CHAPTER 1
What the Facilitator Needs to Know About Providing Gender-Responsive Services

Understanding the need for gender-responsive treatment services for men is critical for anyone who will be using this curriculum. It is also important to understand the process of trauma and its effects on addiction and recovery. There is much room for improvement in traditional treatment for men, and a discussion of the history of the development of gender-responsive services for both men and women and how these have been expanded beyond the binary model can help to explain this. This chapter provides a brief overview of these issues as well as the theoretical foundation for this curriculum.

New Approaches to Men's Treatment

It would be reasonable to assume that men's issues are adequately addressed in alcohol and other drug (AOD) treatment, because the overwhelming majority of treatment was developed for, by, and about men. However, we believe that “gender-neutral” treatment models are inadequate to meet the service needs of both women and men.

If we did not begin with the assumption that we know what men need, what would we discover? If we look at the effects of male socialization, what issues will arise? Through the creation and implementation of this curriculum, we have discovered that, when they feel safe enough, people are willing to look at many important, although difficult, issues commonly overlooked in traditional treatment. Some of these are relationships, sexuality and sexual behavior, power and control, privilege and entitlement, and grief. Working collaboratively with professionals in the field, we have created activities that help participants begin to reflect on their common experiences and that are designed to improve their chances of achieving sustained recovery.

Much of this curriculum would work well for individuals in other behavioral health programs that address issues such as anger management and interpersonal violence.

What We Have Learned

Our understanding of addiction and the best ways to treat it has changed in the past decades. Previously, there was a disconnection between mental health systems and addiction services systems. This left clients stuck between the two as they attempted to deal with their addictions and any accompanying mental health issues. Today, we have clear research that shows the effects of drugs on the brain and the mechanisms of addiction. We have known for some time that addiction is a chronic disease. The service systems, the funding streams, and the research that supports the systems are finally being set up to enable providers to treat clients and evaluate their services in this context. Now, after years of poor outcomes for clients, trainings in co-occurring disorders are becoming the expectation (rather than being regarded as the exception) for addiction professionals.

There also have been changes in what we consider effective treatment for men. Two elements of the old treatment model that have deep roots, especially for men, are no longer considered to be as effective as was once thought. First is the concept of denial and the need to break through an individual's denial in order for them to be receptive to treatment. This approach tends to be shame-based and assumes that the person is willfully ignoring the reality and consequences of the problem. Our understanding of the process of change—through the “stages of change” model—has forced us to rethink the idea of denial (DiClemente, 2006). Rather than simply being about people's lack of ability or willingness to look honestly at their problems, this model puts the burden on the clinician to connect with each client and provide services based on which stage of change the client is in.

Second is the idea that confrontation is an effective strategy for getting people to engage in treatment and be willing to look at their problems. There is no clinical evidence pointing to the therapeutic efficacy of confrontation, and there is ample clinical evidence that this approach results in poor outcomes and can even cause harm (Miller & White, 2007).

Fundamentals of Gender-Responsive Services

Perhaps the most important concepts to consider are those of gender and sex. Sex refers to one's biological identity, traditionally limited to male or female but more broadly interpreted today to include “intersex”—meaning that a person has sex characteristics that do not fit the traditional male/female dichotomy. Gender is a social construct in which specific messages are given to individuals regarding acceptable behaviors and characteristics. The role of gender varies from culture to culture and even within cultures and it is affected by many other factors, such as socioeconomic status, race, ethnicity, and sexual orientation.

In the past, the term gender-specific has meant woman-centered. This came from the need to develop programming for women in a field that assumed that both men and women addicted to alcohol and other drugs would respond to the same type of services. In developing gender-informed services for women, clinicians have realized that it is important to look at how the socialization process has affected the lives of females and influenced their needs in recovery. Similarly, in Helping Men Recover, we have applied what we know about the effects of male socialization to develop a gender-responsive program for those who experience the world from a masculine perspective.

The term gender-responsive indicates the creation of a treatment environment, through site selection, staff selection, program development, and program content and materials that reflects an understanding of the realities of participants' lives and that addresses and responds to their challenges and strengths. The keys to developing effective treatment for men are acknowledging and understanding their life experiences and the effects of living as a man in a male-based society. This means exploring the challenges as well as the benefits (entitlements) that men experience from living in such a society. Sometimes the terms gender-specific and gender-responsive are used interchangeably; however, that is incorrect. Gender-specific is about the services, and gender-responsive is about the whole system.

In a report for the National Institute of Corrections, a multidisciplinary review of the literature and research was conducted on women's lives in the areas of addiction, trauma, health, education and training, mental health, and employment (Bloom, Owen, & Covington, 2003). The report's guiding principles provide a blueprint for a gender-responsive approach to the development of services for women both in and out of the criminal justice system. We believe that these same principles apply to a gender-responsive approach for the development of treatment services for men and gender-diverse people.

Gender-responsive principles include the following:

• Gender. Acknowledge that gender makes a difference.
• Environment. Create an environment based on safety, respect, and dignity.
• Relationships. Develop policies, practices, and programs that are relational and that promote healthy connections to children, family members, significant others, and the community.
• Services. Address addiction, trauma, and mental health issues through comprehensive, integrated, and culturally relevant services.
• Socioeconomic status. Provide clients with opportunities to improve their socioeconomic conditions.
• Community. Establish a system of comprehensive and collaborative community services.

Gender Differences

Gender traditionally has been the experience of growing up male or female with all the social messages about how one should be. That is changing. Even though the past fifty years have helped to redefine what it means to be female, the traditional messages about manhood are still prevalent. We refer to these as “The Man Rules.” Boys are taught to present as strong and not to exhibit any form of weakness. A boy is told not to cry and to “act like a man.” Strength, aggression, and competition are considered to be “manly.” Being manly means being powerful, in control, and self-sufficient. It means never asking for help or acknowledging pain. It means being a fixer and a protector and knowing all the answers.

As treatment services develop to accompany our expanded understanding of society, we embrace the understanding that gender is not just binary: masculine and feminine. Gender occurs on a continuum, and people identify with various experiences and use many terms to define themselves. Here are some definitions of current terms (Green & Mauer, 2015):

• Cisgender: A person whose gender identity matches the biological sex assigned at birth. This is the traditional form of identification. It is sometimes abbreviated as “cis.”
• Transgender: A person whose gender identity does not match the biologic sex assigned at birth. The term can refer to those who were assigned “female” at birth but who identify as boys or men or those who were assigned “male” at birth but who identify as girls or women. The term is sometimes abbreviated as “trans.”
• Gender nonconforming: May describe behavior, expression, or a person whose gender expression is inconsistent with the cultural norms expected for their...