people’s expression of gender should be removed . (.) . (.) . . (.) n/s God made man and woman: anything else is abnormal . (.) . (.) . . (.) n/s Having only two sexes is limiting …an expression of the continuum of gender . (.) . (.) . . (.) . It is necessary to have clear distinctions between women and men . (.) . (.) . . (.) n/s aBased on a scale  = Strongly agree,  = Agree,  = Undecided,  = Disagree, and  = Strongly disagree. Attitudes The majority of both government and non-government AOD workers identified as supportive of LGBT persons, with a small number of respondents expressing negative views (see Table 2). The majority of respondents disagreed330 with adverse statements towards LGBT persons. The results were more mixed when respondents were asked to consider statements concerning transgender per- sons, with more persons, both government and non- government undecided about the following statements:335 “it is necessary to have clear distinctions between women and men,” “having only two sexes is limiting - transgen- der people are an expression of the continuum of gender.” Respondents from both groups were most unsure about the statement “All people are probably born bisexual.”340 While there was a slightly higher rating of positive atti- tudes recorded amongst government respondents com- pared with non-government respondents, there were no statistical differences in mean scores, utilizing indepen- dent samples t-tests for comparisons (see Table 2). There345 was only one attitude item where a significant difference was found. On this item, the need for firm distinctions between male and female, appeared to be more flexible amongst government respondents. Although not statistically significant, the largest differ- 350 ences in attitudes were on the following attitude items: “It is necessary to have clear distinctions between women and men” (0.68 mean difference) followed by “laws that regulate people’s expression of gender should be removed” (0.54 mean difference), “lesbians just can’t fit 355 into society” (0.46 mean difference) and “having two sexes is limiting …” (0.45 mean difference). Govern- ment participants were more likely to agree with all of these statements than non-government organization participants. 360 When asked to consider whether they were “com- fortable” working with LGBT clients, all respondents stated that they were comfortable with Lesbian, Gay and Bisexual clients. However, 3.1% of government and 10.8% of non-government staff stated that they 365 were “not comfortable” working with transgender clients. An overall majority of participants stated that LGBT clients should be “accepted completely,” according to their ISUM_A_1271430 TFJATS_StdSerif-800.cls February 6, 2017 15:44 Trim Info: 8.5in × 11in 6 A. B. MULLENS ET AL. Table . Comparison of government and non-government respondents’ experience, knowledge and familiarity with LGBT issues. Meana  = not at all and  = very Experience/knowledge/familiarity Govt. n =  Non-govt. n =  Mean difference Total n =  Sig. difference (.) Familiarity—Terms summary score . . . . t() = . p = . %CI:.–.) How familiar are you with the term: lesbian persons . (.) . (.) . . (.) n/s How familiar are you with the term: gay men . (.) . (.) . . (.) n/s How familiar are you with the term: bisexual persons . (.) . (.) . . (.) n/s How familiar are you with the term: transgender persons . (.) . (.) . . (.) . Familiarity—Issues summary score . . . . t() = . p = . %CI:.–.) How familiar are you with the issue of: substance misuse prevalence . (.) . (.) . . (.) . How familiar are you with the issue of: relationships . (.) . (.) . . (.) n/s How familiar are you with the issue of: coming-out process . (.) . (.) . . (.) n/s How familiar are you with the issue of: gay-bashing/hate crimes . (.) . (.) . . (.) n/s How familiar are you with the issue of: domestic partnership laws . (.) . (.) . . (.) . How familiar are you with the issue of: legal issues e.g. power of attorney . (.) . (.) . . (.) . How familiar are you with the issue of: coping strategies . (.) . (.) . . (.) . How familiar are you with the issue of: appropriate terminology . (.) . (.) . . (.) n/s How familiar are you with the issue of: homophobia . (.) . (.) . . (.) . How familiar are you with the issue of: heterosexism . (.) . (.) . . (.) n/s How familiar are you with the issue of: internalized homophobia . (.) . (.) . . (.) n/s How familiar are you with the issue of: family issues . (.) . (.) . . (.) . How familiar are you with the issue of: legal protection . (.) . (.) . . (.) . aBased on a scale of  = Not at all,  = Slightly,  = Quite and  = Very. own personal religious beliefs (84.6% of both govern-370 ment and non-government respondents). However, 7.7% and 9.2% of government and non-government workers, respectively, responded that while LGBT people should be accepted, their behavior should be “condemned.” Fur- ther 6.2% and 0.0% of government and non-government375 workers, respectively, felt that they were “sinful and immoral.” Experience/skills/knowledge When asked to consider their familiarity with a range of terms relevant to LGBT people, most AOD respondents380 indicated that they were familiar (statistical compar- isons were made utilizing independent samples t-tests, See Table 3). Government respondents were signifi- cantly more likely to be familiar with the term trans- gender persons, issues of substance misuse, domestic385 partnership laws, power of attorney, coping strategies, homophobia, heterosexism, internalized homophobia and family issues. Familiarity with legal protection was significantly lower (p = 0.001) among government than non-government participants. 390 The largest differences in familiarity were on the fol- lowing issues: the term “transgender persons” (0.39 mean difference), “gay-bashing/hate crimes” (0.20 mean differ- ence), “substance misuse prevalence” (0.18 mean differ- ence) and “internalized homophobia” (0.18 mean differ- 395 ence). Government participants were more likely to be more familiar with these issues than non-government participants. However, overall the mean scores for both groups indicated an uncertainty about most issues, particularly 400 those of a legal nature. Alpha reliability calculations were conducted regarding the 17 items comprising Table 3 regarding self-reported familiarity with LGBT issues (alpha = .927.) ISUM_A_1271430 TFJATS_StdSerif-800.cls February 6, 2017 15:44 Trim Info: 8.5in × 11in SUBSTANCE USE & MISUSE 7 Organization policies and procedures405 Overall, knowledge of organizational policies was simi- lar across government and non-government respondents, with the mean score indicating uncertainty for most items (though government respondents tended to score slightly higher in awareness; statistical comparisons made via410 independent samples t-tests, See Table 4). However, with respect to bullying, use of gender-neutral terms (0.27 mean difference), personal definitions of “family,” confi- dentiality protection, inclusion of both same sex parents, and access to diversity training, government respondents415 identified a significantly higher level of awareness of poli- cies compared with non-government respondents. Other items with the largest differences in awareness of policies between organizational and non-government organizations were: “inclusive language” (0.22 mean dif-420 ference) and “training to identify and address basic health issues that may particularly affect LGBT clients” (0.18 mean difference). Government participants were more likely to be familiar with these policies than non- government participants.425 Discussion This pilot study has provided a snapshot summary regard- ing self-reported LGBT attitudes, knowledge and aware- ness across two Australian AOD service types. This study found that the majority of respondents held accepting430 attitudes towards LGBT clients, irrespective of service context, although respondents reported they were more unfamiliar with policies and procedures related to LGBT clients, and concepts such as ‘gender identity’. Overall, there was strong concordance of knowledge, attitudes and435 awareness between the government and non-government sector, which indicated that government and NGO staff did not markedly differ in their perspectives (i.e., illus- trated by significant difference found in the mean sum- mary attitudes, familiarity and awareness scores).440 The majority of respondents, whether government or non-government, were supportive of LGBT persons. Responses were more mixed with respect to transgender people (though still highly supportive), with a greater per- centage of government and non-government respondents445 expressing uncertainty (24.6% and 30.8%, respectively) as to whether transgender persons are an “expression of the continuum of gender.” There was also a greater unfa- miliarity by staff with issues of gender identity. This may translate to a level of discomfort or uncertainty for some450 staff working with transgender clients. This finding is con- sistent previous research (Eliason, 2000), which demon- strated limited knowledge and awareness regarding LGBT issues and needs. The majority of staff (both government and non- 455 government) identified personal religious and spiritual beliefs that were accepting of LGBT persons. However, approximately 8–9% held personal religious or spiritual beliefs that all LGBT behavior should be “condemned,” which warrant further attention. It is difficult to deter- 460 mine from these self-reports whether this is an expres- sion of personal belief or a statement of their particular religious affiliation’s views towards sexual diversity. Over- all, this study would suggest that the religious tradition of the non-government service did not contribute to sig- 465 nificantly adverse responses towards LGBT clients, com- pared to government service affiliation. Nonetheless, a small minority of staff employed by both government and non-government services did declare negative religious views and this could have serious implications for client 470 access. Given the likelihood that one such staff mem- ber could be encountered during the client journey, the potential for negative personal or religious beliefs towards sexual and gender diversity to potentially harm a client’s entire treatment experience cannot be underestimated. 475 Further research and staff training should seek to better assess such impact and organizational policies to mitigate these. Familiarity with LGBT terms indicate that most staff do have a certain degree of awareness of these issues, 480 however, the results also show that there is a signif- icant percentage of staff whom are not familiar. This was more pronounced for non-government respondents, which may reflect the higher proportion of respondents who were volunteers or operating in non-clinical posi- 485 tions. In particular, legal issues relating to “power of attorney,” “domestic partnerships,” and “legal protection” were familiar to only a minority of participants. Simi- larly, transgender issues were familiar only to a minor- ity of staff (over 40% were slightly and almost 30% not 490 at all familiar for both government and non-government respondents). Most respondents demonstrated awareness of organi- zational policies and practices relating to LGBT clients. However, a significant percentage of both government 495 and non-government respondents were unsure or neu- tral. For almost every item, a higher proportion of non- government staff indicated they were unaware or unsure of organizational policies that may particularly affect LGBT clients (e.g., written access, anti-discrimination 500 or inclusive service policies). This greater uncertainty amongst the non-government respondents was especially apparent for policies relating to transgender persons and those of a legal dimension. Again, these differences may be reflective of the greater number of volunteer and non- 505 clinical staff who responded from the non-government sector. However, the level of uncertainty by staff of both ISUM_A_1271430 TFJATS_StdSerif-800.cls February 6, 2017 15:44 Trim Info: 8.5in × 11in 8 A. B. MULLENS ET AL. Table . Comparison of government and non-government respondents’ awareness of organizational policies regarding LGBT clients. Meana  = strongly agree and  = strongly agree Organizational policies regarding LGBT clients Govt. n =  Non-govt. n =  Difference between means Total n =  Sig. difference (.) Awareness summary score . . . . t() = . p = . %CI:-.–.) Your service displays an anti-discrimination policy with a positive statement . (.) . (.) . . (.) n/s Your service displays pamphlets and posters with positive images . (.) . (.) . . (.) n/s Your staff use inclusive language which recognizes diverse relationships, sexuality and gender identities . (.) . (.) . . (.) n/s Your service has agreed policy and procedures to respond to bullying, abuse or inappropriate behavior . (.) . (.) . . (.) . Your intake forms include gender-neutral options alongside standard terms . (.) . (.) . . (.) . Your service adopts each client’s definition of ‘family’ which may include relatives by blood, same-sex partners, or spouses . (.) . (.) . . (.) . It is obvious to the client that confidentiality is protected and privacy respected . (.) . (.) . . (.) . When a transgender person attends your service staff addresses them as their presenting gender . (.) . (.) . . (.) n/s Their partner is acknowledged or included in the same way a heterosexual partner is. . (.) . (.) . . (.) n/s Staff use gender-neutral partner questions to ask about relationships and sexual behavior at all times . (.) . (.) . . (.) n/s When a child has same-sex parents staff include both in discussions about the child’s health care . (.) . (.) . . (.) . When a young person tells staff they may be LGBT, staff assure them of confidentiality and provide supportive responses . (.) . (.) . . (.) n/s Direct-care staff have had training to identify and address basic health issues that may particularly affect LGBT clients . (.) . (.) . . (.) n/s Staff have had equity, diversity or awareness training which includes working with LGBT people . (.) . (.) . . (.) . Staff know that Queensland legislation recognizes same-sex partnerships as ‘defacto relationships’ . (.) . (.) . . (.) n/s Your service has written access, anti-discrimination or inclusive service policies with specific reference to sexual orientation and gender identity . (.) . (.) . . (.) n/s Staff treat information about sexual orientation and gender identity as highly sensitive information . (.) . (.) . . (.) n/s Your service has links to other agencies that can provide services and support to LGBT clients . (.) . (.) . . (.) n/s The content of your health promotion activities and print resources is inclusive of diverse sexuality and gender identities . (.) . (.) . . (.) n/s Your service consults LGBT clients in the development of health promotion activities . (.) . (.) . . (. n/s Your service is able to refer LGBT clients to appropriate, ‘LGBT-friendly’ specialist services and resources . (.) . (.) . . (.) n/s LGBT staff members at your organization are able to be open about the gender of their partner . (.) . (.) . . (.) n/s Your organizational staff conditions or certified agreement recognize same-sex partners and their families under family leave . (.) . (.) . . (.) n/s When recruiting staff your organization includes sexuality and gender identity in non-discrimination statements such as ….. . (.) . (.) . . (.) n/s aBased on a scale of  –  with  = Strongly Disagree,  = Disagree,  = Neutral/Not Sure,  = Agree and  = Strongly Agree. ISUM_A_1271430 TFJATS_StdSerif-800.cls February 6, 2017 15:44 Trim Info: 8.5in × 11in SUBSTANCE USE & MISUSE 9 service types towards their own organizations’ LGBT pol- icy and practice does underlie the importance of staff training and clear managerial instruction.510 Study limitations As with all voluntary, self-reporting surveys, this study has limitations. The self-selected sample may have attracted a greater proportion of respondents more sup- portive of LGBT issues. While participation was anony-515 mous, social desirability may be a factor (but for differ- ent reasons) in both government and non-government respondent responses, and comparisons regarding demo- graphic features were unable to be made among those who did not participate in the survey from each service. Gov-520 ernment respondents may have modified their answers to satisfy perceived social and professional expectations, whereas non-government respondents, from a faith based organization, may have felt more secure in expressing divergent views that accorded with their own religious525 affiliation. There were demographic and occupational differences between the government and non-government respon- dent samples that may account for some of the variation in attitudes and knowledge (e.g., higher proportion of vol-530 unteers and non-clinical roles and younger age amongst the non-government sample). However, these character- istics are likely to be indicative of many non-government services as a typical reflection of the staff composition rather than sampling bias per se. This would also suggest535 that the differences identified between the two services are indicative of this workforce composition rather than any underlying religious culture. Although based on ser- vice preference, methodological differences between staff completing with survey online (religious affiliated) ver-540 sus via paper-pencil format (government affiliated), may also have impacted response rates and trends; as well as discrepancies in geographical areas represented by each group. Implications for research and practice545 Further research should focus on a comparison of self- reported attitudes and knowledge among staff compared to client perceptions as well as the impact of LGBT staff awareness training on rates of client access and engage- ment with services, and treatment outcomes (Kalinoski550 et al., 2013). Greater consideration should be given of staff beliefs based on workplace role and other demo- graphic features (e.g., rural versus metropolitan; older versus young) and differences in attitudes towards varied LGBT subgroups. Although this study focused primarily555 on attitudes regarding sexual identity, including transgen- der clients, it will be important in future research to study attitudes regarding gender identity as distinct from sexual identify and orientation, to assist with identifying specific knowledge and training gaps (Lombardi & van Servellan, 560 2000). Utilizing a similar survey process with staff from other community and health services may assist to identify staff barriers to service access and utilization among LGBT, and identify areas to target to heighten awareness and 565 identify further training needs (Eliason, 2000). Findings from this study could be used to encour- age AOD services to adopt and strengthen strategies that improve and promote LGBT access, engagement and sat- isfaction with such services; and further enhance health 570 staff knowledge, attitude and skills in screening, assessing and providing care to identified LGBT clients; and sub- sequently work towards improved AOD treatment out- comes for LGBT clients. Given that a small, but mean- ingful percentage of respondents noted personal, reli- 575 gious and/or spiritual views stating that LGBT persons should be ‘condemned’ or are ‘sinful’, this highlights the need for further diversity awareness training (Kalinoski et al., 2013), and/or supervision to explore and address counter transference or other process issues, which may 580 be impacting upon the therapeutic relationship and treat- ment outcomes (Spector & Pinto, 2011). This study highlights the need for a systems approach to address access and engagement of LGBT communi- ties with AOD services. A systems approach comprises 585 focusing on the interrelationship between the organiza- tion, teams/individuals and clients. Such a multifaceted approach builds the capacity and sustainability of orga- nizations, whether government or non-government to address LGBT disparities in AOD use, and more broadly 590 associated discrimination and stigma. Further, it moves the focus of removing barriers from the individual to the organization (Skinner et al.,2005). A systems approach also recognizes the role or insti- tutional policies and procedures in acting as a barrier 595 to LGBT AOD treatment seeking. Organizational/service level initiatives include organizational responsibility for developing teams sensitive to LGBT issues, employing staff experienced with LGBT issues, leading organiza- tional change e.g., introduction of new or modified guide- 600 lines, raising LGBT awareness, and alteration of office space to ensure that they are LGBT friendly (Skinner et al., 2005). These factors all play a role in devel- oping the capacity of organizations and their staff in addressing barriers to treatment and also in providing 605 effective AOD treatment for LGBT clients, and being mindful of unique socio-cultural features among LGBT (see Kelly et al., 2015; Lemoire & Chen, 2005; Mul- lens, Young, et al., 2009), which can impact upon pre- disposing and maintaining factors regarding substance 610 misuse. ISUM_A_1271430 TFJATS_StdSerif-800.cls February 6, 2017 15:44 Trim Info: 8.5in × 11in 10 A. B. MULLENS ET AL. Issues at an team/individual level include increasing awareness among AOD workers and clinicians of LGBT cultural and contextual issues associated with substance use and building the capacity of these teams to assess615 associated harms (e.g., HIV) in a sensitive, respectful and non-judgmental manner (Stall & Purcell, 2000; Stevens, 2012). One means of achieving this is by encouraging teams to ask more questions regarding patterns and con- texts of substance use and to consider the thoughts, feel-620 ings and behaviors associated with the temporal sequence leading up to substance misuse and underlying psychoso- cial mechanisms (Bimbi et al., 2006; Mullens, Young, et al., 2009). Conclusion625 Based on findings from the current study, the majority of AOD staff hold accepting self-reported attitudes towards LGBT clients. This study found few significant differences in attitudes and awareness of LGBT issues between gov- ernment and non-government respondents, and a high630 level of expressed support for LGBT clients. In addition, the religious tradition of the non-government service did not appear to contribute to these differences. However, within both the government and non-government ser- vice, the negative religious beliefs of a small minority of635 staff could potentially affect the client’s overall experi- ence of treatment despite an organizationally supportive environment. This study confirms the need for organiza- tions to take leadership in strengthening training for staff and improving service capacity to deliver LGBT friendly640 AOD treatment practices and to ensure that LGBT sup- portive policy and practice is understood by all staff. In particular, there is scope for improvement in staff awareness of LGBT issues, particularly among a minor- ity of staff and in relation to transgender clients; and645 regarding organizational policies and procedures across government and non-government services relating to LGBT. Declaration of interest The authors report no conflicts of interest. The authors alone Q3 are responsible for the content and writing of the article.650 Acknowledgments We gratefully acknowledge the assistance of management, staff and volunteers of DRUG ARM Australasia and the manage- ment and staff of Queensland Health AOD Services throughout Queensland who participated in and supported this project. References Barrett, D. C., Bolan, G., Joy, D., Counts, K., Doll, L., & Harrison, 655 J. (1995). Coping strategies, substance use, sexual activity, and HIV sexual risks in a sample of gay male STD patients. Journal of Applied Social Psychology, 25, 1058–1072. Bimbi, D. S., Nanin, J. E., Parsons, J. 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