Exploring perceptions of alcohol and other drug (AOD) service workers regarding the inclusion of transgender and gender diverse (TGD) clients in accessing public residential treatment in Victoria, Australia

Abstract

Introduction

There are unique challenges associated with providing inclusive, equitable care to transgender and gender diverse (TGD) people within residential alcohol and other drug (AOD) settings. With an increase in inclusion-based legislation, publicly funded services are required to provide inclusive care for TGD people. This study explored perceptions of AOD service workers regarding the inclusion of TGD clients in public residential AOD services in Victoria, Australia. We assessed workers’ perspectives on their services’ ability to provide TGD-inclusive care, and identified individual services workers levels of TGD inclusive practice.

Method

A mixed-methods cross-sectional design was employed combining a quantitative survey with qualitative perspectives from key informant interviews. The survey (completed by 85 workers) included demographic questions and the Trans-Inclusive Provider Scale (TIPS) and Transgender Inclusive Behavior Scale (TIBS) to measure inclusive practices and behaviors. Key informant interviews provided deeper context and understanding of the barriers and facilitators to TGD inclusive care.

Results

We found significant gaps in TGD-inclusive practices among AOD service workers, despite a general willingness to support TGD clients. Participants who identified as LGBTIQA+ reported significantly higher TIBS scores than non-LGBTIQA+ identifying participants (χ² = 19.132, p = .004), and those with a TGD friend or family member had higher TIBS scores (χ² = 20.030, p = .000). A negative correlation was observed between participant age and TIBS scores (r = −0.344, p = .002), indicating that younger workers exhibited more inclusive behaviors. Qualitative findings highlighted the need for visible indicators of inclusion, enhanced training, and flexible service models to improve TGD inclusivity.

Discussion

While there appears to be a strong desire to provide TGD inclusive care, significant gaps in knowledge and practice remain within the residential AOD sector. Addressing these gaps through targeted training, improved visual signaling, and flexible service provision can work to address inequities in care.

Introduction

There is an increasing need to establish inclusive healthcare guidelines for transgender and gender diverse (TGD) individuals. The World Health Organization (2024) is in the process of developing a guideline on the health of TGD adults, underpinned by improved access to healthcare for TGD people through services that are accessible and respectful. This need is urgent because TGD individuals face significant barriers in accessing inclusive and affirming healthcare. These barriers include discrimination, misgendering, a lack of provider knowledge, and the absence of clear pathways to gender-affirming care, leading to poorer health outcomes, increased mental health distress, and avoidance of medical care (Paschen-Wolff et al., 2024; Reisner et al., 2016).

When assessing the healthcare needs of TGD individuals in Australia, it is important to acknowledge that determining the proportion of TGD individuals accessing healthcare services is difficult, as population surveys assess information on the basis of assigned sex, rather than gender. While some progress has been made, as evidenced by the Victorian Population Health Survey 2017 being the first state-level population health survey in Australia to include questions about gender modality and sexual orientation (Victorian Agency for Health Information, 2020), comprehensive data collection remains limited.While research suggests that between 0.1% and 2.0% of Australians are TGD (Cheung et al., 2018), this may be higher in younger demographics, with 2.7% of high-school-aged Australians identifying as TGD (Strauss et al., 2020). This highlights a likely increased future need for inclusive healthcare services within Australia that are accessible to TGD communities, and a need to understand current barriers and facilitators that prevent or promote access to health services among this population.

Trans and gender diverse individuals have reported both greater use of alcohol and other drugs (AOD), and increased levels of AOD-related harms compared with the general population (Australian Institute of Health and Welfare, 2024; Gilbert et al., 2018; Hill et al., 2020; Reisner et al., 2016). This includes more harmful patterns of consumption, with almost half (47%) of transgender adults reporting binge drinking (consuming alcohol to the point of blood alcohol concentration (BAC) reaching 0.08 grams per deciliter or higher) within the previous three months, compared to 17.1% among the general population in the United States (Ruppert et al., 2021). The Australian National Drug Strategy Household Survey reported that after controlling for differences in age, TGD individuals were 1.6 times as likely to have used an illicit drug in the previous year compared with cisgender individuals (Australian Institute for Health and Welfare, 2024). Despite this, studies on substance use disorders in TGD individuals have been mixed, with a meta-analysis of 20 studies (comprising 18,329 transgender individuals) reporteing no difference in the prevalence of a substance use disorder between TGD and cisgender populations (Cotaina et al., 2022). However, this may represent a systematic bias given that TGD individuals may be hesitant to seek care because of barriers to accessing the AOD system, and/or stigma including minority stress when seeking AOD care (Cotania et al., 2022). Paschen-Wolff et al. (2024) highlight the critical need for lesbian, gay, bisexual, trans and gender diverse, intersex, queer, and asexual (LGBTIQA+)-affirming substance use services to reduce treatment barriers and improve health outcomes for LGBTIQA+ individuals, who often face stigma and discrimination in healthcare settings.

While a recent study explored TGD individuals’ experiences when seeking help within the AOD system (Paschen-Wolff et al., 2024), there remains a gap in understanding AOD workers’ perceptions of their services’ ability to provide inclusive care and the specific behaviors AOD services implement to facilitate and promote access to care for TGD individuals. This study used an online survey and key informant interviews to gather information from AOD service workers in Victoria, Australia concerning their perceptions of service provision regarding TGD inclusion.

Specific aims were to:

1. Assess AOD workers’ perspectives of their services’ ability to provide TGD-inclusive care;

2. Identify the levels of TGD inclusive behavior reported by AOD workers in publicly funded AOD programs.

Methods

Study design and setting

This study employed a mixed-methods, cross-sectional design to collect data within residential AOD treatment settings in Victoria, Australia. Victoria is Australia’s second most populous state, with approximately 6.5 million residents, with over 80% residing in its capital, Melbourne (Australian Bureau of Statistics, 2022). Victoria’s AOD treatment landscape predominantly features a network of both government and non-government public services staffed by a diverse array of professionals (Victorian Alcohol & Drug Association, 2023).

While the exact number of residential AOD workers in Victoria is unknown, the broader AOD workforce in the state is estimated to include approximately 1,500 workers across various settings (Victorian Alcohol & Drug Association, 2023). However, this figure includes both residential and nonresidential service providers, making it difficult to determine the precise proportion of eligible residential service workers who participated in this study. Despite this limitation, the 85 participants recruited from 13 organizations operating 24 residential AOD programs provide valuable insights into the perspectives of service workers regarding TGD inclusion in residential AOD treatment settings. Data was collected between June and August, 2023.

Quantitative data were gathered through a survey delivered to residential AOD services, complemented by qualitative data from key informant interviews.

Survey dissemination

A comprehensive list of publicly funded residential AOD services in Victoria was compiled for this study. The list was developed based on the first author’s extensive professional experience in the AOD sector, supplemented by additional internet and government database searches to ensure completeness. Only publicly-funded residential AOD services were eligible for inclusion.

To commence recruitment, an email inquiry was sent to each service’s general contact address, requesting to be directed to the appropriate key contact. The key contact was determined by the organization itself, ensuring that the most relevant person was responsible for disseminating the survey within their service.

Once contact was established, formal consent was obtained from each organization’s leadership before survey distribution. The survey was disseminated by the participating organization, on the researcher’s behalf. This approach ensured organizational endorsement and internal support for survey participation while maintaining the confidentiality of potential participants.

Eligible survey participants included all staff members who have client contact (regardless of how brief) and any service managers. This encompassed a range of roles, including AOD support workers, clinical staff (e.g. nurses, medical doctors), leadership team members, administration/reception staff, and peer workers. All organizations that were contacted responded to initial contact requests (n = 15), with 13 organizations opting to engage in the survey and two declining participation.

Quantitative survey

The quantitative survey comprised participant demographics (age, gender, country of birth, religion, First Nations status, education, LGBTIQA+ status, location); worker role, experience in the sector and role [years]; and the Trans-Inclusive Provider Scale (TIPS; Kattari et al., 2020) and Transgender Inclusive Behavior Scale (TIBS; Kattari et al., 2018). The TIPS and TIBS were selected for their unique advantages in measuring both attitudes and behaviors. The combination of TIPS and TIBS allowed measurement of both institutional practices and individual behaviors, providing a more comprehensive assessment of TGD inclusion. In addition to demographic and scale-based questions, the survey included service-related questions to capture organizational characteristics (e.g. service type, gender inclusion policies, and physical space accommodations). Incomplete survey responses—defined as participants who did not complete all TIPS and TIBS items—were excluded from the final analysis to ensure data validity.

The TIPS is a validated survey containing 27 questions answerable on a 5-point Likert scale (Kattari et al., 2020). This scale was selected for its robust psychometric properties and specific focus on measuring provider-level inclusion practices. Unlike more general competency measures, TIPS directly assess concrete behaviors and institutional practices that support TGD inclusion. The TIPS was chosen for its specific focus on healthcare providers’ concrete behaviors and institutional practices, rather than general competencies. This scale’s validation with healthcare providers (Kattari et al., 2020) made it particularly suitable for the diverse AOD workforce in our study. Additionally, TIPS measures both passive and active forms of inclusion within service environments. Example items within this scale include, ‘Service has a space on intake forms for preferred names and pronouns’, and ‘Workers refer TGD clients to TGD-affirming healthcare providers for trans health needs’

The TIBS is a validated survey consisting of 15 questions answerable on a 5-point Likert scale, assessing participants’ perceptions of their inclusive behaviors (Kattari et al., 2018). This measure complements the TIPS by focusing on individual-level behaviors and attitudes, providing a more comprehensive assessment of both organizational and personal inclusion practices. The TIBS balanced the TIPS by focusing on individual-level/worker attitude and behavior, and works to capture a broader behavioral indicator of inclusion relevant to all staff (in a range of roles) in residential AOD treatment settings. Example items within this scale include, ‘I ask for pronouns when I meet someone new’, and ‘I try to keep myself updated on acceptable language to use when referring to transgender individuals’.

Qualitative interviews

Semi-structured interviews were conducted with three key informants selected through purposive sampling, focusing on individuals with expert knowledge and significant roles within the Victorian AOD sector. This approach was chosen because key informants are likely to provide high-level insights based on both personal experiences and a broader understanding of the sector’s dynamics, offering depth and context that goes beyond typical interview responses (Gilchrist & Williams, 1999; Pahwa et al., 2023). The interview questions were developed based on existing literature on LGBTIQA+ inclusion in AOD services (Hannan et al., 2022; Leonard et al., 2015) and gaps identified in the quantitative survey, particularly around service-level policy implementation, staff training confidence, and the visibility of inclusive practice indicators. These areas were underexplored in survey responses, prompting further investigation through qualitative methods. The semi-structured format allowed for flexibility, enabling participants to elaborate on their experiences while ensuring consistency across interviews.

All interviews were conducted via Zoom and audio-recorded with participant consent to ensure accuracy. Participants provided signed informed consent prior to the interview, with the study’s purpose, confidentiality measures, and voluntary participation emphasized. The recordings were then transcribed verbatim for analysis.

The interview included demographic questions, service-related questions, and queries about experiences and examples of TGD inclusion and exclusion within residential AOD services (see online supplementary materials). This approach allowed for in-depth insights into the lived experiences and perspectives of AOD workers, enhancing the understanding of the nuances in service provision for TGD clients.

Data analysis and integration

The study employed a convergent parallel mixed methods design, where both quantitative survey data and qualitative interview data were collected simultaneously yet analyzed independently. For the quantitative component, descriptive statistics for participants and services are provided independently. Differences between key participant demographics (age, gender, education, religious status, queer status and having a TGD family member) were compared by summing overall scores and comparing between these groups using t-tests. A Pearson correlation was used to assess the association between age and TIBS score, with p-values <.05 deemed statistically significant for all aforementioned tests. All key informant interviews were analyzed using thematic analysis, following Braun and Clarke (2006) six-step framework. An inductive approach was employed. Qualitative themes were compared with findings to identify converging and diverging insights. This triangulation of data ensured a richer understanding of AOD workers’ perceptions of TGD inclusion. Participants were assigned pseudonyms to maintain confidentiality.

Results

Participant demographics

Survey responses were received from 85 participants with a mean age of 40 years (SD = 12.72 years, range 21-67 years) across 13 organizations operating 24 residential AOD programs. The majority of participants identified as cisgender women (59.4%), followed by cisgender men (34.2%), and gender diverse individuals (6.4%). All demographic characteristics are presented in Table 1.

Table 1.

Participant demographics.

	Number	Percentage
Gender
Men	27	34.2
Women	47	59.4
Gender diverse	5	6.4
First nations status
Aboriginal Australian	7	9.0
Neither aboriginal nor torres strait islander	71	91.0
Sexuality
Queer	21	27.0
Not queer	55	70.5
Not disclosed	2	2.5
Educational status
University educated	50	64.1
Not university educated	28	35.9
Job role
Clinical	20	25.6
Non-clinical	41	52.6
Leadership	12	15.4
Other	5	6.4
Has a TGD friend/family member
Yes	28	35.9
No	50	64.1
Religious status
Religious	36	46.2
Not religious	42	53.8

Note: TGD = Transgender and gender diverse.

Service demographic information

Most participants worked in mixed-gender services or services that cater to both men and women (84.6%), with fewer representing women-only (10.3%) and men-only (5.1%) programs (Tables 2 and 3). Notably, none of the surveyed services explicitly offered TGD-specific programs, highlighting a potential gap in service provision for this population. The majority of services were located in metropolitan Melbourne (72.4%) compared to regional Victoria (27.6%). Significantly, 85.9% of participants reported having TGD individuals access their service, with estimated TGD populations ranging from 0.5% to 30% (Median = 2%).

Table 2.

Service demographic information.

Service demographic type	Number	Percentage
Service type
Detoxification unit	41	49.4
Rehabilitation center	34	41.0
Sobering up service	8	9.6
Who can access participants’ service
Men only	4	5.1
Women only	8	10.3
Mixed-gender service	66	84.6
Service location
Metro Melbourne	21	27.6
Regional Victoria	55	72.4
Do TGD clients access participants’ service?
No	11	14.1
Yes	67	85.9

Note: TGD = Transgender and gender diverse.

Table 3.

Gender segregation.

Question	Number	Percentage
Does the participants’ service have:
Separate recreational or dining spaces
Yes	10	15.1
No	53	80.4
Not applicable	3	4.5
Separate gender-based activities (work function, recreational activities, etc.)
Yes	9	13.6
No	40	60.6
Not applicable	17	25.8
A gender-neutral bathroom/toilet
Yes	19	28.8
No	38	57.5
Not applicable	9	13.7
Separate gender based support/recovery groups (e.g. Men only/women only Alcoholics Anonymous group)
Yes	28	42.4
No	36	54.6
Not applicable	2	3.0
Different sleeping arrangements (e.g. men’s wing/women’s wing)
Yes	57	86.4
No	9	13.6
Not applicable	0	–

Trans-inclusive provider scale results

TIPS results demonstrated varying levels of competency across categories (Table 4): For the Passive Marketing category, the highest score was for Website inclusion (M = 3.15, SD 1.82), while the lowest score was for displaying Transgender pride flags (M = 1.62, SD 1.41). For the Proactive Marketing category, low scores predominated, particularly for the advertising in queer media (M = 1.06, SD 1.16), and limited participation in Pride events (M = 3.14, SD 1.28). For the name and Pronoun Use category, there were medium levels of compliance of using correct pronouns among front-line workers (M = 2.87, SD 1.76), with similar compliance among office staff (M = 3.80, 1.89).

Table 4.

Trans-inclusive provider scale (TIPS) mean responses.

TIPS question	Mean score (SD)a
Trans inclusive passive marketing
Service has transgender pride flag on office door/s	2.35 (1.91)
Service has rainbow pride flag on office door/s	3.10 (1.80)
Service has transgender signals on website	3.35 (2.01)
Service has rainbow flag on website	2.61 (1.73)
Service has rainbow flag/transgender signals on printed material	1.62 (1.41)
Proactive trans inclusive marketing
Service advertises in queer newspapers/on queer websites	1.06 (1.16)
Services advertises at ‘Pride’ (LGBTIQA+) events	1.41 (1.33)
Service has booth at Pride events	1.34 (1.28)
Service advertises on TGD specific websites	3.15 (1.82)
Name and Pronoun Use
Front-line workers use correct names for clients	2.87 (1.76)
Front-line workers use correct pronouns for clients	1.58 (1.79)
Office staff use correct names for clients	3.80 (1.71)
Office staff use correct pronouns for clients	1.89 (1.87)
Intake forms
Service has a space on intake forms for preferred name	3.96 (1.58)
Service has a space on intake forms for pronouns	2.21 (1.89)
Service has multiple gender options/blank space to write in gender	4.26 (1.06)
Comfort with TGD referrals
Workers refer TGD clients out to TGD providers for trans-inclusive health needs	3.89 (1.28)
Workers refer TGD clients out to TGD providers for nontrans-specific health needs	3.70 (1.67)
Workers refer TGD clients out for trans-related surgery	3.46 (1.67)
Internalized trans inclusive knowledge and actions
Front-line workers share their pronouns with patients	2.28 (1.43)
Workers have taken trainings on ‘TGD 101’ topics	2.83 (1.83)
Workers have taken trainings on TGD health topics	1.82 (1.60)
Services have a gender-inclusive bathroom at the office/s	1.51 (1.93)
Services has done research on best practice for TGD healthcare	3.47 (2.00)
Service employs transgender/non-binary staff members	3.00 (2.12)
Workers feel comfortable prescribing hormones	3.50 (1.64)
Service uses a model for care centered on trans health needs	2.00 (1.88)

Note: SD = Standard deviation; TGD = Transgender and Gender Diverse

^a Mean values combined individual TIPS scores/number of responses

Transgender inclusive behavior scale outcomes

TIBS results demonstrated varying levels of inclusive behaviors among AOD service workers (see Table 5), with differences in demographic factors. No significant differences in TIBS scores were found between cisgender men (M = 39.73, SD = 16.77) and women (M = 40.36, SD = 16.05) participants: t(71)=-0.158, p>.05 or between those with (M = 43.18, SD = 17.28) and without (M = 38.67, SD = 16.06) a university education t(76)=1.13, p>.05. However, religious affiliation was associated with lower TIBS scores, with religious participants (M = 33.69, SD = 15.04) scoring significantly lower than non-religious participants (M = 48.12, SD = 15.84), t(75)=4.07, p<.001. Furthermore, participants with a TGD friend or family member scored significantly higher on the TIBS (M = 52.57, SD = 15.07) compared to those without (M = 35.40, SD = 14.66), t(76)=4.91, p<.001), and, LGBTIQA+-identifying participants (M = 52.33, SD = 18.14) provided higher TIBS scores than non-LGBTIQA+-identifying participants (M = 36.95, SD = 14.38) t(74)=3.87, p<.001), suggesting that personal relationships with LGBTIQA+ communities may be associated with greater reporting of trans-inclusive behaviors.

Table 5.

Transgender inclusive behavior scale (TIBS) mean responses.

TIBS question	Mean score (SD)a
I ask for pronouns when I meet someone new	2.63 (1.32)
I use gender neutral language to refer to people whose pronouns I do not know	3.54 (1.41)
I ensure spaces where I host/attend events offer gender-neutral bathrooms	2.13 (1.31)
I use the term ‘cisgender’ to refer to people whose sex assigned at birth matches gender identity	2.4 (1.35)
I have participated in discussions about the effects and/or benefits of cisgender privilege	2.5 (1.43)
I share my pronouns when I introduce myself to someone new	2.55 (1.35)
I have asked my friends, coworkers, and/or family members what their pronouns are	2.29 (1.35)
I read books/blogs/articles by transgender women, transgender men, and gender diverse individuals.	2.69 (1.31)
I speak out against ‘womyn born womyn’ or transgender exclusive policies.	2.73 (1.49)
I initiate conversations about how my community can support transgender individuals	2.56 (1.44)
I try to keep myself updated on acceptable language to use when referring to transgender individuals	3.32 (1.49)
I work to educate myself on issues regarding transgender communities	3.27 (1.37)
I am aware of local resources that offer support to transgender people	3.38 (1.44)
I keep myself updated on whether employment policies in my state/city include transgender people	2.87 (1.45)
I keep myself updated on whether housing policies in my state/city include transgender people	2.69 (1.47)

^a Mean values combined individual TIBS scores / number of responses

A significant negative correlation was also found between participant age and TIBS scores (r=-0.344, p=.002), indicating that younger participants reported more trans-inclusive behaviors than their older counterparts.

Qualitative findings - Key informant themes

Three key informants were interviewed: (1) Janet (she/her pronouns), manager of an LGBTIQA+-specific program; (2) Brad (he/him), manager of an LGBTIQA+ specific program, working in a leadership role; and, (3) Frankie (they/them), senior manager of a residential AOD service. Three themes were identified from the interviews: (1) signs and symbols of inclusion; (2) understanding hidden TGD populations and; (3) inclusive practices during treatment.

Theme 1: Signs and symbols of inclusion

The first theme, ‘signs and symbols of inclusion’, describes participants’ responses about the importance and impact of visible indicators of inclusion within organizations. These signs and symbols, such as LGBTIQA+ specific organizational Accreditation, pronoun badges, and inclusive posters, play a crucial role in signaling an organization’s commitment to inclusivity and support for the TGD community. Participants emphasized the significance of Rainbow Tick Accreditation as a catalyst for initiating conversations about TGD inclusion. In Australia, the Rainbow Tick is a set of quality frameworks that outline essential standards with which organizations must adhere to demonstrate a commitment to providing inclusive and affirming health care for LGBTIQA+ individuals, including TGD (Rainbow Health Australia, n.d). Importantly, the Rainbow Tick goes beyond compliance to provide a key symbol of inclusion, as it provides strong external messaging of an organization’s dedication to supporting and working to enhance the health outcomes of members of the LGBTIQA+ community. Despite its intentions, there were concerns about Rainbow Tick effectiveness in ensuring true inclusivity. Frankie noted that the accreditation process compelled senior managers to “kind of put it on them [senior managers] to really step up and reflect a bit more on whether they were actually inclusive enough at this low benchmark.” In contrast, Janet highlighted that having a Rainbow Tick did not consistently align with her experiences, which varied widely: “I’ve had a range of positive and negative experiences, that don’t seem to correspond to having a rainbow tick or not.”

Additional symbols of inclusion, such as visual indicators in the forms of pronoun badges and inclusive posters were reported as tangible signals of inclusivity. However, the effectiveness and perception of these symbols were questioned, as illustrated by Janet’s remarks: “I recently attended an AOD sector meeting, and almost everyone was wearing a rainbow lanyard. And I said ‘Woah, how do I know who is actually safe?’”

Theme 2: Understanding the hidden TGD population

This theme explores the challenges of accurately capturing and understanding the TGD population within the AOD sector, as well as the perceived risks associated with TGD individuals when disclosing their gender identity. Brad discussed the trust necessary for accurate self-reporting of gender identity during intake, highlighting a skepticism toward mainstream services’ practices: “if a [mainstream] service told me that they just trusted their clients to tell them something like that [being trans or gender diverse], I’d tell them that they must be joking.” Meanwhile, Frankie acknowledged a significant underreporting issue, suggesting a broader trend: “there’s probably a greater number [of TGD individuals] using our residential services that just don’t disclose.”

The theme also captures the misattribution of risk to TGD individuals, as described by Janet: “I think there can be a tendency to pathologize the mental health of TGD people … as though their gender identity is part of a mental illness presentation.”

Theme 3: Inclusive practices during treatment

This theme describes the challenges that arise in creating gender-inclusive physical spaces and providing flexible service provision during the treatment phase. Janet described the confusion often encountered by service providers when attempting to accommodate TGD individuals in single-gender services: “workers often throw up their hands [exclaiming] ‘Oh, what do we do? How do we navigate this’.” Frankie echoed this sentiment, expressing uncertainty about accessibility for non-cis individuals: “I don’t even know if a non-cis [person] can access [a single-gender AOD service Frankie oversees],” but affirmed, “I think we [their service] would support it in principle.”

Flexibility in service provision was emphasized by Brad, who discussed the importance of maintaining connections to the LGBTIQA+ community for TGD individuals: “I think the inclusive services that I’ve spoken to have really made sure that people stayed connected to queer services while they were in resi [residential AOD services].”

Discussion

This study examined perceptions of TGD inclusion in residential AOD treatment services in Victoria, Australia. Findings from both the survey and the key informant interviews indicated substantial deficiencies in delivering inclusive care to TGD individuals. Despite this, information from both the survey and key informant interviews emphasized support for providing gender-affirming care to TGD individuals. Taken together, these results suggest that while there are gaps in TGD inclusive knowledge and practices, there is a desire amongst AOD workers to address these gaps and to support TGD individuals.

Signaling inclusion: How do services and workers let TGD individuals know that they are welcome?

Engaging in proactive signaling is necessary to demonstrate inclusion to the TGD community and attract prospective TGD individuals to a healthcare service (Nisly et al., 2018). Most survey participants prominently discussed visual aids, demonstrating TGD inclusion can take the form of personal display items (e.g. wearing a pronouns badge), or wide-scale organizational activity (e.g. advertising on a TGD website). Within key informant interviews, participants indicated numerous examples of positive signaling, as well as identified areas for improvement.

Findings derived from the Proactive Trans-Inclusive Marketing section of the TIPS revealed both strengths and gaps within an organizational context. Notably, the data indicated competence in areas of wider LGBTIQA+ signaling such as displaying rainbow flags. In contrast, items related to TGD visual inclusion exhibit comparatively lower mean scores, such as displaying TGD flags. These latter results are congruent with insights provided by a key informant, who highlighted the notion that the signaling of inclusivity through visual symbols appears to be tailored more toward the wider LGBTIQA+ community as opposed to a specific focus on the TGD community. This can be problematic, as generalized ‘rainbow’ advertising is often insufficient in signaling safety and inclusion to TGD individuals (Clary et al., 2023).

Has space been made for TGD people?

AOD providers predominantly operate within a binary framework in residential services, offering single-gender and mixed-gender services with binary gender segregation. This framework raises critical questions about how TGD individuals access gender-specific spaces and navigate healthcare services that primarily adhere to cis-normative practices. Norris and Borneskog (2022) noted, “Reducing the amount of fear [TGD] persons have toward the current state of healthcare involves acknowledging cisnormative blind spots and ensuring safe inclusive spaces” (p. 8).

Key informants in this study highlighted a significant ambiguity within AOD services regarding the inclusion of TGD individuals. This lack of clarity affects how TGD individuals are accepted in single-gender services and their access to space in gender-segregated centers. Informants indicated that the absence of clearly defined policies on TGD inclusion may contribute to the apprehension and fear experienced by AOD workers, which could impede efforts to promote TGD inclusion. They suggested that this inconsistency might lead to TGD individuals being denied access to single-gender services that align with their gender identity or to appropriate spaces within mixed-gender centers.

In addition to challenges faced by binary-identifying transgender people, the current gender-segregated structure of residential AOD services presents a profound barrier to inclusion for non-binary and gender diverse clients. These service models often lack any space that aligns with their gender identity/identities, resulting in misplacement, invisibility, or outright exclusion. This reflects a broader systemic barrier in AOD care design, which is further compounded by the absence of any trans-specific or TGD-specific residential AOD services in Victoria, Australia. Such barriers are of serious concern as they can contribute to adverse mental health outcomes for TGD individuals, as discussed by McGuire et al. (2022).

Attitudes toward inclusion

The concept of flexibility has been discussed as a significant factor in providing inclusive healthcare, with Dunbar et al. (2022) highlighting “specifications for some measures might be refined to allow for greater flexibility and to better accommodate” TGD individuals in healthcare (p. 70). Coyne et al. (2023) further discuss ‘flexibility’ through introducing the idea of entire service reform as unnecessary, stating that “existing models of care that can flexibly accommodate the diverse needs of [TGD]” clients (pg. 481) have been identified as having the scope to provide TGD inclusive care.

Key informants extensively emphasized the concept of flexibility as a means of delivering inclusive care. Specifically, by identifying that it is the role of AOD workers to adapt their approach to effectively accommodate TGD individuals. Furthermore, the need to maintain connectivity between TGD individuals and the TGD community/supports during treatment was emphasized, highlighting the need for flexibility in program norms and structures.

When striving to offer gender-inclusive care, the idea of disregarding gender as a means to attain equality among individuals of different genders is found to be an obstacle (Thorson & Johansson, 2004). Therefore, when it comes to promoting inclusion for TGD individuals in healthcare, it is important to move away from a one-size-fits-all approach and adopt a more nuanced and flexible strategy that aims to achieve equity.

Staff perspectives on TGD inclusion

The attitudes of AOD workers on providing TGD-inclusive care has been captured through the survey and reflected upon in the key informant interviews. If it is accepted that healthcare workers who hold positive attitudes toward TGD individuals are more likely to engage in gender-affirming healthcare practices (Chu et al., 2023), the personal attitudes of AOD workers on TGD identities can be viewed as significantly important. In this study, responses to specific questions within the TIBS measure indicated generally low mean scores, suggesting that AOD workers may give limited consideration to TGD individuals in their day-to-day practice. Providing training and education to healthcare workers has been identified as a way forward in addressing transphobic attitudes (García-Acosta et al., 2020; Kanamori & Cornelius-White, 2016). Mean responses from the TIPS indicate a score of 3.22 for the question about workers having taken trainings on ‘TGD 101’ topics and a score of 2.13 for the question about workers having taken trainings on TGD health topics. This highlights the training/education gaps that need to be addressed by AOD organizations to resolve exclusionary attitudes.

Taken together, these findings highlight a reinforcing cycle between inconsistent service practices, limited provider confidence, and TGD individuals’ distrust or avoidance of AOD services. Despite organizational indicators such as Rainbow Tick certification or staff support for inclusion (e.g. through displaying pronoun badges), participants described ongoing tensions between formal policies and lived practice—particularly around the risk of pathologization or tokenistic inclusion. These dynamics reflect broader patterns that contribute to poorer mental health outcomes and reduced service engagement among TGD communities.

While some responses reflected exclusionary attitudes, both the quantitative survey and key informant interviews suggested that many AOD workers are motivated to provide TGD-inclusive care but do not always feel adequately equipped to do so. This highlights the need not only to challenge transphobic attitudes, but also to ensure workers are supported with the knowledge, skills, and confidence required to put inclusive intentions into practice. Targeted training and professional development opportunities are critical to bridging this gap between willingness and capability.

Limitations

Of 15 organizations, 13 distributed the quantitative survey to 24 out of 28 sites. Two AOD services, a small metropolitan rehabilitation service and a large provider with three regional programs, did not participate meaning that the results may not be generalizable to all services in Victoria, or other jurisdictions. A total of 85 participants accessed the survey, with 78 providing complete responses. While approximately 1,500 AOD service workers work in Victoria, many in the nonresidential AOD workforce were excluded. As this study is among the first to apply TIPS and TIBS within the Victorian AOD residential sector, and given the reliance on mean scores, findings should be interpreted with caution—particularly in terms of generalizability and the potential influence of non-normal data distributions. Future research should consider incorporating the broader AOD workforce for a more comprehensive understanding of TGD inclusion.

Conclusion

This study assessed the perspectives of AOD workers and services in creating inclusive residential treatment spaces for TGD individuals. These perspectives were found to vary widely. On an individual level, there was substantial support for TGD inclusion among many workers. Nonetheless, the presence of low scores on TIBS scales demonstrates the existence of knowledge gaps among workers in effectively demonstrating inclusion to TGD individuals. Significant gaps were also identified through discussion on the lack of TGD-specific inclusion-based policy and dedicated inclusive physical spaces for TGD individuals. These gaps were prominent in three key areas: (1) the absence of explicit TGD-specific inclusion policies within residential AOD services; (2) a lack of dedicated, safe, and inclusive physical spaces such as gender-neutral sleeping arrangements and bathrooms; and, (3) insufficient staff training on TGD-inclusive practices. Addressing these gaps is essential to improving access, safety, and equitable treatment outcomes for TGD individuals in residential AOD care.

Funding Statement

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Disclosure statement

No potential conflict of interest was reported by the author(s).