Andrea Moorer dissertation

Institute of Clinical Social Work

TRANSGENDER PEOPLE’S LIVED EXPERIENCE IN AA/NA TWELVE STEP PROGRAMS IN SOUTHERN TEXAS

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By

ANDREA MOORER

Chicago, Illinois February 2026

Copyright © 2025 by Andrea Moorer All rights reserved

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Abstract This study explored the experiences of transgender individuals in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) using Interpretative Phenomenological Analysis (IPA).

Findings highlight the need for inclusive language, safety, and transgender affirming meetings.

This is a call to action for social workers to engage in advocacy, deliver culturally responsive care, integrate LGBTQ expertise into treatment, and promote affirming recovery communities.

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Dedication I dedicate this dissertation to my husband, Torrey and my daughter, Camryn. Their encouragement is the only reason I am here today. To my friend Cory, thank you for listening to my years of complaining and your unwavering support. To Toni, thank you for always asking me, “Are you done yet?” To my pups, Henry, Rose, and Quill—your steady companionship and unconditional love have been my calm through countless years of weekend work.

To Houston Lambda AA, you have been there for me in my time of need, this one is for you.

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Acknowledgements

To my dissertation chair, Amy Groessel Ph.D., your encouragement and hope helped me more than you will ever know. Thank you for pushing me when I couldn’t see the end. To my committee member, Jennifer Tollerson, Ph.D., you have shown me kindness and grace over the years when I needed it the most. Thank you Pat Seghers, Ph.D., for your rational mind and for helping me avert many crises. Your emotional support carried me through some of the most difficult times. To my reader Lou Pansulla, you inspired me to continue researching this topic when I was about to give up. To the participants, thank you for your vulnerability.

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Table of Contents Abstract …………………………………………………………………………………iii Dedication……………………………………………………………………………….iv Acknowledgement………………………………………………………………………v Chapter I. Introduction………………………………………………………………………1 General Statement of Purpose Significance of the Study for Clinical Social Work Statement of the Problem and Specific Objectives to Be Achieved Research Questions to Be Explored Theoretical and Operational Definitions of Major Concepts Statement of Assumptions Epistemological Foundation of Project Foregrounding II. Literature Review………………………………………………………………18 Introduction History of Twelve Step Programs (AA/NA) History of Transgender Population Transgender Experiences in Southern Texas Substance Abuse Among LGBTQ Community Psychosocial Issues Among Trans Population

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Experiences of Trans People in AA/NA Community Guidelines for Working with Transgender Populations III. Methodology……………………………………………………………………..56 Rationale for Qualitative Research Design Rationale for IPA Research Sample Research Plan Ethical Considerations Role of the Researcher

IV. Results……………………………………………………………………..77 Introduction to Results Super- Ordinate Themes I: Intersection of Identity and Recovery Super- Ordinate Theme II: Safety & Acceptance Super- Ordinate Theme III: Sponsor Roulette Super- Ordinate Theme IV: Finding “God” Super- Ordinate Theme V: Community Summary of Results

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V. Discussion……………………………………………………………………..140

Introduction to Findings Family Background Categories Of Meaning Implications Future Research Conclusion

Table of Contents—Continued

Appendices

Page

A. Study Flyer...............................................................................162 B. Phone Interview Script............................................................163 C. Sample Interview Questions....................................................164 D. Formal Consent Document......................................................165 E. References..................................................................................168

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Chapter I Introduction General statement of purpose The purpose of this interpretative phenomenological study (Smith, Flowers & Larkin, 2009) was to explore the subjective experiences of transgender individuals who participated in Twelve Step substance recovery programs, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) in South Texas. This researcher currently resides in Houston, Texas and it seemed appropriate to conduct research in the Houston vicinity to gain a deeper understanding of local LGBTQ AA/NA recovery experiences for this study. According to the GLAAD website on transgender terminology (2023), transgender serves as an umbrella term that may include individuals whose identities or expressions differ from societal expectations of gender. For the purposes of this study, this researcher referred to the earlier use of “transgender,” as it appeared within the broader LGBTQ framework, which described individuals whose gender identity differed from the sex assigned at birth rather than as a broad categorical umbrella. This study included anyone who primarily self-identifies as transgender, yet did not include non-binary or gender non-conforming people.

Significance of the study for clinical social work As a licensed clinical social worker and a licensed chemical dependency counselor, this researcher has witnessed an increased number of diagnosed substance use disorders across all populations. According to the Centers for Disease Control and Prevention there were approximately 105,000 drug overdose deaths reported in the United States in 2023 (CDC, 2023).

In 2018, the Center for Disease Control (CDC) recorded 67,367 drug overdose deaths with

2 46,802 of those deaths related to opioids across the United States. The age-adjusted overdose death rate rose from 20.7 per 100,000 in 2018 to 31.3 per 100,000 in 2023. The LGBTQ person had a greater likelihood than a non-LGBTQ person of experiencing a substance use disorder (SUD) in their lifetime, and they often entered treatment with more severe SUDs (Cochran, 2020). Flentje et. al (2016) asserted “gender minority people including transgender individuals have higher rates of alcohol and drug use, ongoing relapses, including consequences for finances, arrests, health problems, and interpersonal discord” (p.291). A meta-analysis conducted by Ruppert, Kattari & Sussman (2022) found transgender adults experienced high rates of discrimination and low levels of social support, two major factors believed to play a role in the development of addictive behaviors.

Clinical social workers and other mental health clinicians treat LGBTQ patients in various settings, such as emergency rooms, psychiatric hospitals, social service agencies, homeless shelters and substance use residential centers without adequate knowledge of LGBTQ terminology, DSM-V diagnosis or familiarity with AA/NA groups. For example, directing a poor Black transgender individual to a White, heterosexual AA meeting in an affluent neighborhood demonstrated a lack of cultural and contextual awareness. This can be a safety issue, and the transgender person may be at risk for additional physical or psychological harm. (Budge et al., 2013). Referring to an LGBTQ AA/NA meeting was best practice (Senreich, 2010) however, many colleagues were unable to distinguish one AA/NA meeting from another unless they were familiar with specific resources in the community. This is a common occurrence, and the social work community should be cognizant of the special issues transgender individuals may encounter when completing a biopsychosocial assessment.

3 A report by the APA (American Psychological Association, 2015) shows less than 30% of psychology graduate students reported a familiarity with transgender non-conforming issues.

The National Association of Social Workers (NASW) Code of Ethics (2023) states that "social workers should obtain education about and demonstrate understanding of the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical ability" (6.04 (d)). When this researcher graduated from the Graduate College of Social Work in 2014, the UH Graduate Catalog’s MSW course listings did not include standalone courses on gender identity or substance-use treatment; related content was embedded within generalist practice and policy coursework (University of Houston.

(2014). Graduate College of Social Work: Courses [Graduate Catalog]. A poor understanding and misinterpretation of transgender experiences can lead to further marginalization and internalized transphobia. Clinicians often lack crucial information when working with the intersection of gender identity and substance use disorders. This highlights the challenges social workers face and this research study aimed to address these issues.

Statement of the problem and specific objectives to be achieved Twelve-Step (12) meetings promote abstinence. There are approximately 2,500 TwelveStep meetings per week in Houston, and the Twelve Steps of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) have been adopted worldwide (Intergroup AA Houston, 2023).

Some of the principles of the Twelve Steps have been informed by strong Christian beliefs, and many individuals within the recovery community see this as a barrier to achieving sobriety. Most religions, particularly Christianity, have historically discriminated against LGBTQ populations

4 and have maintained strong beliefs opposing homosexuality, further marginalizing this population (Liboro et al., 2014).

In Alcoholics Anonymous (AA), the term God has been replaced with higher power to create inclusivity for all denominations and nonbelievers. Step Two in AA states, “We came to believe that a Power greater than ourselves could restore us to sanity” (Alcoholics Anonymous, 1939, p. 25), followed by Step Three: “We made a decision to turn our will and our lives over to the care of God as we understood Him” (p. 34). Many individuals find Steps Two and Three particularly arduous during early sobriety, and their negative encounters with religion may impede their ability to move forward with the following steps (Kurtz, 1991). The emphasis on spirituality and surrender to a higher power often evokes discomfort for those who have experienced exclusion within faith communities. For transgender and LGBTQ individuals, these steps sometimes reinforce memories of rejection or invalidation from organized religion. These challenges frequently influence where individuals seek recovery support, leading some to pursue non-spiritual or alternative programs.

In addition to a lack of trans-specific Twelve Step meetings, it is worth noting that substance abuse residential treatment centers in the United States lack appropriate clinical programming for the LGBTQ population. A systematic review of the literature by the National Institute of Mental Health (2021) found that less than 7% of SUD programs offered LGBTQ patient services specifically designed to cater to this population (Cochran et al, 2007). This is due to limited research, small sample sizes, and challenges in defining gender identity. If researchers cannot identify the needs of a transgender person through research, mental health professionals may be unable to treat their unique needs. Thus, the referral to AA/NA becomes standard for every transgender substance user and person-centered care is less frequently taken into

5 consideration. Moreover, since outpatient care requires insurance or cash pay, free AA/NA meetings tend to become an alternative for recovery.

Gaps in the literature are apparent when researching the lived experiences of transgender individuals participating in AA/NA. Much of the existing literature addresses transgender biopsychosocial factors or as subjects of observation rather than narrators of their own stories.

These studies fail to capture experiences essential to understanding the nuances of gender identity, transitioning, and navigating a world full of anti-trans legislation. The lack of firstperson accounts especially as it pertained to substance use disorders and the lived experience in AA/NA, does not capture the complexity of the recovery process (Sevelius et al., 2021). Due to the increasing number of transitioning people (Puli & Keuroghlian, 2024), more information is needed to support this growing population. Despite a clinician’s best efforts, the unique needs of the LGBTQ population can be missed (Keuroghlian et al., 2015). By integrating narratives of substance use recovery with trans identity, this study focused on exploring the links between sobriety, selfhood, and belonging. Interpretative Phenomenological Analysis was the methodology used to examine the lived experiences and subjectivity of transgender individuals who have participated in AA/NA. Research Question to be Explored The objective of this qualitative study was to address the following research question: “What are a small sample of transgender people’s lived experiences in AA/NA Twelve Step Programs in Southern Texas?” This study used Interpretative Phenomenological Analysis (IPA) to deeply explore and examine the meaning of the participants’ subjective experiences in AA/NA. Theoretical and Operational Definitions

6 Often substance use disorder (SUD) and “addiction” are used interchangeably but have different meanings according to society, community, and medical practitioners (American Psychological Association, 2022). Addiction is defined as “a treatable primary, chronic disease of brain reward, motivation, memory and related circuitry” (American Society of Addiction Medicine, 2011). The DSM-V does not use “addiction” as a diagnostic term, but it is a common term used around the world to describe a serious drug or alcohol problem. “Addiction” and “Addict” had negative connotations and often create stigma (Kelly & Westerhoff, 2010).

Diagnosing a substance use disorder is a subjective process. Many practitioners are uneducated in the field of SUD, and misdiagnoses may follow the patient for life. For example, many clinicians will diagnose a personality disorder without ruling out other differential diagnoses. Based on personal experience, there is a lack of consensus amongst practitioners and bias in diagnostic practices regarding varying degrees of substance use disorder, such as mild, moderate, or severe. The medical and mental health community often disagree about how to appropriately diagnose and treat SUD (Smith & Jones, 2019).

The number of Americans who identify as members of the LGBTQ community is approximately 18 million (Gallup, 2022). Transgender people comprise approximately 1.6 million individuals. Of this number, roughly 398,900 (18 to 24 years old) identify as transgender, 766,500 (25 to 64 years old) identify as transgender, and 171,700 of adults (65 and older) identify as transgender (UCLA School of Law Williams Institute, 2022). This study further states 36% of all transgender adults reported “high risk behaviors” and, when compared to their cisgender peers, transgender individuals were 7% more likely to report “heavy drinking.” The definition of “heavy drinking” is not quantified and this lack of data could be helpful when implementing treatment interventions such as harm reduction. Other alarming statistics in this

7 research state, “70% of transgender people experienced childhood bullying, 75% experienced emotional abuse, 44% were physically abused and 45% were sexually abused” (UCLA, Williams Institute, 2022). Further, 55% have received conversion therapy and upwards of 64% have chronic stress coupled with 81% of lifetime suicidal ideation.

When researching substance use disorders within the transgender population, challenges emerge due to the homogeneous treatment of the LGBTQ population. This difficulty arises from the varied definitions and understandings of gender identity. For instance, a 2019 survey conducted by SAMHSA examined substance use, substance use disorders, and mental health treatment options among lesbian, gay, and bisexual adults in the United States (SAMHSA, 2019). However, this research fails to adequately capture the unique experiences and needs of the transgender population in relation to substance use disorders.

“Transgender” is a term used to encompass individuals whose gender identity, gender expression, or behavior does not align with societal expectations associated with the sex they were assigned at birth (American Psychological Association, 2023). For example, people in the transgender community may also describe themselves as transsexual, non-binary, queer, or asexual (GLADD, 2022). These distinctions have yet to be researched as they pertain to substance use disorders. Another issue in finding accurate statistics on substance abuse amongst transgender adults is that research tends to focus primarily on high-risk subgroups, such as individuals with HIV, those who live in poverty, and those experiencing homelessness (Ruppert et al., 2021). For the purposes of this study, this researcher referred to the earlier use of “transgender,” as it appeared within the broader LGBTQ framework, which described individuals whose gender identity differed from the sex assigned at birth rather than as a broad categorical umbrella.

8 Within this study, substance users are defined as participants who have a history of abusing drugs and/or alcohol. To classify as a substance user, participants met any DSM-V criteria for substance use disorder, at any level of severity (mild, moderate, or severe).

Throughout the study, this researcher used the term LGBT (lesbian, gay, bisexual, transgender) to refer specifically to the research focus. In citing literature, this researcher followed the acronyms used in the original sources, such as LGBT or LGBTQ/LGBTQIA+. Gender nonconforming identities were not addressed, as the definitions associated with these terms were broad and encompassed a wide range of experiences. Below are keywords, acronyms, and other descriptors used throughout the study to maintain consistency for the reader.

Keywords and Definitions 1. LGBT stands for lesbian, gay, bisexual, and transgender. Historically used as an umbrella term to describe sexual and gender minority groups, particularly in research, advocacy, and policy literature produced in the 1980s and early 1990s. (GLAAD, 2023; The Center, 2023).

2. LGBTQ/LGBTQIA+ expands upon LGBT to include queer and, in some contexts, questioning individuals plus intersex, asexual and others. Emerging in the 1990s, it represents a more inclusive and contemporary term acknowledging the diversity of sexual orientations, gender identities, and expressions exist beyond heteronormative and cisnormative frameworks (GLAAD, 2023; The Center, 2023).

3. Queer- According to GLADD (2021), “queer” encompasses a range of identities and expressions that fall outside of heteronormative and cisgender norms. It is often used as an inclusive and non-binary term that includes individuals who identify as gay, lesbian, bisexual, transgender, genderqueer, non-binary, or any other sexual orientation or gender identity that do not conform to societal expectations.

9 4. Transgender/trans –An umbrella term used to describe a person whose gender identity does not align with the sex they were assigned at birth. This can include nonbinary individuals who primarily identify as transgender (GLAAD, 2023). For the purposes of this study, this researcher referred to the earlier use of “transgender,” as it appeared within the broader LGBT framework, which described individuals whose gender identity differed from the sex assigned at birth rather than as a broad categorical umbrella.

5. Gender Identity – Gender identity is defined as a person's internal sense of one’s gender. Not all genders are on the binary and have nothing to do with sexuality. For some people, gender identity is non-binary that falls along a continuum which is difficult to define and changes depending on how society uses the definition.

6. Gender dysphoria – Clinically significant psychological distress caused when a person's assigned birth gender is different from the one with which they identify (DSM-V, 2013).

7. Alcoholics Anonymous (AA) – Alcoholics Anonymous is a free international fellowship of people who have a problem with alcohol. It is nonprofessional, self-supporting, multiracial, and apolitical. Membership is open to anyone who wants to address their drinking problem.

8. Narcotics Anonymous (NA) – Narcotics Anonymous is a free international fellowship of people who have a problem with drugs. It is nonprofessional, self-supporting, multiracial, and apolitical. Membership is open to anyone who wants to address their drug problem.

9. Substance use disorder (SUD) - substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically significant impairment. According to the DSM-V (2013), substance use disorders are on a continuum of mild, moderate, and severe based on how many criteria are met. This includes all drugs and alcohol excluding tobacco and caffeine use disorders. An example of a substance use disorder includes the abuse of over-

10 the-counter medications. For the purpose of this study, SUD means alcohol or drugs.

“Addiction” is used interchangeably with SUD. 10. Recovery- Defined as attending at least one AA/NA meeting per week or biweekly and abstaining from drugs and/or alcohol.

11. Twelve Steps of AA/NA – A set of guiding principles in addiction treatment that outline a course of action for tackling problems including alcoholism, drug addiction and compulsion (See Appendix A). Throughout this dissertation, the term “Twelve Step or 12-Step program will be used to refer to mutual aid recovery programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). While the official doctrine of these programs is formally known as the “Twelve Steps,” the use of “12-Step/12-Steps” as it appears in the cited literature to maintain consistency with published sources.

12. World Professional Association for Transgender Health (WPATH) - a nonprofit organization that has written the Standards of Care for transgender people. WPATH aims to “promote evidence-based care, education, research, public policy, and respect in transgender health (WPATH, 2025, https://www.wpath.org/).

13. Human Rights Campaign (HRC) - The largest LGBTQ+ civil rights organization in the United States. It advocates for equal rights and protections for LGBTQ through political lobbying, public education, and research (Human Rights Campaign, 2025.)

14. Lambda- Lambda Center Houston is a Twelve Step recovery clubhouse dedicated to serving the LGBTQ community and its allies. It provides a safe and welcoming environment for individuals seeking recovery through programs like Alcoholics Anonymous (AA) and other Twelve Step meetings. Beyond recovery support, the center fosters community through

11 social events such as drag shows, car washes, luncheons, plays, and volunteer opportunities (Lambda Center Houston, 2025).

Statement of Assumptions In order to preserve the integrity of Interpretative Phenomenological Analysis (IPA), this researcher engaged in the processes of epoche and bracketing to acknowledge and set aside assumptions. This requires pausing personal beliefs and assumptions to explore participants' lived experiences. Although full objectivity cannot be achieved, these reflective practices are critical for minimizing bias and enhancing the credibility and rigor of the analysis.

The following assumptions held by this researcher were acknowledged and reflexively was maintained in awareness throughout the study: 

Transgender individuals may feel unwelcome or invisible in AA/NA meetings, especially due to the absence of trans-specific groups at LGBTQ AA/NA clubs such as Lambda Club in Houston.



AA/NA meetings held in LGBTQ-affirming spaces, such as the Montrose Center in Houston and Lambda in Dallas, Texas, often lack meetings tailored to transgender individuals, despite inclusive messaging.



Transgender individuals may prefer alternative recovery models (e.g., SMART or Refuge Recovery) due to greater inclusivity and less emphasis on religion or spirituality.



Most transgender individuals may not have sponsors, citing challenges finding culturally competent support.

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Most transgender people had difficulty working all the twelve steps due to the religious components of AA/NA.



Transgender people may relapse more frequently than LGB peers due to reduced support in traditional programs.



Minority stress affects transgender individuals at higher rates than their LGB counterparts.



Transphobia within LGBTQ communities may create division and exclusion in AA/NA spaces.

Epistemological foundation of project The qualitative phenomenological methodology used in this study is Interpretative Phenomenological Analysis (IPA), developed by Smith, Flowers, and Larkin (2009). The philosophical grounding of this study was crucial to understanding its interpretive lens. A constructivist perspective recognizes the influential role of individual and social constructions in shaping the understanding of reality (Berger & Luckmann, 1966). It acknowledged that perceptions of the world are not fixed, but rather shaped by subjective experiences, beliefs, and cultural contexts (Hall, 2003). Reality is understood as a construct that is interpreted through individual and collective lenses (Gergen, 1999). Moreover, interactions with the environment and other people contribute to the creation of meaning, highlighting the significance of individual interpretation and the existence of diverse perspectives (Burr, 2003).

Knowledge, within this framework, emerges through ongoing processes of negotiation and sense-making by individuals (Burr, 2003). By utilizing qualitative data, this researcher acknowledged that the assumptions made in the research may not have been known to the reader,

13 as they were based on interpretations and perspectives gathered from participants and by the researcher. In this constructivist view, the researcher sought to understand the subjective perspectives and interpretations of participants, acknowledging that reality was individually constructed. Within this approach, data collection methods involved open-ended interviews, observations, reflective journaling, and member checking (Creswell, 2013). The focus was to gain insight into the unique perspectives and lived experiences of individuals within their social and cultural contexts. It was important to note that multiple beliefs about reality existed, as they are shaped by diverse interpretations. Constructivism promoted reflexivity, encouraging this researcher to critically reflect on biases, assumptions, and role in the research process (Bloomberg & Volpe, 2021). This researcher acknowledged their active involvement in the construction of knowledge and engaged in ongoing dialogue and interpretation with participants and committee members.

Butler (1990) stated, “gender is not something that one is, it was something one does, an act… a 'doing' rather than a 'being.” Gender is shaped by culture, language, and societal expectations (Butler, 1990; Burr, 2003). For example, prior to Western colonization, individuals in Native American cultures who did not conform to gender norms were often recognized as embodying alternative gender roles and identities. Some people were identified as “Two Spirit” and were considered specially chosen by the divine to hold roles as healers and ceremonial leaders (Herdzik, 2021). Instead of being biological, gender was defined by expression based on lived experience and societal messages. By viewing gender through this lens, this study highlighted how individuals made meaning of their identities through their own lived experiences, particularly within recovery communities. Gender is understood as flexible and opens space for understanding a wider range of gender identities. Viewing gender from a

14 constructivist perspective allows for a deeper understanding of diverse gender identities and expressions, particularly those that do not fit neatly into male or female categories. The reflections that followed were presented to situate this research within the lived realities of this researcher’s personal and professional experiences.

Foregrounding This researcher has a 27-year career in social services and a personal journey through long-term recovery. Throughout this time, tension was observed between sexual orientation and gender identity AA/NA members. For instance, transgender individuals were at times rejected by other lesbian, bisexual, and gay individuals. In a notable case, a trans woman chose not to attend a women-only meeting due to feeling excluded. She stated she did not “pass,” and the other women in the meeting asked her to leave because she was not fully transitioned (personal communication, 2022). Interestingly, this researcher saw this person again who was no longer transitioning and was now male identifying (personal communication, 2025). Paradoxically, trans men had been observed actively participating in men-only meetings without incident. At times, transmen had been more discreet, whereas trans women might have needed expensive procedures to “pass,” such as facial feminization surgery, rhinoplasty, and breast augmentation.

This disparity affected meeting attendance in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), leading to additional challenges, particularly in gender-specific meetings.

Trans people often struggled with the steps of AA/NA because the program promotes powerlessness and a patriarchal view of recovery (Personal Communication, 2020, 2021, 2022).

In meetings, transgender individuals often tell stories of rejection from family, friends, and coworkers. They speak about feelings of intense despair and loneliness, with no safe place in which to achieve sobriety. This led to curiosity about the lived experiences of transgender

15 individuals in religious or spiritual recovery programs, such as AA/NA. For instance, how was gender identity explained, and how did it fit into a world of recovery and within the LGBTQ community? This research study addressed how biopsychosocial factors, substance use, and internalized transphobia play a role in substance use disorders. In this study, transgender individuals often used substances as a means of coping with the emotional pain caused by internalized shame, stigma, and rejection (Hendricks & Testa, 2012; Sevelius et al., 2016).

Additionally, the lack of transgender-specific AA/NA Twelve Step groups highlighted the importance of understanding how social workers could screen and refer to appropriate substance use services without further marginalizing trans individuals. Many trans people adopted the “veil of protection”—a form of self-preservation that often led to withholding critical information out of fear of judgment (Sevelius, 2013; James et al., 2016). Social workers needed the skills to build rapport and determine if a trans person lacked a sense of safety. This could be achieved by verbally assuring the person they were safe while using appropriate pronouns and inviting the individual to discuss their substance use. Literature on transgenderspecific AA/NA meetings remained sparse. As a result, this researcher included several searches on the LGBTQ community and AA/NA Twelve Step meetings. The literature review focused on social work-related terms such as trust and appropriate Twelve Step referrals. Further education was needed to help social workers identify transgender-specific needs. We could—and needed to —do better.

Theoretical Framework It should be noted that, at the time of this study’s hearing proposal, no specific psychodynamic theoretical frameworks were identified, as IPA suggests that introducing theory prior to data collection may risk predetermining the analytic process (Pietkiewicz & Smith,

16 2014). Thus, this researcher waited to introduce detailed theoretical lenses until the emergent themes were identified during the data analysis process. In Chapter V, a discussion of the findings in this research study explored what emerged, including attachment wounds, experiences of rejection, and the longing for connection. The theoretical lenses of selfpsychology, attachment theory, and minority stress theory were integrated throughout the discussion of the findings to deepen the understanding of transgender people’s subjective experiences in AA/NA. Understanding these dynamics was critical for interpreting study participants’ lived experiences in their recovery from addiction. Further, the data from this study examined unconscious conflicts related to gender identity, shame, and trauma that contributed to substance use among transgender individuals. Trauma added to minority stress and substance abuse was a way to manage intense psychological pain. Kohut’s (1971) theory of selfpsychology illustrated how self-object failures could lead to a fragmented sense of self. For many transgender individuals, these failures mirrored early developmental experiences and using drugs or alcohol became a form of self-soothing. This concept was built on Winnicott’s theory (1965) of the true and false self, and he stated “living inauthentically due to social rejection or trauma contributed to internal conflict, dissociation, and coping through substance use. The false self was more about functioning and surviving than truly being (Winnicott, 1965).

A search of the literature found some studies researching the subjective experiences of LGBTQ individuals. Rose’s (2001) work explored early rejection among gay men, highlighting how a core sense of shame, abandonment, and unworthiness shape one's sense of self over time.

Similarly, Downs (2005) explained that many LGBTQ individuals develop shame because of societal rejection and invalidation, often leading them to mask their emotional pain through maladaptive coping strategies such as alcohol and drug use. Damaging narratives often led to

17 internalized phobias, dissociation, or an inability to trust others. More studies are explored in the Literature Review Chapter, also emphasizing a gap of literature that focuses on the lived experiences and psychosocial challenges of transgender individuals in AA/NA. This researcher’s aim was to explore the dynamics in greater depth and through these various theoretical lenses.

By integrating these ideas, this study highlighted how early relational failures and trauma contributed to addiction dynamics. This deeper understanding enables social workers to implement affirming gender identity interventions that address both the symptomatology and the underlying psychological needs of transgender clients.

18 Chapter II Literature Review Introduction The purpose of this qualitative research study was to gain a deeper understanding of a small sample of transgender people living in South Texas and their lived experiences attending Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). Transgender populations have increasingly advocated for rights and recognition, increasing the frequency with which they have been studied. There is a limited understanding of the lived experiences of transgender individuals and the literature often focuses on secondary concerns such as biopsychosocial issues rather than primary narratives. This study sought to understand the lived experiences, addressing gaps in the literature and the importance of additional research. By shifting away from external narratives of minority stress and focusing on how participants made sense of their own experiences, this approach is aligned with phenomenological and psychodynamic foundations of this study.

Numerous acronyms have been used to describe the LGBTQ population; however, for the purposes of this study, the researcher primarily conducted a literature review which focused on transgender adults and their experiences within mutual support groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). Overall, this researcher found sparse literature on transgender populations and their lived experiences in AA/NA. Further, much of the literature on transgender individuals was recent and included nonbinary or genderqueer populations. It is important to note that the literature review vacillated between the use of “alcoholic”, “addict”, and “substance user.” The words alcoholic and addict are stigmatizing; however, this term was a necessary part of an established Twelve Step program. The term “substance user” or “those with an alcohol/drug use disorder” was a newer term and many

19 alcoholics and addicts did not identify with this kinder definition. From a psychodynamic lens, AA/NA is considered a relational intervention often mirroring early attachment with sponsors, community and higher power (Fonagy & Target, 1997).

The literature review was conducted using search engines such as Google; psychoanalytic journals; journals available through the ICSW (Institute for Clinical Social Work) library, such as Pep-Web and Ebsco; nonprofit and government websites; newspaper and magazine articles; books; AA/NA literature; and personal observation while attending AA meetings. Keywords such as, “Alcoholics Anonymous”, “Narcotics Anonymous”, ‘LGBT’, “LGBTQ”, “alcoholic”, “drug addict”, “transgender”, “substance use disorder”, “addict”, “gender identity”, “transgender non-conforming,” and “treatment” were used during this literature review. This researcher focused specifically on trans people who identified as having a substance use disorder and attended AA and/or NA meetings. Literature that addressed other LGBTQ populations—such as queer, intersex, asexual, and others were intentionally excluded to maintain a clear and defined scope. Literature that addressed “gender non-conforming” was specifically defined since this population described multiple gender identities. Further, it was difficult to grasp older definitions of transgender individuals or the population because some of the language and descriptors were offensive and a conscious effort was made to cite literature that used the recommended 2025 definition of terms supported by World Professional Association for Transgender Health (WPATH).

To better understand the transgender population for the purpose of this study, the literature review examined the following: 1) History of Twelve Step programs (AA/NA); 2) History of Transgender Population; 3) Transgender experiences in the Southern States; 4) Substance Abuse among LGBTQ Community; 5) Psychosocial Issues Among Trans Population;

20 6) Experiences of Transgender People in AA/NA; and 7) Guidelines for Working with Trans People.

History of Twelve Step Programs (AA/NA) Alcoholics Anonymous To help the reader better understand AA and NA, an in-depth examination of both programs is provided. Twelve Step program foundational texts like the Big Book of Alcoholics Anonymous, were originally developed in the 1930s with a primary focus on white, middle-aged men, shaping the culture and assumptions of these recovery models (Nuttbrock, 2010).

Vulnerable populations such as LGBTQ, women, and people of color were often excluded or disproportionality represented in AA/NA meetings. This is due largely to the year the programs were created and less had been known about alcoholism and drug addiction in the 1940s and 1950s. (Alcoholics Anonymous, 1939).

AA was originally built from a Christian organization known as The Oxford Group, a religious movement popular in the United States and Europe in the early 20th century (Mullins, 2010). The principles were embedded in religious teachings and included six basic principles: 1) Human beings are sinners, 2) Human beings can be changed, 3) Confession is a prerequisite to change, 4) The changed soul has direct access to God, 5) The age of miracles has returned, and 6) Those who have been changed are to change others. If a member acknowledged and practiced these beliefs, sobriety was promised (Mullins, 2010). The Twelve Step phenomenon started when Bill Wilson (referred to in AA literature as “Bill W”) attended an Oxford Group rigid with Christian beliefs and he was unable to remain sober (Alcoholics Anonymous, 1939). The unmanageability of his alcoholism landed him in a hospital battling for his life. Since there was a

21 lack of treatment during this time, most alcoholics were sent to hospitals or sanitariums to “sober up” or die. While Bill was in the hospital, he met Dr. Silkworth who believed alcoholism was a disease and that it should be treated in that manner (Alcoholics Anonymous, 1939). Over the years, many people denied alcoholism was a disease and considered it a choice until the American Medical Association declared alcoholism an illness (American Medical Association, 1956). Other medical organizations followed, and the American Psychiatric Association (1980) eventually identified substance use disorder as a primary mental health disorder.

In 1937, Bill W decided to leave The Oxford Group soon after, the “Big Book” of Alcoholics Anonymous was published in 1939. AA literature contains the Twelve Steps, Twelve Traditions, Twelve Promises and several personal stories in the back of the book from various alcoholics (Alcoholics Anonymous World Services, 2001). To achieve sobriety, the following Twelve Steps must be worked through with another alcoholic often referred to as a sponsor.

After they were completed, the alcoholic should have had a spiritual experience, and the desire to drink was forever removed. The only way to remain sober was to live by these steps and carry the message of sobriety forward. To date, more than 30 million copies of the Big Book have been sold and there are AA meetings all over the world (Matsuzaka, 2018). The Twelve Steps of Alcoholics Anonymous are: Step 1) We admitted we are powerless over alcohol and that our lives have become unmanageable; Step 2) We believe that a power greater than ourselves can restore us to sanity; Step 3) Made a decision to turn our will and our lives over to the care of God as we understand him; Step 4) Made a searching and fearless moral inventory of ourselves; Step 5) Admitted to God to ourselves and to another human being the nature of our wrong; Step 6) We are entirely ready to have God remove all these defects of character; Step 7) We humbly ask Him to remove our shortcomings; Step 8) Made a list of all persons we had harmed and became

22 willing to make amends to them all; Step 9) Made direct amends to people whenever possible except when to do so would injure themselves or others; Step 10) Continue to take a personal inventory and when we were wrong promptly admitted; Step 11) Sought through prayer and meditation to improve our conscious contact with God as we understood him, praying only for knowledge of his will for us and the power to carry that out; and Step 12) Having had a spiritual awakening as the result of these steps we tried to carry the message to alcoholics and practice these principles in all our affairs (Alcoholics Anonymous, 1939, p. 59).

The term “Him” was capitalized in the Big Book to describe God’s influence in achieving sobriety and emphasized that belief in a higher power was key to the recovery process (Alcoholics Anonymous, 2001). Religion and spirituality were separately defined and not used interchangeably because these terms had different meanings for each member. AA was promoted as a spiritual program, although the Twelve Step relied heavily on God and “Him.” This was often confusing for individuals who did not believe in God, rejected patriarchy, or had a problematic relationship with male dominance. Spirituality was encouraged when the concept of God could not be attained. The goal was to give new members inspiration and hope that, if they remained sober and followed the program, their lives would improve.

The Big Book has been published in 70 languages, and there are more than 2.1 million members and over 129,000 AA groups worldwide (Alcoholics Anonymous, 2023). In Houston, there are more than 2,500 AA meetings per week (Alcoholics Anonymous Houston Intergroup, 2025). As the Twelve Step philosophy has grown, so have the types of groups that have formed.

For example, there are LGBT groups, women’s and men’s groups, atheist and agnostic groups.

There have been numerous programs developed from the Twelve Steps of AA such as Al-Anon, Al-Ateen, Narcotics Anonymous, Meth Anonymous, Cocaine Anonymous, Overeaters

23 Anonymous, and Codependency Anonymous that have replaced “alcohol” with their own respective problem (Harlow, 2017). Many inpatient and outpatient treatment centers have required AA or NA attendance; however, there was a lack of evidence to determine their efficacy (Matsuzaka, 2018).

The AA Membership Survey (2022) identified approximately 87% of members as White, 7% Hispanic, 3% Black, 2% Native American, 1% Asian, and .5% “other (Harlow, 2017). Many inpatient and outpatient treatment centers have required AA or NA attendance; however, there was a lack of evidence to determine their efficacy (Matsuzaka, 2018).

Despite the global reach, AA/NA’s historical and cultural foundations have largely centered on White, cisgender, and heterosexual experiences. With 87% of AA members identifying as White and the majority of meetings reflecting normative frameworks of recovery, transgender individuals often enter these spaces with a sense of cognitive dissonance.

The largest study to date addressing alcohol and treatment interventions was the Project Match Study (Project Match Research Group, 1997). The study compared Twelve Step Facilitation (TSF) programs, Cognitive Behavioral Therapy (CBT) and Motivational Enhancement Therapy (MET). The results were as follows. 

TSF was a therapist led evidence-based intervention that helped individuals develop coping skills to manage triggers, thoughts, and behaviors related to alcohol use. It was based on the principles of Alcoholics Anonymous (AA) and encouraged participation in AA meetings.

This was different than peer led Twelve Step AA/NA meetings.

● CBT involved identifying and challenging irrational beliefs related to alcohol use, learning new coping strategies to manage triggers and high-risk situations. It aimed to help individuals develop healthier thought patterns leading to positive behaviors related to alcohol use.

24 ● MET aimed to motivate change in drinking behavior. It involved understanding the stages of change and readiness to abstain from alcohol (Project Match Research Group, 1998).

Project Match was conducted by the National Institute of Alcohol Abuse and Alcoholism (1989) and was an eight-year study that cost $27 million (Project Match Research Group, 1997).

Twelve Step manualized facilitation was implemented by therapists with individual clients over 12 to 15 sessions (Smith & Johnson, 2010). The intervention was based on the behavioral, spiritual, and cognitive principles of Alcoholics Anonymous (AA). This approach was vastly different from attending AA meetings independently. The study was considered a failure because the data did not support the hypothesis and different treatment modalities for alcoholism did not yield different results (Cutler & Fishbain, 2005). The idea of matching a client characteristic with TSF, MET and CBT did not make sense. This study excluded clients with serious mental health and addiction issues, the environment was rigidly controlled, and the sample was not representative of the real world, (Project MATCH Research Group, 1997). According to the Project MATCH Research Group (1997), client engagement and not the type of therapy, was a key factor in recovery. Therefore, proving that mutual Twelve Step groups were effective.

In a recent AA Membership Survey, 63% identified as male and 87% identified as white (Alcoholics Anonymous World Services Membership Survey, 2022). It is important to note that gathering data from AA/NA was difficult, and statistics may be unreliable because the groups were founded on anonymity. AA is defined as a fellowship of men and women who have a desire to stop drinking. Anyone can attend meetings even though they may have relapsed or are in a pre-contemplation stage of change. Everyone (18 and older) is welcome, including all races and ethnicities. There are specialized AA/NA groups for teenagers called Al-Anon.

Narcotics Anonymous

25 Narcotics Anonymous (NA) is a nonprofit fellowship of men and women who have various drug problems and want to abstain. It was founded in 1953 by Jimmy Kinnon in Los Angeles, California (Narcotics Anonymous, 2008). Similar to Alcoholics Anonymous (AA), NA has a 396-page book detailing a Twelve Step program of recovery, with Twelve Principles, and Twelve Promises (Narcotics Anonymous, 2008). The book was published in 1983, with updated language, and was based on AA’s Big Book (Meil & Mills, 2021). In AA, Step One required the admission, "We admitted we were powerless over alcohol,” while the NA Step One asserted, “We admitted we were powerless over our addiction.” Although discussions about drugs were generally discouraged in Alcoholics Anonymous (AA) meetings, Narcotics Anonymous (NA) permitted members to discuss alcohol use within the context of their recovery. Today, NA members hold 76,000 meetings weekly in 143 countries (Narcotics Anonymous, 2025).

According to Narcotics Anonymous World Services Membership Survey (2022), approximately 57% are men, 42% are female, and 1% are identified as “other.” In addition, 70% are white, 13% African American, 7% Hispanic, 4% multiracial and 6% other (Narcotics Anonymous Membership Survey, 2022). Approximately 80% are heterosexual, 8% gay or lesbian, 7% bisexual and 5% other (Narcotics Anonymous World Services, 2022). Unlike Alcoholics Anonymous (AA), Narcotics Anonymous (NA) is known for attracting a “hard-core and tougher population,” with a more rigid meeting format focused on sharing experience, strength, and hope (Narcotics Anonymous World Services, 2020). Many Twelve Step NA groups focus on a particular class of drugs, such as Crystal Meth Anonymous. This group often includes discussing sex, sobriety, and love addiction (Crystal Meth Anonymous, 2025).

Like AA, NA provides a global recovery structure, its demographic data highlights a predominantly cisgender, heterosexual community. For transgender individuals, this can lead to

26 feelings of invisibility or disconnection. The lack of representation and rigid group norms can unconsciously reenact early childhood experiences. While the structure and shared language of Narcotics Anonymous (NA) can offer support, its ability to foster healing depends on whether meetings welcome transgender individuals as they make personal meaning of recovery.

Gender Language in AA/NA Alcoholics Anonymous historically was a male-dominated fellowship and continues to adhere to this format depending on the location of the AA meetings (Kaskutas, 2009). Marty Mann is one of the first lesbians who attended AA in 1941 (Sanders, 2010). She authored her personal story “Women Suffer Too” in the back of the AA Big Book. This was the first time AA acknowledged alcoholism affected women (Alcoholics Anonymous World Services, 1955). The pronoun “Him” was gendered language and continues to be spoken at AA meetings, even today.

Over the years, there have been many women-only AA/NA meetings that focus on the female experience. Although the Big Book remains in its original form with some updates, there have been books specifically written for women in Twelve Step recovery. For example, Stephanie Covington’s book, entitled “A Woman’s Way Through the Twelve Steps" was based on the feminist perspective and how women can modify the Twelve Steps for their own personal recovery (Myllmaki, 2011). The book was accompanied by a workbook to help women journal about their recovery experiences (Covington, 1994), which includes the following principles: Step 1) We admitted we were powerless over our addiction and that our lives had become unmanageable. Acknowledging the need for change without shame or blame; Step 2) Came to believe that a power greater than ourselves could restore us to sanity. Opening up to trust, connection, and healing—whether spiritual or relational; Step 3 ) Made a decision to turn our will and our lives over to the care of this power as we understood it. Letting go of control and

27 reclaiming healthy interdependence; Step 4) Made a searching and fearless moral inventory of ourselves. Exploring our lives with honesty and self-compassion—not self-judgment; Step 5) Admitted to ourselves, to this power, and to another woman the exact nature of our wrongs.

Creating safety in vulnerability and connection; Step 6) Were entirely ready to have this power help us remove these defects of character. Letting go of outdated survival strategies and internalized shame; Step 7) Humbly asked this power to help us remove our shortcomings.

Embracing humility as strength, not weakness; Step 8) Made a list of all persons we had harmed and became willing to make amends to them all. Taking responsibility with kindness toward self and others; Step 9) Made direct amends wherever possible, except when to do so would injure them or others. Repairing harm while maintaining safety and boundaries; Step 10) Continued to take personal inventory and when we were wrong promptly admitted it. Practicing ongoing selfawareness and growth; Step 11) Sought through prayer and meditation to improve our conscious contact with our power, seeking only knowledge of its will and the power to carry it out.

Deepening spiritual or mindful connection in a way that feels meaningful; and Step 12) Having had a spiritual awakening as a result of these steps, we tried to carry this message to other women and to practice these principles in all our affairs. Sharing recovery through authentic relationships and compassionate action.

The re-authoring of the Twelve Steps is seen as a symbolic effort to integrate parts of the self that had once been excluded or shamed. Although this process focuses on women, transgender individuals can reframe the steps in ways that align with their gender identity and emotional truth. This speaks directly to the research question, which centered on how transgender individuals made sense of recovery within structures that were not originally designed for them.

28 Binary gender language is sometimes spoken throughout meetings, and there was a need for nonbinary language such as they/them. Over the years, this researcher observed that within predominantly LGBTQ meetings, female-to-male (FTM) participants appeared to be more readily accepted by peers than male-to-female (MTF) participants (Serano, 2007). For example, trans men used binders to hide breasts, started hormones to promote hair growth, and dressed in male clothing (Sevelius et al., 2016). For trans women, it was much harder to express their gender. Some trans women struggled with a deep voice, a prominent Adam’s apple, facial or body hair growth, and difficulty finding women’s clothing or shoes. Societal constructions around gender, biological sex, and identity made it difficult for a trans person to express themselves (Butler, 2004). In addition, there was the reality of misogyny. This was defined as transmisogyny, which described overlapping forms of oppression, misogyny, and transphobia (Serano, 2007; Resource Center for Sexual and Gender Diversity, 2022).

Nuances are important to understand when treating and referring a transgender person to Twelve Step groups or treatment (Hendricks & Testa, 2012). This information may help the medical and mental health communities understand the need for services that are different for FTM than MTF. The definition of “transgender” defines many populations and treatment should be geared toward subgroups, for example, gender non-conforming, queer or intersex (American Psychological Association, 2021).

Religion and Spirituality in AA/NA Neff et al. (2006) suggested Christian teachings have limited effectiveness in treating substance use disorders. Twelve Step groups were helpful, but evidence-based interventions such as motivational interviewing and CBT have been extensively researched and studied with

29 positive outcomes reported (Miller & Rollnick, 2013; Beck, 2011). Treatment programs, inpatient and outpatient, have historically adopted a rigid Twelve Step philosophy but these programs are shifting more towards trauma focused work and holistic methods (White, 2014; SAMHSA, 2014). Attendance in AA/NA has become an option instead of a requirement.

For example, this researcher visited Sabino Recovery in Tucson, Arizona, a residential substance abuse facility treating co-occurring disorders. They rely heavily on clinical evidencebased interventions such as Neurofeedback, EMDR, Brainspotting, Equine therapy, Adventure therapy, massage therapy, acupuncture, meditation, physical activity, and yoga and not religion (Sabino Recovery, 2025). This is a traditional 35-day residential program, and patients may stay up to 90 days if they choose. This facility is mostly self-pay and some out of network benefits could be reimbursed. More programs are moving away from the traditional “hardcore” AA/NA meetings. Twelve Step groups are offered but not required. The treatment landscape is changing, and the gold standard of care has moved away from religion, embracing more spirituality or agnostic beliefs.

Religious practices such as prayer and confession sometimes reinforce stigma against transgender individuals by framing gender identity as spiritually corrupt. Christianity often rejects homosexuality and other gender-diverse identities. Many LGBTQ individuals experience gender identity incongruence, which often feels confusing and isolating (Liboro, 2015). The Lord’s Prayer has often been used to close AA/NA meetings; however, its explicitly Christian language could be alienating or uncomfortable for individuals from non-Christian or secular backgrounds (Alcoholics Anonymous World Services, 2001; Narcotics Anonymous World Services, 2020).

30 One safe church in Houston is Resurrection Metropolitan Community Church (MCC), which was created primarily to serve LGBTQ individuals. According to its website, “Resurrection MCC strives to be a congregation that models the strength found in diversity, the transforming power gained through forging community partnerships, and an unwavering voice for equality” (Resurrection Metropolitan Community Church, 2022). Spirituality in AA/NA can be a substitution for God in AA/NA literature. Spirituality is defined as an individualized way of connecting with the world (Liboro, 2015). Spirituality integrates the holistic wellness of a person into a biopsychosocial perspective (Warren, 2012). Mental, physical, and spiritual health play a role in sobriety and contribute to achieving balance and wellness.

For individuals who feel oppressed by the concept of God in Twelve Step meetings, there are alternative sobriety programs that do not incorporate religion, such as Refuge Recovery (Refuge Recovery, 2023) and SMART Recovery (SMART Recovery, 2022). SMART Recovery does not focus solely on substance use but addresses problematic behaviors through a cognitive behavioral therapy (CBT) approach, including evidence-based worksheets (SMART Recovery, 2022). Refuge Recovery is based on a Buddhist system designed to address all forms of addiction (Levine, 2014). By following this path to recovery, individuals may achieve lifelong well-being and happiness that best supports their sustained sobriety.

The AA/NA Powerlessness Concept Accepting the notion of powerlessness, rather than helplessness, is considered essential to effectively working through the Twelve Steps in AA/NA. Many people in the LGBTQ community feel powerless throughout life. For transgender women in AA, feminists say Step One is unhelpful and unhealthy (Myllmaki, 2011). The meeting format and gender language have been developed for heterosexual white men and not for the transgender community

31 (Stevens, 2012, 2013). The meaning of powerlessness, as indicated in Step One in AA/NA, means you did not have control over the use of drugs and life has become unmanageable. It does not mean power over self and decisions are relinquished. The use of a sponsor is suggested to help guide the person through the most difficult concept, admitting a lack of control over substances. The Big Book of AA says, "We admitted we were powerless over alcohol— that our lives had become unmanageable" (Alcoholics Anonymous World Services, Inc., 1939, chap. 5).

Sponsorship Sponsorship is suggested in AA/NA programs, but not required. A sponsor is considered someone who takes the newly sober person through the Twelve Steps and offers support along the way (Covington, 1994). This can be described as a cross between a life coach, drill sergeant, and an unlicensed therapist. A sponsee is someone who was willing to follow a program of recovery and takes suggestions from their sponsor. Having a sponsor is a significant predictor of abstinence after six to twelve months of sobriety (Witbrodt, et al., 2014). Furthermore, a sponsor has the added effect of increasing attendance by the substance user at recovery meetings.

Sponsorship can also be a positive experience used to help individuals with daily stressors. For example, many interpersonal relationships are affected by addiction (Lander, 2013). The sponsor serves as someone who supports the sponsee in making life decisions based on the Twelve Steps.

A sponsor and sponsee are considered to have a special relationship due to the nature of selfdisclosure between them (Kaskutas, 2009).

Sponsorship is helpful for many, however, a study by Myllaki (2011) found women new to AA potentially may be harmed emotionally by a sponsor and relapse as a result. Recovery should be viewed as a holistic experience and having social support, spirituality, and affiliation

32 with Twelve Step fellowships are associated with greater life satisfaction among individuals in recovery (Laudet et al., 2006).

This researcher observed sponsors who interfered in the treatment process by contradicting therapists and imposing their personal views upon new AA/NA members. Some members believe taking medication for depression or anxiety constituted dependence on a substance. Encouraging a sponsee to stop medication may pose serious risks for someone who has been diagnosed with bipolar disorder who requires medication to stabilize. Because sponsors are not clinicians, they guide the sponsee the way their sponsor worked with them. Interestingly, this pattern can also mimic family of origin dynamics and the enactments between the dyad can become traumatic and harmful. Clinicians who are not well-versed in the subtleties of addiction often overlook these dynamics and are unable to clinically treat them effectively. These insights are based on this researcher’s direct clinical experiences working with AA/NA members in addiction treatment settings, consistent with the qualitative principle of the researcher as an instrument of inquiry (Bloomberg & Volpe, 2019).

A concerning phenomenon in AA/NA is known as the “13th step.” Although not part of the official AA/NA program, this slang term is used in the recovery community to describe an “old timer” with several years of sobriety who attempts to initiate a sexual relationship with a new AA/NA member. This behavior is regarded as predatory and abusive, often causing feelings of distrust and emotional unsafety among group participants (Harris, 2024). Dossett and MetcalfWhite (2024) documented how newly sober women are approached by male members seeking romantic contact, which often creates discomfort. This was a common practice that this researcher encountered early in sobriety, regardless of gender or sexual orientation.

33 This section of the literature review informs this study’s research question by exploring how sponsorship in AA/NA may influence the recovery experiences of transgender individuals.

While sponsorship often promotes abstinence and provides emotional support, it also introduces risks, particularly for marginalized groups (Myllaki, 2011, Witbrodt et al., 2014). Rather than fostering connection, sponsorship sometimes reproduces family-of-origin trauma, which contributes to relapse and disengagement from recovery spaces (Kaskutas, 2009; Covington, 1994).

History of Transgender Population The definition of “transgender” describes people whose gender identity differs from the biological sex assigned at birth (American Psychological Association, 2022). It can be assumed this term applies to someone who has transitioned from male to female or female to male, but it is a much broader category. Gotfried (2022) explained gender identity as an internal sense of being that is not contingent upon sexuality or sex. For some people, gender identity is fluid along a continuum that is difficult to define and can change, depending on one’s social construction.

Transgender individuals may define themselves as transsexual, non-binary, gender nonconforming, or asexual (Gay and Lesbian Alliance Against Defamation, 2023). The descriptors are inherently subjective and rely on individuals' interpretations, whether they were assigning the categories or identified with them. The idea of “transgender” has always existed across many cultures and countries (Beemyn, 2020). Transgender individuals have historically hidden in underground communities where they are accepted and allowed to express themselves without judgment.

Early History

34 In the 1850s, there were laws prohibiting a person from appearing in public in clothing “not belonging to his or her sex,” which today is referred to as cross-dressing or transvestism (Beemyn, 2020). During this time, a license was required to attend these events so participants would not be arrested for violating the crossdressing ordinance (Stryker, 2017). The meanings of transvestite, transsexual, transgender, and crossdresser have changed over time and may be considered offensive, outdated and inappropriate. In 1910, Magnus Hirschfield defined the word transvestite: “it comes from the Latin word “trans” or “across” and “vestis” or “clothing” to refer to people who feel a sense of peace when they wear clothing of the opposite sex” (Beemyn, 2020). One of the more famous transvestites in cinema was the character, Dr. Frank N Furter, played by Tim Curry in The Rocky Horror Picture Show. This film was representative of queer culture in the 1970s and is considered a cult classic loved by many including a heterosexual population. A person who cross dresses can be gay, straight, or asexual (Grant et al., 2011).

One of the first open and public “transsexuals” was Christine Jorgensen. She underwent a “sex change” in 1952, which was later referred to as a gender transition (Feinberg, 1992). After Jorgensen came out, she was harassed by politicians, media, and people in the community.

Transgender people were labeled as “deviant” and often referred to as “pedophiles” (Stryker, 2017). Jorgensen advocated for her rights and brought awareness regarding transitioning (Meyerowitz, 2002). As the population’s visibility has increased, there has been an increase in assaults and murders (Human Rights Campaign, 2019). In 1994, Brandon Teena was a transgender man in Nebraska who was sexually assaulted and murdered by two men when they discovered his biological sex. In 1999, Hilary Swank played Brandon Teena in the film, Boys Don’t Cry, and she won an Academy Award for Best Actor in a Leading Role.

Current Status

35 Transgender studies initially emerged on the Internet allowing people a space to be supported and understood while remaining anonymous. There has been activism for transgender rights and transgender individuals who continue to advocate and challenge laws and bills that marginalize them (HRC, 2022). The most recent debates restricting the rights of transgender people have negatively impacted trans and non-binary youth’s mental health (Trevor Project, 2020). The World Professional Association for Transgender Health (WPATH) has created the Standard of Care 8 Guidelines for trans healthcare, which are rooted in ethical care, patient autonomy, and protection of human rights (2022). These include: 

Person-centered care: Health care must be individualized, with TGD (transgender and gender diverse) people as active participants in their care.



Affirmation of gender diversity: Gender diversity is recognized as a normal and positive variation of human experience, not a disorder.



Informed consent model: Gender-affirming medical interventions should be based on informed consent, reducing unnecessary psychological gatekeeping.



Comprehensive health care: SOC-8 addresses hormone therapy, surgeries, primary care, mental health, voice/communication, reproductive health, and more.



Adolescent/youth care: Recommends a careful, multidisciplinary approach for youth, including family support, social transition, and access to interventions when appropriate.



Nonbinary inclusion: Provides guidance for the care of nonbinary and gender-expansive individuals.



Sexual and reproductive health: Advises comprehensive counseling and access to sexual and reproductive health services.

36



Cultural competence: Emphasizes awareness of cultural, social, and legal contexts impacting TGD people worldwide.



Ethical care and human rights: Stresses patient autonomy, dignity, and the ethical obligation to protect human rights.



Ongoing research and adaptability: Encourages continued research and adaptability to new evidence and evolving community needs.

WPATH (2025) has offered a formal provider certification since 2018 to licensed

healthcare and mental health providers. The certification requires completion of foundational and advanced coursework, an ethics module, and ten hours of clinical consultation. Prior to this, there was no standardized certification process. There are only 14 medical and mental health providers certified in Houston (WPATH, 2025). Peer support advocates, mental health technicians, intake coordinators and crisis support workers cannot obtain certification, but can attend classes. The exclusion of unlicensed professionals represents a significant limitation within transgender health (World Professional Association for Transgender Health [WPATH], 2024).

Activism has empowered gender expression, and gendered language has been implemented in some mental health and substance abuse treatment communities such as The Menninger Clinic in Houston, Texas (Menninger Clinic, 2016). Medical and mental health providers at The Menninger Clinic have been mindful of chosen names and gender identity. This heightened awareness stood in contrast to earlier eras when gender expression was regulated and subject to legal restriction (Beemyn, 2020; Stryker, 2017).

Landmark Legal Cases and Laws

37 The New York City Stonewall riots in 1969 propelled a modern LGBTQ rights movement (Library of Congress, n.d.). Within this larger movement, transgender people sought to find their own voice. The World Professional Association for Transgender Health (2022), formerly the Harry Benjamin International Gender Dysphoria Association, was created in 1979, with the goal to“ provide evidence-based healthcare to assist transsexual, transgender, and gender nonconforming people with safe and effective ways to maximize their overall health and psychological well-being” (WPATH, 2023, para.1). By the 1990s, the definition of transgender was used to define a larger group of people whose gender identity differed from their gender assigned at birth (Beemyn, 2020). Transgender rights have expanded; however, it does not appear that this progress was on firm ground given the current political climate (Human Rights Campaign, 2022).

There are a few pivotal and landmark cases that have codified the rights of transgender people. In Colorado (2013), the “Cory Mathis” case ruled a six-year-old trans girl was able to use the girls’ bathroom at her school (Erdely, 2013; Mathis v. United States, 2016). Another ruling by the Supreme Court regarding Title VII of the Civil Rights Act of 1964 provided protection from discrimination based on sexual orientation and gender identity in the workplace (Civil Rights Act of 1964). Although visibility and acceptance of transgender individuals have come a long way, they remain vulnerable, and efforts continued to advocate for and secure rights. For example, President Trump’s military ban in 2017 excluded transgender people to serve in the Armed Forces. This decision was reversed by President Biden in 2021. Since returning to office in 2025, President Trump has issued multiple executive orders overturning transgender rights, including banning gender-affirming care for minors, restricting military service, eliminating federal

38 recognition of gender identity, banning trans people in sports and eliminating EEOC guidelines that protect transgender people from workplace harassment (AP News, 2025).

In Florida, Governor DeSantis successfully passed of a state bill which asserts medical treatments for transgender youth constitutes a form of child abuse (Smith, 2021, 2022). In Texas, Governor Greg Abbott directed the state's Department of Family and Protective Services to investigate certain gender-affirming care for transgender children as possible child abuse (Ghorayshi, 2022). For people under eighteen, this includes hormone therapy and puberty blockers (Smith, 2021). The Texas Legislature passed a bill in March 2022 prohibiting Texas Children’s Hospital in Houston— one of the largest hospitals in the United States—from prescribing hormone blockers to transgender children. These decisions are discriminatory and contribute to minority stress (Meyer, 2003). Minority stress theory proposes that members of stigmatized minority groups experience chronic stress resulting from social prejudice, discrimination, and internalized stigma (Meyer, 2003). These stressors are additive to general life stress and contribute to adverse mental and physical health outcomes among marginalized populations, including sexual and gender minorities (Hendricks & Testa, 2012).

In a recent study by Clever Real Estate company, Houston was ranked second as the least LGBTQ friendly city in the nation and tied for 4th with Memphis, Tennessee “with the fewest LGBTQ affirming health care providers” (Clever, 2023). In 2025, over 360 anti-trans bills were introduced in U.S. state legislatures, with at least 48 enacted into law (Human Rights Campaign, 2025; ACLU, 2025; Trans Legislation Tracker, 2025). In 2024, more than 500 anti-trans bills were introduced across the United States, and over 75 were passed into law (Human Rights Campaign, 2024; ACLU, 2024; Movement Advancement Project, 2024). Legislation, politicians, and society in general continue to challenge the rights of transgender people; these

39 anti-trans bills fuel hatred and discrimination by keeping transgender lives in the news, further marginalizing transgender populations (Human Rights Campaign, 2021).

Another example of anti-trans legislation is Texas Senate Bill 29 (SB29), which proposes that public school students were required to compete in interscholastic athletic competitions based on the sex assigned at birth (Texas Senate Bill 29, 2021). The bill was met with strong opposition from LGBTQ advocates and, ultimately, it did not pass during that legislative session.

However, a similar policy was enacted with the passage of House Bill 25 later that year, and additional restrictions have continued to be proposed in Texas in 2024 and 2025 (Texas Legislature Online, 2021; Human Rights Campaign, 2024; ACLU, 2024).

Relevant History of the Diagnostic Statistical Manual (DSM) The first Diagnostic and Statistical Manual (DSM-1) was created in 1952 to manualize mental health disorders (Diagnostic and statistical manual of mental disorders: DSM I, 1968).

Homosexuality was a diagnosis listed under sociopathic personality traits (American Psychiatric Association, 1952). The DSM II removed the diagnosis of “homosexuality” and psychiatrists rejected the notion of resolving homosexuality during analysis (American Psychiatric Association, 2013). Despite pushback from analytic psychiatrists, “homosexuality” was changed to “sexual orientation disturbance” (DSM-II, 1973). This change in definition allowed for “conversion therapies” to advertise as legitimate treatment interventions and as a result they gained popularity in the 1980s and 1990s.

Exodus International, founded in 1976, was a Christian organization that promoted "conversion therapy" or "reparative therapy" to change sexual orientation (Exodus International, 2013). Exodus shut down in 2013. Conversion therapy promised to “cure” homosexuality by praying and changing behaviors, suggesting patients go as far as marrying members of the

40 opposite sex (Stolakis, 2021). Conversion therapy used shame, verbal abuse, and exorcisms. As of today, approximately 23 states have banned conversion therapy for LGBTQ youth (Movement Advancement Project, 2024). Although Texas is one state that still allows conversion therapy, the National Association of Social Workers Code of Ethics prevents any practitioner from using this type of “therapy” (National Association of Social Workers [NASW], 2012).

In the DSM III, the term “sexual orientation disturbance” was replaced with “ego dystonic homosexuality” (American Psychiatric Association, 1980). After seven years, the published revision of DSM III for “ego dystonic homosexuality” was replaced with a new heading titled “psychosexual disorders.” This was the first-time identity disorder was addressed and defined.

For example, gender identity disorder was further broken into subcategories such as transsexualism, gender identity disorder in childhood, and atypical gender identity disorder (American Psychiatric Association, 1980). By the time, the DSM-IV was published in 1994, the term “transsexualism” was eliminated and “gender identity disorders” was replaced with “gender identity disorder.” This was the first time the DSM addressed the diagnosis as a sexual disorder and not a psychological one (American Psychiatric Association, 2000).

In 2013, DSM-V was published and “gender identity disorder” was replaced with “gender dysphoria.” The American Psychiatric Association started to recognize the need to be mindful of the LGBTQ population and took initiative to no longer pathologize these terms (American Psychiatric Association, 2013). For example, the American Academy of Child and Adolescent Psychiatry (AACAP) adopted a policy in 2018 asserting there is no evidence to support the use of "conversion therapies" that pathologize specific sexual orientations, gender identities, or gender expressions (AACAP, 2018). This is defined as a set of practices employed by a provider aimed at changing an individual's sexual orientation or gender identity, typically from LGBTQ to

41 heterosexual identities (Substance Abuse and Mental Health Services Administration [SAMHSA], 2015). The AACAP further argued these harmful “interventions” lacked scientific evidence and should not be included in any behavioral health plan for children and adolescents (AACAP, 2020).

Historical Treatment Options for Transgender Population Historically, there has been an absence of LGBTQ substance abuse centers until the Pride Institute opened in Eden Prairie, Minnesota in 1986 at the height of the AIDS epidemic (Marcotte et al., 2020). This facility provided long-term residential treatment, partial hospitalization, intensive outpatient programs, and sexual health psychoeducation (Pride Institute, 2023). There are often a variety of issues that individual’s face, such as HIV, process addictions, and family rejection, which are all specific to LGBTQ recovery (Pride Institute, 2023). Early treatment was developed by white heterosexual males for white heterosexual males, and there was a gap in services for other cultures, races, ethnicities, genders, and sexual orientations (Stevens, 2012). Although many treatment centers advertised that they catered to the LGBTQ community, this is often not the case (SAMHSA, 2013).

In 2007, researchers conducted an investigation into organizations that advertised “specialized substance use services” for LGBTQ populations. However, there was no clear description or definition of what constituted “specialized services.” Of the 911 inpatient centers surveyed, more than 70% reported offering the same services provided to the general population, and only eight programs were identified as specialized (Cochran et al., 2007). Notably, the survey did not differentiate between inpatient and outpatient settings, which is a critical omission, as the intensity of programming and the amount of provider contact varied significantly between the two (National Institute on Drug Abuse [NIDA], 2023, Glynn &

42 Vanberg, 2017). Very few treatment centers in the United States remain authentically aligned with LGBTQ affirming care models. Breathe Life Healing Center in Los Angeles is recognized for its integrative and trauma-informed approach that addresses substance use, co-occurring disorders, and identity-based stressors within an affirming environment (Breathe Life Healing Center, 2025).

In early sobriety, it is often difficult to identify needs and wants without the use of alcohol, and navigating a sense of self can be overwhelming. Effective treatment for transgender individuals needs to include exploration of underlying trauma and symptomatology. “The predominant treatment interventions for substance use treatment are cognitive behavioral therapy (CBT), process groups, Twelve Steps, and psychoeducation” (Lyons et al., 2015). There is a significant gap in education and training among mental health professionals and providers, and this is problematic when addressing co-occurring disorders (Fisher & Piazza, 2012). Since substance abuse counselors are often not trained to treat mental health disorders, this constrains the quality of treatments (American Psychological Association, 2013). This further illustrates how systemic treatment gaps and institutional shortcomings likely shape the subjective experiences of transgender individuals with substance use disorders. These barriers affect more than identity formation, safety, and emotional connection, all of which are central to meaning making in early sobriety.

Transgender Experiences in Southern Texas Texas has the second largest self-identified LGBTQ population in the nation (ACLU Texas, 2024). Texas and Florida reported the most fatal cases of transgender violence from 2013 to 2019. This is not a coincidence, since both states have consistently challenged rights of

43 transgender people and have taken affirmative steps in their own legislatures against marginalization (Human Rights Campaign Survey, 2019; USTS, 2015). In a 2017 communitybased survey titled The Grapevine: A Southern Trans Report, 135 individuals who identified as transgender or gender nonconforming (TGNC) across 13 Southern states participated; 58% of transgender women and femmes reported experiencing high levels of violence perpetrated by strangers (Southern Equality Research & Policy Center, 2017).

A recent study in 2022 by the Movement Advancement Project (MAP) reported that out of 23 states with “negative policies against gender identity”, 13 were southern states. Only 14% of Texans are protected against discrimination in regard to gender and sexual orientation within employment, housing and public accommodations in certain cities (Movement Advancement Project, 2022). This is a small number of people considering the population of Texas is approximately 31.3 million (U.S. Census Bureau, 2024). At that time, there was an absence of state protections for hate crimes based on gender identity in Texas (Movement Advancement Project, n.d.; KUT, 2019). As of May 2025, the City of Houston does not have a nondiscrimination ordinance that explicitly protects transgender individuals in employment, housing, or public accommodations (City of Houston, 2025).

Within this context, place is more than just South Texas — it is also a relational and psychological setting where identity can be affirmed or erased. AA and NA meetings are environments shaped by a hundred years of history, shared language, and group norms. For trans individuals, entering these spaces could evoke rejection of their identities. While public histories like Christine Jorgensen’s and Brandon Teena marked pivotal events in trans visibility, they also carry a weight that influences how trans individuals navigate recovery spaces. Fear, stigma and historical exclusion have shaped the internal worlds of many trans people.

44 Racial Minority Transgender Population Transgender people hold several marginalized identities. The American Psychological Association found that minority transgender women experience more police violence and are less likely to receive help than other groups (APA, 2015). The Human Rights Campaign Survey (2019) reported twenty-two transgender and gender nonconforming people were murdered, 91% of which were African American women, 81% were under the age of 30, and 68% lived in the South. Since 2013, there has been an increase in the murder of transgender women of color (82%) across the United States (HRC, 2019, Grant, et al., 2011).

According to the Human Rights Campaign (HRC), there has been a significant increase in the number of violent fatal incidents against transgender and gender non-conforming individuals in 2020, with HRC tracking a total of 44 fatalities and approximately 75% of the fatalities were identified as Black or Hispanic. In 2021, there were at least 60 fatalities, (88% people of color), 41 fatalities (85%) in 2022, 33 (80%) fatalities in 2023, and 36 (78%) fatalities in 2024, with black transgender women being overrepresented (Human Rights Campaign, 2020, 2021, 2022, 2023, 2024).

Nearly one in five (19%) Black transgender women are living with HIV. Research found that a person of color who identifies as a sexual minority has an increased chance of experiencing daily discrimination (Rood et al., 2016). In this researcher’s experience, racial minorities also experienced shame from their families and communities depending on their culture (Eylem et al., 2020). Pioneer Monica Roberts of Houston, Texas created the blog TransGriot in 2006, where she shared mainstream news about the transgender community (Talusan, 2020). She was pivotal in highlighting violence against trans people, particularly Black transgender women. From 2013 to 2021, Houston was repeatedly listed among U.S. cities with

45 the highest reported murders of Black transgender women (Halliwell et al., 2024). This data underscores how transgender identity cannot be understood in isolation from race, geography, and violence.

This research study incorporated how trans individuals made meaning of recovery in spaces not built with their identities in mind, such as AA/NA. This study highlighted the intersection of identity, community, and healing within mutual aid settings (Smith, Flowers, & Larkin, 2009; Sevelius et al., 2016).

Substance Abuse Among LGBTQ Community The number of Americans who identify within the LGBTQ community is approximately 13.9 million and approximately 1.6 million of those identify as transgender, 1.3 million of whom identified as transgender adults (HRC, 2023). The Center for Behavioral Health Statistics and Quality further investigates studies that examine substance use disorders in transgender adults.

Gender identity was difficult to research because the reporting of gender identity was complicated and subjective (Flores et al., 2016).

In 2019, The Substance Abuse and Mental Health Services Administration (SAMHSA) conducted a survey on Drug Use and Health among Lesbian, Gay, and Bisexual Adults. This comprehensive, national household interview survey targeted substance abuse, substance use disorders, mental health, and treatment services in the United States among the LGBTQ population. (SAMHSA, 2020). Unfortunately, the category “transgender” was not included. This exclusion by researchers may indicate they did not know the difference between sexual orientation and various gender categories. Finding accurate statistics on substance use among

46 transgender adults was difficult because the research focused primarily on high-risk subgroups such as transgender females with HIV, poverty, and homelessness. (SAMHSA, 2019).

Houston has several AA Twelve Step meetings geared toward LGBTQ communities but there is a lack of in-person transgender meetings, and most meetings remain online (AA Intergroup, 2023). Additionally, there are no known NA meetings specifically aimed at the transgender population (Narcotics Anonymous World Services, 2023). Due to anonymity and a large non-binary gender non-conforming population, it was difficult to accurately capture a representative sample of transgender individuals participating in AA/NA. The lack of transspecific data in substance use research reflects a broader pattern of exclusion. This connects directly to this study’s research question and highlights how invisibility has been part of the lived experience of trans people participating in NA/AA. Overall, the transgender population is not appropriately represented in national substance use studies (Keuroghlian et al., 2015). Much of the available research consists of cross-sectional studies that include existing quantitative data, systematic literature reviews, AA/NA membership surveys, meta-analysis, personal communications, and statistical information on the LGBTQ population. The existing research has several limitations, including a lack of representation of the transgender population and an absence of insider information regarding the format and interpersonal dynamics within AA/NA. Meetings vary within AA/NA and their independence from each other creates difficulty in researching the effectiveness of Twelve Step programs.

Meetings that are considered more supportive, usually have members with longer sobriety and stricter formats that model boundaries. Since meeting types vary and the foundation of these programs is anonymity, it was difficult to capture the true representation of AA/NA members in qualitative and quantitative studies.

47

Psychosocial Issues among Transgender Population Transgender individuals face many psychosocial challenges such as minority stress, stigma, and discrimination. These factors contribute to disparities in mental health, substance abuse, healthcare access, housing and overall well-being. Meyer's minority stress theory (1995) focuses on explaining health disparities experienced by individuals who belong to marginalized or stigmatized groups, such as sexual and gender minorities (Hendricks & Testa, 2012). This theory was born from the Minority Stress Model, originally used to explain prejudice, social stress, and mental health among all minority populations leading to poor health consequences (Myer & Frost, 2013). It has been adopted to help examine the disparities in treatment among the transgender population.

Dickey and Budge (2020) used the model to define external stressors: 1) prejudices such as harassment, 2) severe anxiety that something bad is going to happen, and 3) internalization of challenges. This internalized stress is related to self-identity and may sometimes lead to internalized transphobia (Bockting et. al., 2019). The American Psychological Association (2015) recognizes that Meyer’s model (2003) explains how minority groups develop resilience to the negative effects of stress. Research has shown that having a dual minority status (being a person of color who is also a sexual minority) further complicates and heightens experiences of stigma (Rood et al, 2016). Fonagy’s (1999) theory of mentalization helps to deepen this understanding by illustrating how people may reflect and interpret their internal worlds, which is a crucial part of participants’ recovery stories that unfold in AA/NA meetings.

Hendricks and Testa (2012) theorized the risks of suicide and investigated completed suicide rates among a transgender population. The Minority Stress Theory suggests there were

48 three specific proximal stressors (internalized stressors): 1) concealing one’s gender identity, 2) internalized stigma, and 3) expecting rejection (Hendricks & Testa, 2012). All these factors may lead to long-term effects on a person’s sense of safety and well-being. Ongoing acute stress, when transmitted through the body, often leads to increased cortisol production and a higher likelihood of developing illness or disease (van der Kolk, 2014). The therapeutic community relies on Bessel van der Kolk’s research and findings over the years to explain the biology and psychology of trauma. He posits that “traumatic experiences can lead to changes in the amygdala, a part of the brain involved in processing emotions, resulting in heightened fear responses.” He also noted that the prefrontal cortex, the area of the brain responsible for decision-making and self-regulation, is affected by trauma, reducing one’s ability to manage stress and emotions (van der Kolk, 2014). This area of the brain also plays a role in decisionmaking and emotional regulation, which decreases the ability to self soothe, leading to the use of drugs or alcohol as a maladaptive coping skill (Bocketing, 2008).

This research study incorporated Minority Stress Theory to interpret how experiences of stigma and internalized transphobia influenced the ways transgender individuals made meaning of recovery. These stressors were not only social but also deeply internal, potentially affecting one’s sense of safety and belonging in AA/NA. Trauma theory (van der Kolk, 2014) explains how chronic stress impacts the body and brain, particularly in environments that mirror past harm. Qualitative psychodynamic studies, such as Scott Rose’s (2001) work on early rejection among gay men, suggest that these experiences become internalized over time, thereby shaping identity, emotional regulation, and recovery processes (Rose, 2004).

Suicide and suicide attempts are a major psychosocial issue, and transgender individuals face “significantly increased risks” compared to the cisgender population (Kirakosian et al.,

49 2023). Joiner’s Interpersonal Theory of Suicide (2005) sought to explain why individuals die by suicide. Among transgender individuals, two primary contributing factors include perceived burdensomeness and a lack of belonging, both of which lead to suicidal ideation and behaviors (Krychiw, 2019). The acronym IS PATH WARM is a widely used suicide risk assessment tool that clinicians use to screen for suicidality (National Institute of Mental Health, 2021). Each letter represents a risk factor linked to completed suicides (Krychiw, 2019). The letters stand for: Ideation, Substance abuse, Purposelessness, Anxiety, Trapped, Hopelessness, Withdrawing, Anger, Recklessness, and Mood changes (Joiner, 2005). This tool helps clinicians determine interventions, treatment planning, and discharge timelines. Thoughts and cognitive distortions are often difficult to challenge, which in many cases contributes to substance use disorders.

Additionally, family rejection and lack of social support are significantly correlated with major depression and completed suicide (American Psychological Association, 2015). Other psychosocial and physical problems may include unemployment, financial stressors, homelessness, workplace stigma, HIV, and legal problems (Frost, 2011). The following statistics are relevant to this study because they illustrate how mental health disparities and systemic rejection shape meaning making, and substance use among transgender individuals: 

It is estimated that 20% of transgender women are infected with HIV (Gotfried, 2020).



Twenty percent have been homeless at some point in their lives( Redfern et al., 2016).



HIV in the transgender community is mainly contracted from drug use and prostitution. The US Transgender Survey Report (2015) estimated respondents in the survey are living with HIV at nearly five times the rate of the general US population.

50 

Research also supports the link between stigma-related stressors and smoking (Frost, 2011). Hughto et al. (2021) asserted 30% of LGBT population smoke, although the study did not differentiate between cigarettes or vaping devices.

Psychosocial problems continue to create barriers for transgender individuals, including, but not limited to, limited access to healthcare, experiences of microaggressions while navigating the system, and a lack of provider knowledge specific to transgender needs. Thirty-three percent of those who saw a clinician in the previous year reported at least one negative experience related to their transgender identity (Grant et al., 2011). These rates were even higher for people of color and individuals with disabilities (Mizock & Mueser, 2014). Negative experiences include being refused treatment, verbally harassed, assaulted, or having to educate a provider about their own healthcare needs (Berjot & Gillet, 2011). This lack of provider knowledge creates unsafe environments where clients often feel misunderstood. According to the NASW Code of Ethics (2021), “Social workers should have a knowledge base of their clients’ cultures and be able to demonstrate competence in the provision of services that are sensitive to clients’ cultures and to differences among people and cultural groups” (section 1.05[b]).

Due to the expectation of rejection from society, transgender individuals typically live in areas where LGBTQ populations are more prominent. For example, the Montrose area in Houston is known as a diverse community where self-expression and identity is celebrated. The area offers an abundance of community mental and physical health clinics that specifically serve LGBTQ populations. Lambda has served as the AA home for the LGBTQ recovery community since 1978. Unfortunately, the meeting schedule at that time lacked in-person, transgender-specific meetings: however, there are now virtual trans meetings available that include AA members

51 from around the world (AA, 2022).

This section informs this study’s research question by detailing the complex challenges faced by transgender individuals (Grant et al., 2011; Hughto et al., 2021). The high rates of suicidal ideation, compounded by societal rejection and inadequate care, shape how transgender individuals make meaning of their experiences (James et al., 2016; Kirakosian et al., 2023). The lack of affirming spaces in healthcare and recovery settings highlights how institutional failures impact identity development and help-seeking behaviors required for addiction recovery (Mizock & Mueser, 2014; National Institute of Mental Health, 2021).

Experiences of Trans People in AA/NA Community The Pew Research Center found that 92% of the LGBTQ population reported feeling more accepted in U.S. culture than ten years ago (2021). According to the Houston AA/NA website, the transgender population remains underrepresented and lacks AA/NA-specific meetings (Alcoholics Anonymous, 2023; Narcotics Anonymous, 2023). Available qualitative research asserts that some transgender people feel AA/NA supports their transition yet they also report microaggressions when interacting with AA/NA members at meetings (Matsuzaka, 2018).

Some trans individuals seek out heterosexual AA/NA meetings because they feel less exposed in those settings. The literature regarding trans culture in AA/NA remains virtually nonexistent despite ample literature on the experience of gay and lesbian members (Matsuzaka, 2018).

Because each AA/NA group is autonomous and self-supporting, there is no consistency regarding guidance in the way meetings are conducted (Kaskutas, 2009). To better serve the transgender population, clinicians and peers need to take a greater interest in transgender

52 recovery. In addition, the transgender population needs to take an active role in establishing recovery meetings.

Guidelines for Working with Transgender Populations Research indicates that transgender clients feel less connected and supported by their providers than gay, lesbian, or bisexual clients (Senreich, 2011). In many circumstances, transgender patients educate and correct their providers, which creates frustration and a loss of trust in the provider (Seelman, 2018). Recommendations for working with the transgender population have been addressed by several LGBTQ organizations (Stevens, 2012). In 2015, the American Psychological Association created guidelines for working with transgender and gender nonconforming people. These guidelines sought to address the lack of understanding among many providers regarding gender identity and sexuality (APA, 2015), listed below:



Affirmation of Gender Identity: Psychologists are expected to respect and affirm clients’ gender identities and expressions, using correct names and pronouns.



Awareness of Minority Stress: Practitioners need to understand and address the unique stressors, discrimination, and stigma clients may have encountered.



Cultural Competence: Providers are encouraged to engage in ongoing education to deliver culturally responsive care to trans clients.



Non-pathologizing Stance: The guidelines discourage pathologizing gender diversity or using stigmatizing language.



Advocacy and Social Justice: Psychologists are encouraged to support trans clients in overcoming systemic barriers and act as allies.



Attention to Intersectionality: Providers need to consider how race, class, ability, and other identities intersect with gender identity.

53 

Support for Medical and Social Transition: Psychologists are expected to support clients’ choices in medical, social, or legal affirmation processes.



Confidentiality and Informed Consent: Respect for client confidentiality and informed consent is essential.



Family and Community Engagement: When appropriate, clinicians are encouraged to engage families and communities in supporting client well-being.

Clinical training needs to include a myriad of topics such as the proper use of pronouns,

mindful language, unconscious discrimination, and the clinician’s awareness of their own transphobia, which could contribute to transference and countertransference (Austin et al., 2016; Lev, 2013). For example, transgender women face the possibility of being retraumatized while in treatment if they are denied access to women’s essentials such as makeup and razors. This poses a threat to their sense of self and may exacerbate gender incongruence, leading to a range of psychological and clinical complications (Bouman et al., 2017; Mizock & Lundquist, 2016).

While transgender participants experience increased minority stress and familial discord resulting in relational trauma, emerging data explores the deficit model as problematic and explores gender identity as strength to healing Lee et al., (2025). Transgender participants shared their stories of trauma as “something that happened to them”, not the defining factor of who they are. Further research from Lee et al., states participants described therapy, chosen family, and identity affirmation as corrective relational experiences. This aligns with AA/NA, sponsorship and community as the foundation for corrective experiences, reduction in shame, and the ability to establish healthy boundaries. In addition, relational trauma can extend to the therapy room where ruptures and repairs are healing.

54 Summary Gender dysphoria and gender transition are complex and challenging for many providers to understand. Transgender individuals navigate societal norms and expectations that did not align with their gender identity. Research shows that transgender individuals experience higher rates of mental health concerns, such as depression, anxiety, and suicidality, as a result of discrimination, stigma, lack of support, and internalized transphobia (Budge et al., 2013).

The literature review illustrates how most Twelve Step programs do not adequately address the lived experience of transgender individuals who participate in these programs. This gap in knowledge is concerning given that Twelve Step programs are widely used in addiction treatment. It is important to explore the experiences of transgender individuals in these programs, including any challenges or barriers they may face related to gender identity, social support, and access to appropriate care. Further research in this area could be used to develop more inclusive and supportive treatment approaches for trans individuals. Most data were too broad, and gender definitions were difficult to establish, given that the LGBTQ community is constantly evolving.

Understanding the sociological aspects is also crucial, and awareness not only enhances clinical understanding but also informs more appropriate treatment planning, therapeutic approaches, and referrals to transgender friendly AA/NA meetings. This study highlighted how transgender individuals internalized experiences of rejection, trauma, and belonging. As the findings and discussion will further illuminate, the internal meanings participants made from these experiences are aligned with the phenomenological aims of the study (Meyer, 2003, Sevelius et al., 2016, van der Kolk, 2014). For instance, public health systems and policies are external, however, they also shape internal worlds. Internalizing transphobia is reinforced by society, and the narrative includes rejection, pathology, or invisibility. The Twelve Steps often

55 miss providing a space that can create meaning, and the search for identity is often lost in the throes of addiction. Finding self through meaning-making and belonging within the AA/NA community may help address early developmental wounds through corrective experiences with peers who mirror family system dynamics. There are no studies to date that comprehensively examine the lived experiences of transgender individuals living in South Texas who attend AA/NA, and there continues to be difficulty obtaining this kind of data because a condition of participation in these groups is maintaining anonymity. Therefore, this gap in the literature warrants further investigation.

56 Chapter III Methodology The purpose of this interpretative phenomenological analysis (IPA) study was to explore the lived experiences of a small sample of transgender individuals living in the South Texas who attend Alcoholics Anonymous and Narcotics Anonymous Twelve Step recovery programs. The aim of the study included examining how identity, community, and the sociocultural context of place influenced the participants’ perceptions of recovery, belonging, and safety. IPA attempts to illuminate the nuanced and often overlooked lived realities of trans people navigating recovery spaces in South Texas. Additionally, this researcher sought to understand psychosocial factors that exacerbated substance use and further marginalized this population, even within their own community.

There have been few research studies that specifically address rates of substance use among a transgender community (Matsuzaka, 2018). The findings obtained from this research identified structural discrimination within AA/NA recovery programs which may provide critical information to the recovery community on how to develop transgender-supportive policies and procedures within treatment. In order to appropriately treat and refer transgender clients to safe and respectful Twelve Step AA/NA groups, it is imperative that social workers and healthcare providers seek to understand the specialized needs of transgender individuals. This study included a central research question: What are a small sample of transgender people’s lived experiences in AA/NA Twelve Step Programs in Southern Texas?

57 Rationale for Qualitative Research Design While there exists a significant body of quantitative research focused on addiction recovery—often centered on treatment efficacy, relapse rates, and clinical outcomes—these studies tend to prioritize measurable variables over lived experience. For example, yearly AA surveys employ quantitative methods and exclude lived experience. These studies focused on biopsychosocial statistics rather than the meaning making process (Alcoholics Anonymous World Services, 2022). These approaches, while valuable, fail to capture the experiences of marginalized populations—particularly transgender individuals in a conservative setting such as Houston, Texas. To address this gap, this researcher chose a qualitative design guided by interpretative phenomenological analysis (IPA), which emphasizes the exploration of participants’ lived experience and the meanings they attach to their recovery journeys. This methodology allows for deeper insight into how gender identity, Southern culture, and recovery practices intersect within the participants' world.

Lived experiences of the study’s participants were best studied through Interpretative Phenomenological Analysis (IPA), which allowed this researcher to explore how individuals constructed meaning within their specific sociocultural realities (Smith, Flowers, & Larkin, 2009). This researcher sought to understand the phenomenon of recovery within a transgender person’s unique experience. Conducting qualitative research required carefully exploring participants’ experiences as they were shaped by social contexts, life events, roles, groups, and interpersonal interactions (Creswell & Creswell, 2018; Locke, Spirduso, and Silverman).

The definition of social qualitative research has continued to evolve over time. As described in the Sage Handbook of Qualitative Research (1994), this approach explores human

58 behavior and experiences through the collection and analysis of interviews and observations (p.

43). Social qualitative research emphasizes the importance of context, interpretation, meaningmaking, and updated theories and epistemologies (Denzin & Lincoln, 2018). Creswell (2013) noted that epistemological assumptions in qualitative research are co-constructed between researcher and participant. The subjective experience of the dyad offers insights that may be interpreted through rigorous analysis. Through a qualitative approach, this researcher aimed to better understand participants’ meaning- making by entering their world and exploring personal, subjective factors such perceptions of their Twelve Step recovery experience in AA/NA. Rationale for IPA This researcher used interpretative phenomenological analysis (Smith, Flowers, and Larkin, 2009) as the primary methodology since this method relies on a hermeneutic approach of interpretative inquiry rather than a purely descriptive orientation. A hermeneutic approach seeks to understand the meaning and significance of participants’ experiences and perspectives as expressed in their words and actions (Laverty, 2003). This involved interpreting data through a process of questioning and “dialoguing” with the text to gain deeper insights into the underlying meanings and themes that emerged (Gadamer, 1976). IPA is considered appropriate when research questions are open, exploratory, and seek to understand participants making sense of their lived experiences (Larkin & Thompson, 2011), which is a double hermeneutic frame.

Compared to traditional phenomenology, IPA explores the “how” rather than the “what” of a given phenomenon (Smith et al., 2009). Interpretation is the key to IPA and the task is to translate the experiences of participants and give a voice to the phenomena under study. In turn, this provides valuable insights for theory and practice.

59 As a novice researcher and someone in long-term recovery, it was important that this researcher did not misinterpret or mischaracterize participant experiences. Reflexivity refers to the critical self-awareness and ongoing processes through which researchers examine how their own personal background, values, beliefs, positionality, and assumptions influence all stages of the research process (Smith & Osborn, 2003). This includes research design, data collection, analysis, and interpretation (Finlay, 2002; Berger, 2015).

It is acknowledged that this researcher does not identify with any of the sexual or gender minority groups represented in the LGBTQ community, and an intentional effort was made to approach participant narratives with an open mind and cultural competence. A reflective journal was maintained throughout the research process to document this researcher’s thoughts, emotions, feelings, and interpretative decisions in order to be grounded in the participants’ lived experience. This researcher also implemented member checking, discussed later in this chapter (Carlson, 2010).

Creswell and Creswell (2013) state “IPA was developed from three key areas of philosophy of knowledge; phenomenology, hermeneutics, and idiography” (p.11). Husserl defines phenomenology as a first-hand experience in a person’s consciousness explored through descriptions of affect, perception, and behavior (Creswell & Creswell, 2013; Finlay, 2011).

Some questions that were asked to the transgender participants include “How did that make you feel when that happened?” and “What have your experiences been like?” Husserl also discusses the importance of bracketing preconceived thoughts from the researcher’s own experiences in the world to preserve the rawest form of data (Smith, Flowers & Larkin, 2009).

This researcher considered the philosophical underpinnings of IPA, particularly double hermeneutics, which is the process of making sense of participants who are themselves making

60 sense of their recovery experiences. The act of interpretation is repetitive as the researcher moves between the whole and the parts of the text (Smith, Flowers, & Larkin, 2009). These interpretive layers are supported by memo writing, peer debriefing, and regular consultation with the dissertation committee.

Heidegger built upon Husserl’s ideas of phenomenology. He argued that the traditional approach to interpretation focuses on finding one “correct” meaning, and this is inadequate because it fails to recognize that the nature of meaning making is complex and dynamic (Heidegger, 1962). Specifically, Heidegger discussed “complexity” and “dynamism” to develop the concerns within three areas of the above-cited philosophy. Heidegger sought to understand intersubjectivity and meaning made from people’s experiences (Emery & Anderman, 2020).

Intersubjectivity “is the concept which aims to describe this relatedness and to account for our ability to communicate with, and make sense of each other” (Smith, Flowers, and Larkin, 2009).

The second concept related to IPA is hermeneutics, which is the theory of interpretation (Creswell & Creswell, 2013). IPA is referred to as a “double hermeneutic” methodology because the researcher seeks to try to make sense of participants who are themselves trying to make sense of what is happening to them – essentially making sense of the participants sense making (Smith & Osborn, 2015; Emery & Anderman, 2020). Gadamer defined a difference between understanding meaning and understanding the person, and he felt understanding the person was more important (Gadamer, 1976).

The third concept in IPA is idiography. And this is concerned with the “particular” (Smith, Flowers, & Larkin, 2009, p. 29). In other words, not looking at generalized findings, but looking at the person in their environment and who, what, where, how this researcher seeks to understand the participant.

61 This study also addressed the theory of social construction, which asserts that people are born into a world in which meaning already has been made, and individuals are subject to many cultures and communities with differing ways of being (Scotland, 2012). Adopting a social constructivist lens allows for exploration of how gender identity and recovery experiences are constructed, negotiated, and challenged within social contexts.

Because this researcher does not share any characteristics with this population other than as a person in recovery, it was necessary to learn how to address gender-specific approaches in transgender health research. As this researcher noted earlier, there is an abundance of literature on lesbian, gay, and bisexual substance users, but little qualitative research regarding the transgender substance user. There was some research regarding transgender women and HIV and transgender women's health. Ultimately, IPA allowed this researcher to ask open-ended questions and deeply listen to understand how a small sample of individuals see themselves and exist in a world where perceived discrimination is ongoing, particularly within AA/NA groups.

Throughout this study, academic literature fell into two groups: a) transgender individuals are placed in binary categories and/or there are no accommodations for the larger gender nonconforming continuum, and (b) non-binary categories are difficult to pull data from. The US Transgender Survey (2015) was the first large study of its kind to address this gap (James et al., 2016). Without these separated gender identities, it was difficult to obtain an accurate representation of the transgender community. Applying a gender inclusive approach is beneficial to understanding health disparities that are shared across gender groups (Restar et al., 2021). For this study, this researcher focused on people who identify as transgender individuals, not including nonbinary or gender non-conforming people.

62 Research Sample Smith, Flowers, and Larkin (2009) suggest that a sample size in an IPA study should be determined based on the research question, the nature of the phenomenon being investigated, and the depth of analysis required to gain meaningful insights. IPA typically focuses on a small sample of participants, often ranging from 4 to 10 individuals. Smith, Flowers, and Larkin (2012) hypothesized that smaller sample sizes are more effective since this type of research is time consuming and there is a greater need for attention to detail, time, and reflection. The goal of this study was to dive deep into individual subjective experiences and discover the nuances of AA/NA so that rich information was obtained (Bloomberg & Volpe, 2019). The quality of data is favored over the quantity of data. This researcher had originally intended to interview 8-12 participants because this researcher expected that this sample size would yield valuable insights.

However, this researcher was only able to recruit six participants even after exhausting all proposed outreach methods. One person was eventually excluded from the study after the interviews because they did not fit the inclusion criteria. According to Creswell (2013), a smaller sample is preferred, as a larger sample size could introduced more variability.

The participants in the study consisted of five people, aged 18 years and older, who reside in Houston, Texas, and identify as transgender according to the inclusion criteria. For the purposes of this study, transgender is defined as individuals whose gender identity differs from the sex they were assigned at birth. All participants sought support through regularly attending AA or NA meetings to address substance use. Regular attendances was defined as attending meetings once a week or every other week. Individuals of all races and socioeconomic backgrounds were invited to participate in the study.

Inclusion Criteria

63 

Identify as transgender, not nonbinary or gender nonconforming



Self-identify as having a drug or alcohol problem



Have attended weekly or biweekly AA or NA meetings in person or online and have been sober for at least six months or longer.



Willing to participate in 2 (60 minute) interviews



Be audiotaped using a recorder



Sign informed consent

Exclusion Criteria 

Refused or unable to give informed consent due to mental health or substance use



Participant was under the influence of drugs or alcohol



Participant does not identify as transgender

Research Plan The following list summarized the steps for this study: 

Six (18-year-old or older) transgender participants were recruited. This researcher accessed resources as an LGBTQ-friendly therapists in the community as well as a person who attends AA/ NA. This allowed the purposive sampling process to begin.

● This researcher posted flyers at the local LGBTQ AA/NA meetings at Lambda Center in Houston, Texas. This researcher also posted flyers at the Montrose Center, University of Houston LGBTQ resource center, Legacy Healthcare, and Pride Charities. This

64 researcher reached out to other social media outlets such as transgender Facebook groups, LinkedIn, WPATH members, and colleagues and identified participants. Interested participants were invited to email, text, or call to see if they were a candidate for the study. ● Once a participant agreed to the study and all inclusion criteria were met, this researcher set up two (60) or one (120) minute interviews with each person that was completed within one week after they agreed to participate. Prior to the interviews, consents were signed. ● This researcher utilized peer debriefing with a stakeholder in the transgender community.

● Due to various health concerns with this population and taking into consideration ongoing COVID-19 infections, participants were given a choice to either meet in-person or by video. Three of the participants chose an in-person interview at this researcher’s office, participant four chose an in-person interview at a loud coffee shop and participant three chose Lambda for the first interview, and the second interview was conducted over video. Each participant was given instructions regarding the importance of a quiet and private environment while in person or on video. Participants were advised that they would be recorded during the entirety of all interviews, and that they could stop at any time due to discomfort. This researcher had two quality tape recorders and a cell phone available in case one of the devices corrupted the audio.

65 ● Audio recordings were transcribed by a transcription service, rev.com. This researcher analyzed each interview several times to identify themes and subthemes during the research until reaching saturation. ● This researcher analyzed the data using the steps outlined in the Smith, Flowers, and Larkin (2009) framework. ● After the Super-Ordinate and associated themes were identified, the data were used in the interpretation of the emergent themes.

Data Collection Data collection requires a high level of skill on the part of the interviewer (Creswell, 2013). Strong, compassionate engagement and empathetic responses are necessary (Smith & Osborn, 2003). Efforts were made to avoid making participants uncomfortable or triggering feelings of stigma and microaggressions. This researcher checked in regularly throughout the interview process, asking participants how they were feeling. All participants indicated that they were grateful to be included in the study and that they felt comfortable. Active listening was practiced, and silence was used intentionally to provide space for participants to expand on their thoughts.

A semi-structured interview protocol with open-ended questions was used to allow participants to freely discuss their understanding of what it meant to be transgender and to share the experiences they perceived while participating in substance recovery programs such as AA or NA (Creswell & Poth, 2018; Patton, 2014; Smith, Flowers, and Larkin, 2009). The interviews

66 were face-to-face with the exception of one video interview for participant three. Face-to-face interviews allowed for real time observations of nonverbal communication by participants that could not be observed during telephonic and some video communications, given the point of view of the camera (Patton, 2015).

Interviews were recorded with two devices to ensure no data were lost due to equipment failure. During interviews, this researcher used a reflective journal which included notes of thoughts, insights, opinions, prejudices, and potential topics for follow-up questions when and if the opportunity arose to interview some or all participants another time. Creswell and Poth (2018) posited that notetaking is an important part of the data collection process in qualitative research as it allows researchers to capture the nuances of the data, and to develop a deeper understanding of the research. The following are a sample of questions used, drawn from an Interview Question Guide for the semi-structured interviews: 1. Please tell me what it is like to be in a Twelve Step program of recovery, and do you connect your experience to your transgender status?

2. Please describe your history with substances.

3. Have you been in treatment before or/and have attended any Twelve Step groups?

4. Have you ever been to AA/NA? How do you feel when attending an AA/NA meeting?

5. Do you have a sponsor, and have you worked on any of the Twelve Steps?

6. How do you feel about the heavy religious component of AA/NA? Why or why not?

7. Have you ever felt unwelcome by the LGB population in AA/NA, and how did you handle it?

67 8. What does AA/NA need to do to better serve the transgender population?

This researcher gathered additional data by attending AA/NA meetings in person at Lambda. An “open” AA/NA meeting allows anyone to attend. A “closed meeting” is reserved for those identifying as having an alcohol or drug problem. Given years of attendance at Lambda, this researcher was able to snowball sample. In addition, this researcher reviewed Facebook groups, reached out to colleagues specializing in the LGBTQ population, and explored other social media pages aimed at transgender issues and recovery.

Data Analysis There were multiple steps to data analysis. This researcher used the six steps for conducting IPA research described by Flowers, Smith, and Larkin (2009), which emphasizes the importance of analyzing textual data to uncover meaningful themes and patterns (Miller & Milton, 2016; Bloomberg & Volpe, 2019). The six steps include: 

Familiarize and immerse in the data: Read and re-read the interview transcripts and data several times to capture the lived experiences of transgender individuals, identify themes, and subthemes.



Focus on emergent themes: Identify and label meaningful sections of the text. For example, look for short phrases of key concepts, significant statements, ideas, or descriptions within the data. Grouping together these initial codes helps break the data into manageable parts. These themes should be identified and drawn from the participants own language.

68 

Search for connections: After generating initial codes, look for patterns or themes that emerge from the coded data. This helps organize and group codes that relate to similar themes.



Review themes: Review and refine initial themes. This may involve reorganizing, renaming, or merging themes to ensure they accurately represent the data. Make sure the complexity of the participants experiences is represented. Bracketing was conducted during this phase.



Define and Name Themes: Clearly define each theme and provide a meaningful name or label for it to convey an overall description of the phenomenon. The naming of themes should be reflective of the data and its context.



Writing the Report: The final step involves drafting a report or manuscript that presents findings. The researcher deepened the analysis by using a detailed description of the research process, the identified themes, and supporting quotes or examples from the data, thus supporting the study’s research question. After all interviews were collected, participant data was analyzed, and the main and sub-research questions were answered.

Member checking was utilized during this phase and individualized data was compiled and shared with each participant, allowing an opportunity to review and correct any errors. All participants responded, except for Participant Four, who did not reply despite multiple follow-up attempts. The final report provided a rich, detailed account of participants' experiences, supported by direct quotes and contextual examples.

Ethical Considerations

69 There are many ethical concerns associated with conducting qualitative research and concerns increase when study participants are members of a marginalized group (Creswell, 2013). Ethical considerations include informed consent, potential for harm, and confidentiality.

This researcher sought approval from an ethics review board (e.g., Institutional Review Board) required by ICSW. This ensured that the study complied with ethical guidelines and regulations.

Informed consent was obtained before and throughout the research study. The written informed consent fully informed each participant about the purpose and nature of the research, the procedures involved, any potential risks or benefits, and how participants data would be used.

Central to this process, this researcher conveyed autonomy and determined if the risks were worth the benefits (Bloomberg and Volpe, 2019). This researcher requested that each person read and sign a consent form, which was verbally reviewed to ensure their understanding.

Participants’ were screened for intellectual or cognitive impairments, including intoxication, which could hinder their understanding of informed consent. This researcher confirmed they understood that participation was voluntary and that they could withdraw any time without fear of retaliation. (Bloomberg & Volpe, 2019).

The potential for harm was an important ethical consideration. Efforts were made to prevent harm by respecting participants’ autonomy, culture, and values. Attention was given to power dynamics and personal biases, with a focus on minimizing any negative outcomes. If participation triggered trauma or distress, three referrals were provided to local therapists for additional support.

Anonymity and confidentiality are required with human subjects (Creswell & Creswell, 2013). Bloomberg and Volpe (2019) advocate for de-identified data by methods such as using fictitious names or codes and excluding identifying data such as ages, addresses, email, or phone

70 numbers. Discretion was maintained when interviewing transgender participants, however, it should be noted all the participants were living authentically, and they did not want to hide their status. Four of the five participants utilized email and/or text, and Facebook messenger to communicate even though these platforms are not privacy protected. Confidentiality meant this researcher is the only one who knows the participants actual names. This was discussed in the informed consent. Bloomberg & Volpe (2019) further defined confidentiality as “an ethical duty of confidentiality [which] included obligations to protect information from unauthorized access, use, disclosure, modification, loss or theft” (p.201). Surprisingly, all participants wanted to use their names throughout this research study. The researcher decided to use aliases created by the participants to preserve safety. All information was securely stored and managed to protect participants information. This included safeguarding digital and physical records by enclosing documents in a locked home safe as required by IRB regulations. As a part of this study, a $20.00 visa gift card was offered at the end of each interview session, totaling $40.00.

Issues of Trustworthiness Trustworthiness refers to the extent to which qualitative methods and results are reliable, consistent, and believable. To ensure trustworthy qualitative research, Guba (1981), among other researchers, stated that certain criteria needed to be met, such as credibility, dependability, confirmability, and transferability. Many of these ideas overlap to ensure the qualitative data is accurately represented. Because the study is phenomenological, results could have been influenced if not carefully interpreted from participants’ words without bias. Therefore, the researcher followed the aforementioned guidelines to ensure rigor and richness of the data.

Credibility

71 Credibility (believability) refers to whether the “participants’ perceptions correlated with this researcher’s portrayal of them” (Bloomberg & Volpe, 2019, p. 202). Participants were invited to discuss a rich, detailed, first-person account of their experiences (Smith, Flowers, & Larkin, 2009, p. 32). Building upon insights, various strategies were employed to achieve credibility. For example, addressing biases through reflective journaling was one way to capture thoughts and feelings as they immediately arose. Additionally, keeping a journal on hand or using other means of dictation to capture thoughts was appropriate. The importance of free association and self-reflection was essential in contributing to the richness of the data (Bloomberg & Volpe, 2019).

Another way credibility was established was by spending additional time observing and immersing in the physical environment. Because this researcher had already attended AA/NA meetings, this was not as challenging as it might have been for someone considered an outsider to the recovery community. This researcher also attended LGBTQ meetings. Lambda Club’s homepage defines their club as “LGBTQ and Allies 12-step Recovery Club” (Lambda Houston, 2023). Member checking was conducted to ensure accuracy as this is considered the gold standard in qualitative research (Motulsky, 2021). This researcher sent information electronically to participants and verified demographics along with their words and answers to the interview questions (Creswell & Creswell, 2017). This allowed for feedback to ensure this researcher accurately represented the experiences of transgender individuals. Other means used to establish credibility included seeking peer debriefing and addressing negative findings or outliers in the research. Peer debriefing and triangulation of the data strengthened the understanding of the phenomenon studied (Bloomberg & Volpe, 2019).

72 Dependability Dependability focuses on the “consistency and stability of the study’s procedures and findings over time” (Bloomberg & Volpe, 2019, p. 204). To achieve this criterion, all processes during the research were documented and thoroughly explained in addressing the research question. Lincoln and Guba (2020) stated that an “audit trail” is needed when data were collected and analyzed, such as maintained and reviewed field notes and transcripts, which allowed for biases to be challenged. This researcher established an audit trail by keeping a reflective journal and making memos progressively throughout the study.

Confirmability Due to the sensitivities surrounding transgender experiences, confirming the objectivity and neutrality of the findings is essential. Confirmability was achieved by recognizing this researcher’s biases and creating an audit trail, similar to that used in dependability (Bloomberg & Volpe, 2019). One way to accomplish this is through peer debriefing, which is defined as consulting with colleagues to gain additional professional perspectives (Bloomberg & Volpe, 2019). For example, a peer reviewed the paper and examined the research process and data collection methods to allow for corroboration. Triangulation of data allows for multiple data collection methods, which strengthens the validity of the research and minimizes preconceptions, enhancing the objectivity of the analysis (Bloomberg & Volpe, 2019).

Lambda not only hosts AA/NA meetings but also offers many activities such as drag shows, plays, and holiday gatherings. By engaging in these additional activities, this researcher gained a deeper understanding of the dynamics at play. The more time spent in the community, the richer the data and the deeper the insights (Bloomberg & Volpe, 2019). Other ways to

73 enhance confirmability include defining and addressing critical self-reflection. Transparency is required so that readers can see how the methods, theory, and analysis contribute to the study’s findings.

Transferability Transferability refers to “how well the study has made it possible for readers to decide whether similar processes will be at work in their own settings and communities by understanding in depth how they occur at the research site” (Bloomberg & Volpe, 2019, p. 205).

It is important to provide rich detail regarding the various contexts, backgrounds, and identities within the transgender population to ensure the transferability of the findings (Bloomberg & Volpe, 2019). Through this technique, readers are able to better assess and recognize the complexities of transgender experiences beyond a single narrative.

Limitations and Delimitations Within qualitative research, there are always limitations and delimitations to a study. One limitation in this study is the population that was selected. This researcher is not a member of the transgender community, so trust and acceptance could have been an issue; however, that assumption proved to be inaccurate. There were initial concerns that participants may experience discomfort if asked invasive questions or if misgendered. This concern is valid, as research indicates that “more than six in ten trans adults had been discriminated against because of their gender identity and/or expression, with verbal attacks being the most commonly experienced form of discrimination reported” (Kirzinger et al., 2023).

74 Another limitation involves the potential for unintentional power dynamics or fear among participants. This researcher could have been mistakenly perceived as affiliated with a government system or with an inaccessible and costly mental health or substance use treatment program. However, this was not the case, and all participants expressed gratitude and engagement in the study. Nearly half of transgender adults (47%) reported a time in the past year when they needed but did not receive mental health services or medication due to cost, compared to one-fourth of cisgender adults (Kirzinger et al., 2023).

Subjectivity within Interpretative Phenomenological Analysis (IPA) allows for interpretive flexibility but also introduces potential bias. Researchers from different backgrounds may arrive at differing conclusions. This study mitigated bias through bracketing, memoing, and peer debriefing, consistent with standard IPA procedures. Smith and Osborn (2019) note that IPA is time- and resource-intensive when collecting and analyzing data. To address this limitation, this study established clear parameters for data collection and interviewing. For example, completing five to six interviews within six to eight weeks was considered manageable.

Extending the interview period too long may have increased the risk of participant dropout or data fragmentation.

Finally, while quantitative research allows for statistical analysis to confirm or refute hypotheses (Tufford, 2017), qualitative research captures the depth, meaning, and richness of human experience. This strength is central to understanding the lived realities of transgender individuals in recovery communities.

Role of The Researcher

75 This research study utilized a double hermeneutic approach, as part of IPA methodology.

Bloomberg and Volpe (2019) consider the researcher to be an “instrument,” focusing on examining one’s subjectivity and biases and reflecting on how these factors may shape the research process (p. 47). This researcher’s social, political, and value positions were acknowledged, as these perspectives inevitably shape interactions with marginalized populations and did not exempt this researcher from forming biases (Creswell & Creswell, 2017).

This researcher has more than 27 years of professional experience working within state agencies, nonprofit organizations, law enforcement agencies, hospitals, and outpatient settings, treating a wide range of disorders including depression, anxiety, substance use disorder, gender dysphoria, relational issues, trauma, and personality disorders. This background includes working with individuals across diverse ages, races, ethnicities, genders, and socioeconomic statuses.

As both a helping professional and member of Alcoholics Anonymous (AA), personal experiences, ethics, and prior struggles shaped interpretive frameworks (Creswell & Creswell, 2017). Interest in the topic stem from this researcher’s exposure to addiction and identity issues within the family system. This researcher’s father, diagnosed with acquired immunodeficiency syndrome (AIDS) in 1991, passed away in 1992. During the AIDS epidemic, increased awareness and empathy toward the LGBTQ community developed, fostering a lifelong interest in working with this population. In subsequent years, this researcher observed a growing number of transgender youth and young adults undergoing gender transition while receiving substance use and mental health services. This population frequently faces isolation, marginalization, and limited access to supportive advocates, even within the broader LGBTQ community.

76 During this study, the researcher was not perceived as an outsider, as participants were forthcoming in sharing their lived experiences, even when those experiences were painful.

Initially, there was concern that participants might distrust a White, middle-aged, heterosexual woman, and that establishing rapport might be difficult. However, throughout the research process, this researcher remained nonjudgmental, understanding, and empathetic while engaging with participants’ perspectives. Open-ended questions were utilized, detailed observations were recorded, and comprehensive notes were maintained for each participant.

Active listening and reflection were used during interviews to clarify statements or topics that were not immediately understood. This researcher maintained the role of investigator throughout the process, though occasional shifts into a clinical mindset occurred. When these moments arose, this researcher redirected attention back to the research role.

77

IV Results This study explored the research question, “what are a small sample of transgender people’s lived experiences in AA/NA Twelve Step Programs in Southern Texas?” The following section presents the Super- Ordinate themes that emerged from that data using Interpretative Phenomenological Analysis (IPA) of participant interviews. The themes that emerged from the data include: 1) Intersection of Identity & Recovery, 2) Safety & Acceptance, 3) Sponsor Roulette, 4) Finding “God”, and 5) Community. These all represent meaning making and lived experiences in the participants’ lives in AA and NA as transgender individuals. Each Super- Ordinate theme included several associate themes which allows for a deeper exploration and further analysis of emotions, expression, and quotes of rich data for each participant. The conversations shared during interviews include painful experiences, moments of gratitude, and the conceptualization of AA/NA. This study’s participants consisted of six (n=6) transgender individuals lived experiences in AA/NA programs. It should be noted that, during the coding process, Participant Two (AS)

78 was excluded from the study due to a misunderstanding regarding gender. Although Participant Two identifies as “transgender”, they had not transitioned as it is defined in this study’s participant criteria. Participant Two self identifies as gender non-conforming, which is a term under the umbrella of the transgender category.

Family Background and Childhood Challenges Participants in this study varied in gender identity, income level, and abstinence duration, reflecting a diverse set of lived experiences in recovery. The average age of participants was 47 years old, reflecting an older, more mature population. Table 1 presents an overview of key demographic information for the five transgender individuals interviewed, including their educational backgrounds, employment, religious identification, and participation in Twelve Step meetings.

Table 1.

Family Background Information for Participants

79

Koatie Andrews.

Koatie Andrews is a Caucasian, single, 64-year-old transgender man who has been sober for seven and a half years. He has never been married and has no children. He graduated with a high school diploma and he makes dentures for a living. Koatie Andrews grew up in a religious intact family with his mother, father and two siblings. The interviews were conducted at the researcher’s psychotherapy office in Houston, Texas. Koatie Andrews explains he had a very difficult childhood, experiencing abuse and trauma from a young age. His history of substance use began early with alcohol and later drugs, escalating in adolescence as a coping mechanism for emotional pain, particularly related to unresolved trauma. In addition to early substance abuse, Koatie Andrews suffered from depression, anxiety, overeating and self-harm. He had two psychiatric hospitalizations, one when he was 14 years old due to a suicide attempt. He describes how his mental health affected him during his addiction and sobriety.

80 I had been abused in a lot of ways. I'd been sold as a kid. My father told me … Nobody would love you; nobody would believe you, and you'd be all alone. I started drinking alcohol at eight years old, and actually it was used to seduce me….be able to do what they wanted. I really had my first taste of alcohol, probably when I was two years old. By 15-years-old, I was regularly buying alcohol and drinking throughout the school day, and it continued to get worse as I got older.

So, it was really weird most of my life and when I hit 12, it’s like I woke up and I felt all of this pain. I didn’t know what was going on and I kind of started suspecting something happened, but I didn’t really know. And it was just this overwhelming pain inside. And of course, I drank more, but it just didn’t work. I also started wanting to lose weight when I was a kid, my mom and I went to overeaters anonymous. And that to me was just like the beginning of AA and I was so hard on myself.

Observations.

This researcher met with Koatie Andrews in my office for both interviews. He presented casually, dressed in shorts, a T-shirt and sneakers. He sat on the couch without hesitation and was very friendly and open in his demeanor. He responded to the flyer that was posted at the local LGBTQ Club in AA. He wanted to share his experience of hope and healing. Koatie Andrews shared his story in a factual manner, with minimal emotional expression. Throughout the conversation, this researcher checked in regularly to ensure he was comfortable, and he stated, “yes.” This researcher connected easily with Koatie Andrews and he was a pleasure to interview.

He has a history of attending therapy and Alcoholics Anonymous for years, demonstrating

81 commitment to recovery. He is confident in his sobriety and his identity as a male transgender individual.

Jonah.

Jonah is a 44-year-old Latino transgender man with eight months of sobriety. He holds a master’s degree from Harvard and works as a high school teacher for a local charter school.

Jonah is single and has no children. He currently lives with his parents and his younger brother, whom has special needs. He has an older sister who was raised by their maternal grandparents after his mother became pregnant at the age of 15. Jonah’s family is deeply religious. The interview took place at Lambda AA/NA in a space where people occasionally entered and exited.

Although concerns of confidentiality were discussed, Jonah expressed that he was comfortable sharing his story openly and chose to remain in the room. He then began to describe his childhood and his progression with substance abuse.

My dad worked in logistics, worked at a company doing shipping stuff. Basically, backbreaking blue collar labor. He's been doing that since he immigrated to this country.

My mom used to work, but my little brother has special needs, so she's been a homemaker and full-time caretaker of my brother probably since 1986. We found out he had special needs in the early 90’s. I also have an older sister. My mom had her when she was very young, she was 14 when she got pregnant and had my sister at 15. My grandparents raised my sister, so we are not really close, which sucks. I hate that. I wish we were closer.

82 Jonah began drinking heavily in his freshman year while attending Rice University in Houston. His drinking progressed, and he experienced alcohol poisoning which led to serious consequences resulting in campus restrictions. Jonah experimented with drugs, but alcohol remained his primary issue. He was arrested on several occasions driving while intoxicated (DWI) and public intoxication, the most recent DWI in 2023. His license is currently suspended.

He started his journey in sobriety attending AA in 2008, relapsing several times over the years.

Jonah reported his family was mostly accepting especially when coming out. Initially he struggled with sexuality and later gender identity. However, the religious views he grew up with contributed to his alcoholism.

I told my parents when I was 19. I softened the first blow—that I was bisexual—and my mom was amazing in her response. Basically, she said a few things; I can't remember.

Then she ended the convo with, “Well, what do you want me to do, stop loving you?” It was a beautiful moment.

My dad, though, was sitting kind of turned away from me, looking to his right, I think, and I'm across the table from him. He had his hand over his face, kind of covering his eyes, so I couldn't really see his face. But he basically said, “Well, just don't let it ruin your life,” or something like that. And he walked away. I know my alcohol has progressed—in very large part because of me being trans and societal acceptance.

Observations.

This researcher initially connected with Jonah after he found the posted flyer at Lambda AA. This researcher met with him on two occasions: once in person at AA and once virtually.

For the in-person meeting, Jonah was dressed in a shirt and jeans. He expressed a preference for

83 meeting in a public space and he did not have any concerns regarding confidentiality.

Throughout the interview, this researcher checked in multiple times to assess feelings of safety.

Jonah presented as highly gregarious and intellectually gifted, sharing that he holds a master’s degree from Harvard. He spoke openly and with enthusiasm about his challenges with sobriety and his experience as a trans individual. This researcher found him delightful and easy to connect on all topics. He outwardly presents as having a strong sense of self, but appears to struggle to fit in. The second meeting occurred virtually as Jonah had lost his driver’s license due to a DWI. His demeanor and presentation remained consistent with the initial meeting. It took several times to schedule the video meeting due to travel and his schedule.

Remy.

Remy is a 61-year-old transgender woman from Texas with five months of sobriety. She has struggled with substance use for much of her life, beginning with alcohol at age ten and later progressing to drugs such as marijuana, cocaine, and crystal methamphetamine. She experienced her first hangover at ten years old. She grew up in an Irish family where alcohol was central to big celebrations and gatherings. This normalization of drinking significantly influenced Remy’s early substance use patterns until late adulthood.

The interview took place at a loud coffee shop with no confidentiality. Remy stated she was “more comfortable” in this environment than an office setting. We moved two times due to noise. This researcher checked in multiple times regarding the obvious lack of confidentiality and she stated, she didn’t care and she is “an open book.” The second time we moved outside, this researcher restarted the interview and a woman with a week of sobriety approached us and stated she overheard the conversation. Remy stopped the interview and spent 15 minutes talking

84 to her and they made plans to attend an AA meeting later that night. Remy was easily distracted and tangential and reported her “unmedicated ADD” keeps her off track. We were able to restart the interview with some prompting. Remy stated that substances and sex became a way to cope with feelings of alienation, struggles with identity, and social acceptance, particularly during adolescence. Remy described growing up in a family where alcohol, racism and homophobia were deeply ingrained in her culture.

Remy has been married twice. The first marriage lasted for two years when she was 28 years old and resulted in one daughter, now a teacher and mother of two. The second marriage at 35-years-old lasted 17 years but ended as Remy grappled with her gender identity and addiction.

After years of coping with alienation and substance use, Remy is now five months sober and actively participates in her own recovery programs. She describes other addictions and how it affected her relationships.

My whole family—it was the German. Okay. So, it was like, “Hey, birthday party, let’s drink; hey, death in the family, let’s drink.” Any festivity they could get away with alcohol, they used alcohol to celebrate. Alcohol was a constant presence. There was always alcohol for dinner time, alcohol for bed... But my family—none of them were drinkers in the morning. It was the evening drinkers.

Later on, someone did mention to my parents, like, “Hey, whose little kid is that getting beer?” While the rest of the family was celebrating someone's life, they were also celebrating my demise. They didn’t stop me from drinking. I guess they thought, like, well, it’s just part of growing up—she’ll learn.

My redneck cousins. My redneck family. Wow. So, we were brought up not to be racist —to accept everyone for their abilities, not what color they are. I found that to be—well,

85 let's put it this way… my parents didn't like me dating a Black person. That made my brain do backflips when I found out their true colors.

My parents, their parents, and then my cousins—they were always being homobashers.

They were always taught to grow up and hate homosexual people. I grew up Catholic, and I tell people—I say, “I'm a recovering Catholic.”

Remy also discussed childhood abuse in a way she appeared to be disassociated.

So, I was sexually abused when I was a child, probably about five, by older neighborhood boys. And it wasn't traumatic for me. I actually liked it, but it was still child abuse. And I don't know what part that has played in my life, I've never been psychoanalyzed or anything. A lot of people don't believe in that psychoanalysis stuff.

Remy discussed family dynamics with her sister, most recently caring for their mother during her dementia diagnosis.

I remember my mom talking to her and just letting it flow—whatever she wanted to talk about. And my sister was like, “Why are you doing that? She needs to snap out of it.”

And I’m like, “No, that’s the worst thing you can do.” My mom had dementia. What you don’t do—you don’t try to force the memory. You just let it flow.

Observations.

Remy found this researcher’s information through a fellow AA member and she was given contact information. She choose a local popular coffee shop that is always busy in an LGBTQ friendly part of Houston. Upon arrival, she was at the coffee bar sitting waiting. She was dressed in a camisole top and pants with make-up. She was gregarious, fun and

86 unapologetically herself. She thought the interviews were videotaped, and when this researcher stated it would be verbally recorded, she stated, “I would have done the video.” Remy was easily distracted and the loudness of the coffee shop was distracting for this researcher. At times, the interview became tangential and this researcher had to redirect the conversation. Remy was fun to be around, easy to connect with and a self-described “party girl” who likes to make a statement and “shock” others.

Hannah.

Hannah is a 22-year-old Caucasian transgender woman who began using drugs since she was 17 years old. She has been sober for 21 months and she attends NA regularly. She is an only child and her father abandoned her when she was young, calling her father “a deadbeat.” Hannah is not currently in a relationship and has never been married. As a child, she went to AA with her mother and was able to acquaint herself with the program. She described her parents and how addiction has played a role in her life.

My dad is a deadbeat. He left when I was a baby—around two years old. My mom is an alcoholic and a drug addict. And then I essentially was raised by my grandma. My mom was around too, but my grandma provided the most material support and stuff.

My grandpa—my mom's dad—died before I was born, but from what I've heard, he was a real piece of shit. He was a meth head and a killer. And then, yeah, my grandma's father —he killed himself, and she walked in and found him. It's kind of been a trickle-down of generational trauma down onto me.

Hannah reported her history with substances.

87 I swore off drugs until around the age of 17. I refused to use any drugs. I remember I was 14—I was in the bathroom at school, and I saw some kids with weed. I got all scared and shit, even though I was essentially living in a fucking drug house, more or less. The sight of weed freaked me the fuck out.

But yeah, I got to 17, and I started smoking weed with someone I was dating at the time. I cried and apologized to my mom and stuff. And after that, I started drinking and stuff, and I would try to get as drunk as possible. I would smoke weed, and I would try to get as high as possible and usually end up passing out.

I was always very reserved—I didn’t know, just very uncomfortable in my own skin— and that all evaporated. And then I did 3 methylenedioxymethamphetamine (MDMA), and it was like that, but on steroids. Like I said, I was dancing all night.

Observations.

Hannah arrived at my office dressed in a shirt and pants, male presenting. She stated she does not have the money to buy nice women’s clothes, and with her gender dysphoria, she dresses how she feels. Hannah had a flat affect and did not display emotions. This researcher had to ask numerous times throughout the interview how she was feeling. She indicated she felt safe, and she was comfortable discussing her addiction and trans status. Hannah often asked, “What do you mean?” as this researcher proceeded with the interview. She did not expand on answers, and she was not resistant. She felt distant, and it was difficult to connect with her. This researcher attempted to joke due to discomfort and fear of offending her.

Alexia.

88 Alexia is a 44-year-old transgender woman who has been sober for 16 months following a long history of substance use that began at age 14. Her drug use was exacerbated by a fourwheeler injury where she became addicted to pills after several back surgeries. Alexia is currently studying for her license to become an alcohol and drug counselor. Alexia was raised in an intact family with her religious parents and two siblings, a brother who is a Southern Baptist minister. Her mom died around 2009, and she was Alexia’s only family support. Her father and siblings currently do not speak to Alexia, although she was taking her children the next day to see her father and make amends (Step Nine). She was married to her first wife, and they had four children—one set of triplets from IVF and an 11-year-old girl.

After Alexia’s divorce from her first wife, she married again and later divorced after a few years due to her decision to transition. She used alcohol and drugs to manage depression, anxiety and feelings of loneliness during adolescence and early adulthood. By 2010, she had been charged with her fourth felony DWI. Her substance use affected aspects of her life such as legal issues, health complications, job losses and interpersonal relationships.

My second marriage was falling apart, and I moved, and I was having thoughts of suicide, and I was already drinking and taking a lot of benzos—either Xanax or anything I could get. I ended up going and staying at a friend's house to try to sober up in Angleton, and it didn't work. I ended up drinking more because he was an alcoholic. And then, when I did try and stop, I started having seizures, and that had never happened before. I could stop for short periods of time and just feel horrible for a couple of days.

Well, this time I couldn't do that.

Observations.

89 Alexia came to my office professionally dressed and in make-up. She responded to the flyer posted at AA. She was very kind and vulnerable and it was easy to have a conversation. She answered all questions without hesitation in a succinct and meaningful way that indicated years of suffering. This researcher enjoyed time with Alexia and found her engaging, as if she was a friend.

Super-Ordinate Themes of NA and AA Experiences The following themes emerged from the data, reflecting shared experiences among study participants in NA and AA. These themes show how gender identity, sponsorship, safety, and belonging contribute to the richness of the participants’ recovery program. While each story is unique, commonalities were identified. Table 2 outlines the core Super-Ordinate and associated component themes identified across the study’s small sample of participants.

Table 2.

Super-Ordinate Themes and Associated Component Themes

90

Super-Ordinate Theme I: Intersection of Identity and Recovery The theme Intersection of Identity & Recovery explored the relationship between identity and the process of recovery, focusing on the experiences of transgender individuals within AA/NA spaces. Within this Super- Ordinate theme, there were two associate component themes: Embracing Trans Identity and Walking into a Meeting. Recovery can be challenging for transgender individuals as they frequent environments that are different from their lived experiences, especially in Houston, Texas. Trans people also face many challenges due to the most recent conservative political climate and anti-trans legislation. Since the 2024 presidential election, many transgender rights have already been reversed with a new agenda against the population. The climate within AA/NA appeared to be more somber, especially within the LGBTQ club, Lambda.

Embracing Trans Identity.

91 This component theme highlights the significance of authenticity and self-acceptance as a transgender person in AA/NA. For many transgender individuals, recovery involves reconciling gender identity and self-worth, while addressing stigma and ongoing personal struggles this marginalized population endures. Embracing one's trans identity can become empowering, yet the inability to do so can impact sobriety and cause the individual to relapse.

Koatie Andrews.

Koatie Andrews’s alcoholism and transgender identity is part of his recovery journey.

Koatie Andrews started to transition in 2015 and achieved sobriety in 2016. Initially, he struggled to find self-worth and acceptance within himself and as a member of AA. And so, I guess what I'm thinking is, if there's going to be people who maybe are not familiar with trans people reading this or whatever, it's that it's important to know that we're just like anybody else, and we just want to live our lives without the hassle of having to prove our worth or anything. And a lot of that is just me. I have felt all my life —I never was worthy to live—but to be understanding of other people in general, because we never know what someone's gone through or even what they're going through right now. And that's probably the biggest thing I've been learning lately—is to just have more compassion for other people.

They don't have to be gay or trans. It's just about connecting with people, because it doesn't matter what sex someone is or what they like—that's their own business. It's just about connecting. And so, my biggest thing, I was created in love, and all humans are.

And that if we can connect back to that and be that help for other people—because you got to heal at some point. If you don't, you're just going to get more and more miserable.

92

Koatie Andrews discussed life as a trans man over the past seven years in AA. He had worked tirelessly attending meetings, seeking talk therapy and completing work with sponsors.

He credited asking for help and reaching out to others as paramount for his success. He wanted people to understand what it is like to be transgender.

Being trans is part of my life, and it was part of my alcoholism. There were two people in AA that were trying to make me do what they thought I should do, even when it came down to my transitioning and having top surgery. This one person was like, Oh no, you shouldn’t do that. I ended up having to set a boundary and basically getting him out of my life, which was the first person I really did that with. It's important to know that we're just like anybody else, and we just want to live our lives without the hassle of having to prove our worth or anything. And a lot of that is just me. I have felt all my life—I never was worthy to live—but to be understanding of other people in general, because we never know what someone's gone through or even what they're going through right now. And that's probably the biggest thing I've been learning lately—is to just have more compassion for other people.

Jonah.

Jonah was forthcoming about his transgender identity within the AA community, viewing it as a critical aspect of his recovery. In reflecting on his path, he noted that early self-awareness of his gender identity laid the foundation for his transition. He initially came out as bisexual, then as a lesbian, in an effort to “soften the blow” for his family. In 2017, he received his first

93 testosterone shot—coincidentally on Trans Day of Visibility. Jonah spoke openly about the ways his trans identity and struggles with alcoholism are deeply interwoven.

I knew when I was four or five that I felt like a boy but couldn’t explain it. There was no role model or anyone to talk to. I'm also Chica. All my parents are Mexican and Latino culture, especially back then, we didn't talk about this shit. I know my alcoholism progressed in very large part because of me being trans. I had no role models, and afraid of what society would think, with family would think, what not. I mean, I didn’t try transition until I was 37 years old. I don't feel like my transness has impacted me in any negative way. Here at Lambda, I have yet to go to other meetings at other clubs in person.

This time around in my sobriety, I have an online meeting I go to every Sunday because my sponsor got me into it. It's lovely. I have mentioned I'm trans a couple times. It's a mixed co-ed meeting at a different group out of Rosenberg, and everyone's cool as shit, but it's not in person. It's online, so I feel safe saying, yeah, I'm a trans guy.

Remy.

Remy described a lifelong struggle with feeling like she didn't fit the gender she was assigned at birth. She had a long history of addictions including process addictions. Remy has strong male facial features, and she is often misgendered. She has been on testosterone shots and she is contemplating facial feminization surgery. Remy presents as very confident and unapologetically herself.

I never saw myself as being a man, and so I had to be an actor and act like one. It wasn't until about a year and a half ago that I finally said, “fuck it.” I'm either going to sink or I'm going to swim.” And I'm tired of playing the lie. Embracing my true identity as a

94 trans woman has been empowering. I do seem to attract a lot of people at the groups and they're looking at me. Someone who has mentioned that I am an unusual character. They try to figure out one little piece of juicy information because I'm trans, I'm different. I put myself out there for people. I'm like, I'm the bullseye and the target. I'm able to help people with my ideas and my experiences.

Despite facing challenges such as being misgendered with comments like “the men’s group is down the hall” when attempting to attend women’s meetings, Remy has remained persistent in advocating for herself. She continued to openly disclose her transgender identity and ask whether she was welcome in recovery spaces. When confronted with discrimination, Remy addressed it directly, asking questions like, “I’m trans—am I welcome here?”

Hannah.

Hannah described difficulty with embracing her transgender identity, although she has been on hormone replacement therapy since she was a teenager. She has been diagnosed with gender dysphoria and she tends to default dressing more masculine and explains. Her addiction has been exacerbated by family history of addiction and feelings of being different.

At this point in my life, I think it's a matter of not wanting to put in as much effort. I don't really like the way I dress most of the time. It is a matter of not having money for clothes, not knowing what to buy or where to go for it. And then there's also the factor of… I feel uncomfortable and insecure sometimes. I have this mentality that presenting more masculine will get eyes off of me as opposed to dressing feminine stuff and being visibly trans. So, a lot of the time I default to using a deeper voice. I will lower my voice, or I'll dress more masculine. It is kind of like this feedback loop because I am dysphoric.

95 In my experience it has been me projecting my own insecurities onto other people and creating a divide. I’ve had times where I fought, and I have said some pretty homophobic shit. I feel like trans and addiction kind of go hand-in-hand. And especially in the LGBT community. It’s very normalized. It’s very common in that kind of scene.

Hannah shared her experience of being trans in NA. She described it as challenging with feelings of anxiety and discomfort; however, she found that most people in the meetings were accepting. She is more comfortable now, but she is occasionally misgendered. She did not feel people did this on purpose to be malicious.

Alexia.

As a child, Alexia struggled with her identity and always felt like she never truly fit in with the "guys.” She would fantasize about “cutting it off,” referring to her genitals, wishing she had been born a girl. Alexia was afraid to let her family know about her feelings, fearing they would no longer love her. She felt she had to hide this part of herself due to her Southern Baptist upbringing. Internalized transphobia exacerbated Alexia’s use of drugs and alcohol. Alexia started transitioning in 2020, shortly before her second marriage.

I thought I was supposed to get married, have kids, have a house, have a job, do all this manly stuff. Yeah, I had already messed around with guys before, but I was embarrassed and ashamed of it, so I thought that I couldn't do it. So it was like my whole life, it was kind of, I didn't fit in because I didn't know how to fit in. So, it was really hard because I always felt that I was never adequate. And instead of working through it, I didn't know any better. I used substance and alcohol and kept telling myself, I can make this work, I can make this work.

96 I don’t feel like I have to explain myself, my gender. So, I usually keep that out of the conversations. I do speak to my therapist about transgender issues and stuff, because I try to separate it.

After Alexia transitioned, she began attending various AA meetings around Houston.

There were times she felt hypersensitive about how others perceived her, but she later acknowledged, “The biggest issue was me,” stating she “got in her own way.” Despite many challenges, Alexia was determined to be true to herself.

It was time to be me, for sure. I wasn't scared anymore. At first it was me being hypersensitive. I was the biggest roadblock, not thinking that I could find a support group or not or thinking that people were going to judge me when I went into treatment. And so, the biggest roadblock was me.

Walking into a Meeting.

The next associated component theme is walking into a meeting, which appeared to be one most difficult and humbling experiences for those in addiction; walking into a meeting and being unsure what to expect. Some refer to AA/NA as a “cult” and the stigma surrounding this description can automatically provide hesitation walking into a meeting. Meetings can differ by age, race, socioeconomic status, gender and sexuality to name a few. Some meetings can be judgmental, friendly, fun, inclusive or depressing. Trans individuals may face an extra layer of feeling unsafe, a threat to their identity, or rejection from peers.

Koatie Andrews.

97 Koatie Andrews had experienced feeling unsupported at certain AA meetings, particularly due to his transgender identity and mental health challenges. Koatie Andrews initially struggled in AA due to a negative self-perception but gradually found recovery through AA meetings and NA literature. He found more acceptance and connection at Lambda meetings, which are focused on the LGBTQ community in recovery. He explained what it was like walking into an AA meeting for the first time.

I was scared to death. It was a Saturday morning and I got there purposely late to go in as they were starting. I couldn't get away as quick, but I was crying. I did take a chip that day. And they just said, "keep coming back." I went back the next morning. There was a crowd in the front with coffee. So, I got a coffee and then I sat down by this guy, and he just started asking me questions. The big reason I mainly just go to Lambda is because they're my people. What really surprised me early on was there being so many straight people and their acceptance of our community. I never expected that. I had these blinders on and that all straight people were the same and all Christians are the same. And I'm learning more and more. Now, I understand now that not all straight people are the same.

Jonah.

Jonah felt a strong sense of acceptance in recovery meetings, noting that being transgender is “not an issue.” The focus remained solely on the shared experiences of addiction and recovery. He appreciated the diversity of perspectives in the group and valued the openness that allows for meaningful dialogue. Additionally, the meetings provided a spiritual home, creating a deeper connection with God and strengthening his faith, which played a vital role in his recovery.

98 Yeah, I first came in [to a meeting] going, okay, I remember there being one openly trans guy in the meetings back when I was first in AA. Now, I don't know whether there are going to be a lot of trans guys or trans women. I've seen several “maybes” as far as transmasculine people, I don't know how they necessarily identify, but besides myself and a good buddy of mine that came in about a couple of weeks after I did, I don't know of any other openly trans people.

I mean, Lambda is built for L-G-B-T-Q people, so I feel perfectly fine here. I felt fine here as a lesbian. I feel perfectly accepted here as a trans guy. Yeah, they're going to be cisgender folks, Queer or not, that might have questions or whatever. I'm used to that anywhere. I've heard of a couple of lesbians questioning whether a trans woman should be at the women's meeting, So, I feel like meetings are the best version of church I've ever experienced. My being trans, no one even sneezes at it. That's not even a thing.

That's not part of the conversation where my transness has impacted societal rejection and my alcoholism. Okay, that's valid, but otherwise my being trans has zero to do with this. The disease itself doesn't discriminate. We're all there for this purpose and it's to talk about how God's got us through it.

Remy.

Remy stated that this was her first time participating in a structured approach, such as AA. Remy described her experiences in Twelve Step groups, which included navigating the social dynamics, and dealing with both supportive and challenging interactions. Remy had been to several meetings around Houston. She explained how she presented herself.

99 I throw myself out there. I found the best thing to do for myself is to get out of my comfort zone and throw myself into the fire. And I've been to the women's meetings. I walk in and they say the men's group is down the hall, and I have to jump in. I say, I'm trans. I said, ‘Do you want to see my HRT prescription?’ I don't know why that came out.

I walked into another women's meeting over at Spring Branch, and this time I walked in, I said, ‘Hi, I'm Remy and I'm trans. Am I welcome here?’ People turned around, some of their mouths dropped—like I knew I wasn't welcome there. And the other girl said, ‘Hey Remy, we're glad to see you here. Join the group.”

Even though Remy appears to be confident at times, when asked if she has gone to any additional women’s meetings she stated, “I don't feel I'm wanted. I feel like I'm kind of like a sore thumb.” Remy’s outward confidence contrasts with her inner insecurity. Though she seems self-assured, she feels out of place, revealing a tension between her appearance and internal struggle.

Hannah.

Hannah considered NA meetings a vital part of her life. Growing up she attended AA and NA with her mother who was in recovery. Initially, she felt anxious about rejection in NA but found most members to be respectful despite occasional misgendering or inappropriate comments. Hannah attended a few AA meetings and found it was too religious and less diverse.

She had a hard time connecting with others in the program. Regarding women’s groups in NA, she found acceptance although she struggled to connect with cisgender women because of differing life experiences. Hannah discussed her experience walking into gay and heterosexual AA and NA meetings.

100 I feel like I went into NA thinking people would be shitty towards me because I was trans or something. I had this sense of anxiety or discomfort, and I learned to get past that. I've come to a realization that most of it is just me making it a thing in my head due to my own personal insecurities.

In straight NA meetings, I mean, everyone's cool and stuff. No one's a fucking dick over there. They're not overtly trying to be affirming and stuff, but they're not breaking their fucking backs. But I mean, no one really gives me shit or anything. I don't really go to AA meetings. It's just the people. This could be some weird tribal mentality thing, but I find AA people to be a bit insufferable. The program is different. You go into the AA meeting; they're saying the Lord's Prayer and shit.

Alexia.

Alexia had been to AA prior to transitioning. Her first meeting was in 2001 when she was arrested for her first DWI. She never attended the meetings seriously until 2023 when she decided to remain sober and work the program. Her apprehension about others’ opinions was deeply rooted in her own intrapersonal struggles. Alexia had been to several meetings in different parts of Houston, and she found a smaller straight meeting she liked.

I just feel more comfortable, and I fit in. They don't speak politics at all, so that's good.

Even on the back porch where they're all smoking, when I go out there and sit with them, nobody's talking politics. Some of the trans meetings can be pretty judgmental. Well, I don't get into politics, and I was told by one trans person that “I was out of touch with trans views.”

101 The theme of intersection of identity and recovery and the associated component themes illuminated how transgender people are often faced with anxiety while attending Twelve Step groups. Being able to challenge transphobia and internalized transphobia is life altering. This requires vulnerability, authenticity and the gift of desperation to become sober and stay sober.

The ability to step forward, despite feelings of inadequacy, reflects the broader experience of identity affirmation.

Super- Ordinate Theme II: Safety and Acceptance The core concept of safety and acceptance is linked within the transgender experience.

Safety in the trans community comes in several forms—physical, emotional, and social (Myers, 2003). Physical safety can be compromised if a trans man or trans woman attends a discriminatory Twelve Step group in a different part of Houston. Although some people argue AA/NA is a safe place for all suffering from addiction, this is not necessarily true. According to the ACLU of Texas (2015), the repeal of Houston's Equal Rights Ordinance eliminated local protections against discrimination based on gender identity. Physical violence against a transgender person is not considered a hate crime (Texas Penal Code §12.47; Texas Department of Public Safety, 2022). Attending Twelve Step groups can be frightening for marginalized populations, and the utmost care and consideration in referring a transgender person to AA/NA is necessary. Some people in the AA community are not accepting and misunderstand transness.

Safety and acceptance are two concepts that overlap. For the purpose of this study, these concepts will be addressed each separately.

Safety as a key experience.

102 Safety is a central concern for transgender individuals in AA or NA, where the group’s vulnerability can be dangerous or healing. The recovery community professes to be inclusive; however, some meetings can be discriminatory with a lack of understanding around gender identity. For many trans participants, physical and emotional safety is dependent on whether meetings are respectful. Pronouns and identity can significantly impact a person’s sense of self and connection.

Some trans individuals describe having to research meetings before disclosing any information. This may contribute to isolation within AA/NA and create a barrier between not only heterosexual people, but within the LGBTQ community. Safety can only be established by allies, inclusive language, and trans-affirming sponsors. This atmosphere allows for healing and connection.

Koatie Andrews.

Koatie Andrews reported he initially experienced instances of feeling unsafe and unsupported at certain AA meetings, particularly due to his transgender identity. His experience with NA has been limited and primarily online, where he felt less connected and did not engage.

Lambda provided Koatie Andrews with a sense of belonging and support during recovery. Over time, Koatie Andrews’s frequent attendance at certain meetings allowed him to meet friends and develop important relationships. Koatie Andrews reminisced about a time where he shared his story at the Heights Group, a predominately heterosexual club and initially he didn’t feel safe.

However, approximately 30 friends in recovery from Lambda came to the club to support him and listened to his story.

103 I didn't really feel so safe at the Heights, but with all my support group there, it's like, okay, no one's going to fool with me. I mean, they packed it out. I'm not kidding. There was no room to sit. It made me feel really good. And they were very supportive.

Jonah.

Jonah discussed a lack of safety as a graduate student at Harvard University, where he transitioned. He suspected he was a victim of a hate crime after he experienced a physical attack that left him with a head injury. He continued to have difficulty remembering the sequence of events during that night. Due to this experience, Jonah had a heightened fear response.

In regard to feeling safe at Lambda, Jonah stated.

I mean, Lambda is built for LGBTQ people, so I feel pretty fine here. I felt fine here as a lesbian. I feel perfectly accepted here as a trans guy. Queer or not, they might have questions or whatever. I’m used to that anywhere. I’ll mention my being trans once in a while in a share, but it’s not the most important part of my identity anymore. It’s used to be because I realized I’m very cis- passing. I also attend an online meeting and a suburb of Houston, so I feel safe saying I’m trans.

Remy.

This is the first time Remy has participated in a formal program with a structured approach, such as a Twelve Step group. Previously, she attempted to unsuccessfully abstain on her own, often referred to as "white knuckling.” During the interview Remy referred to herself as a “celebrity of sorts” and reported she does not care what other people think. Although the Heights group is considered a heterosexual group, Remy felt comfortable enough to share her

104 trans status. Remy also stated she felt sexually harassed at some meetings. Men touched her inappropriately and she “gave them a stare” so they would not do it anymore. While Remy seemed to brush it off and not "make waves," it appears she does not always feel safe in these meeting spaces as a transgender woman. When validating Remy’s safety concerns, it appeared she was dissociated from the seriousness of the acts and minimized the concern.

I know they'll come up to me and touch me inappropriately. I mean, hello. Go grab me on my butt? I just give out a mean stare, so they don't do it anymore.

Hannah.

Hannah denied feeling unsafe at the NA meeting she attends, which is held at The Montrose Center. This organization is located in the LGBTQ area of town, and it is one of the largest nonprofit social service agencies in Houston. There are several transgender individuals that attend meetings at that location. She had not encountered any direct harassment or discrimination at the Twelve Step meetings. Since Hannah grew up going to AA/NA meetings due to her mother’s addiction, she knew what to expect and what meetings are safe.

“The Sooner the Better,” it’s an LGBTQ meeting. I go over there. I didn’t really like that one at first, but I’ve been going over there more often because it’s closer to where I live. I go over to the Gulf Coast Club, which is a heterosexual club. That’s my main place that I enjoy. I go there, and I know everyone there. I feel like the most I would get in those meetings is passive aggression. But everyone kind of has to get along. Everyone has to do their best to be there for each other, trust each other. I don’t feel like I’m unprotected or anything.

105 Alexia.

Alexia found several welcoming AA/NA communities, but also experienced feeling unsafe, uncomfortable, and guarded. She is an older transgender woman and finding the right meeting was challenging. Alexia described the younger transgender population as heavily invested in politics that tend to take over discussions in the meetings at Lambda. Alexia was hypersensitive about feeling safe in these groups, likely due to past trauma and experiences of discrimination. Alexia mentioned having to be "careful" about what is shared at times. She preferred small meetings and groups as opposed to large groups like Lambda.

Personally, I feel more comfortable at the Bay Area Club, going to straight meetings and talking to the women that do accept me. And I can tell you they truly accept me, and I feel safer doing that. Not everyone’s like that, but yeah.

Acceptance and rejection.

Recovery often requires individuals to navigate complex psychosocial stressors, especially for transgender clients who have faced societal rejection. These adverse experiences often heighten anxiety, fear and exclusivity upon entering AA or NA. Conversely, acceptance can serve as a protective factor—offering a sense of physical and psychological safety despite gender identity. Trans individuals most likely will attend multiple meetings in pursuit of inclusive spaces that foster authenticity and belonging.

Koatie Andrews.

Koatie Andrews struggled with feelings of acceptance and rejection throughout his recovery. He was supported by Lambda, despite initial challenges. Mostly, he was surprised the

106 heterosexual population at AA was supportive. Koatie Andrews recalled not being able to trust his family, especially his abusive father. His father would often say “nobody would believe you and nobody would love you.” Koatie Andrews faced many hardships as a young child and developed PTSD. The constant rejection led to many mental health issues and feeling suicidal.

Although he felt accepted, he remained cautious in his interactions, and he was mindful of how people might react to his transgender identity. Koatie Andrews distanced himself from people who made him uncomfortable, regardless of whether they were part of the LGBTQ community.

I don't think I'd have lived any longer actually knowing I'm trans and not being able to do anything about it. Early on people would tell me in AA when I was disclosing my mental health issues and trans status. Well, this is not the place for that. And I would think, of course, I wouldn't say anything, but I think that's part of the reason I drank.

Jonah.

Jonah felt accepted as a transgender man in AA meetings. He mentioned that his transition “was not an issue or part of the conversation in meetings.” He had only attended LGBTQ meetings and he felt the focus of these meetings was on the shared experience of addiction and recovery. During his journey, Jonah felt both acceptance and rejection in sobriety and within his community.

I feel pretty accepted by folks, I’m making friends slowly. What’s funny is now that I am sober, though, I’m not as gregarious as I was in my drinking days, so I’ve had a hard time making friends. A lot of people here probably think I’m a gay dude because I am passing.

I’m organically making friends here that I’m comfortable with. I am being very cautious of who I talk to it. Maybe somebody doesn’t want to talk to me.

107 I can’t judge the groups based on a few experiences one woman because I’ve started to meet a lot of really great people. As hard as it was for me to reach out for help yesterday to ask for rides, I got those offers, so I know that my tribe is there.

Remy.

Remy experienced rejection and acceptance when entering women's meetings and LGBTQ meetings, with people misgendering or questioning her presence. Remy felt resistance from other women when she revealed her transgender status. However, Remy had positive experiences where group members were welcoming.

There was one heterosexual meeting I went to, and I walked in there and I said, “Hey I’m Remy, I’m trans and am I welcome here?” And I could see all three ladies there who look like I just interrupted their party. And the others were very welcoming, and I fed off their energy and it was great.

I don’t feel like I’m wanted. OK, yeah, I feel like I’m kind of a sore thumb.

Hannah.

Hannah had not experienced any overt discrimination or rejection at NA meetings.

Although she found herself in some uncomfortable situations with people, she had never felt threatened. The meetings have a culture to “get along" and “support each other.” Hannah explained some of her interactions with her peers.

I feel I went into NA thinking people would be shitty towards me. I have the sense of anxiety, and I have to learn how to get past that. I’ve come to a realization that most of it

108 is just me. In my experience, it’s me projecting my own insecurities onto other people and creating a divide. I’ve had times where I said some pretty homophobic shit.

Alexia.

Alexia had felt a sense of discrimination and lack of acceptance at some AA meetings, particularly at the larger meetings. She had attended meetings at two straight clubs and one gay club. Certain heterosexual clubs were conservative and not very accepting. At Lambda, Alexia felt some people were "judgy" and “not very open”, especially transgender people discussing politics. This made Alexia uncomfortable and unable to tolerate some of these meetings with younger trans peers always discussing transgender issues.

At first, it was me being hypersensitive. I had the biggest roadblock, not thinking that I could find a support group or not, or thinking people were going to judge me when I went into treatment, and so the biggest roadblock was myself.

My whole life, I didn’t fit in because I didn’t know how to fit in. It was really hard because I was inadequate. And instead of working through it, I use substances and alcohol.

There’s a few people that I really like at Lambda and then there’s some that are very judging. I feel like I’ve been judged my whole life, so I don’t wanna go somewhere and get judged. Where I go now, the heterosexual club, I don’t feel like I have to explain myself or my gender. So, I usually keep that out of conversations.

109 Super-Ordinate Theme III: Sponsor Roulette One of the most important concepts of AA is the sponsor relationship. Although the Twelve Steps of AA and The Big Book of Alcoholics Anonymous do not explicitly use the term “sponsor,” the concept is integrated throughout the literature. The Twelve Steps states, “Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.” The implication is that once the steps are completed successfully, the alcoholic will help others through the steps, coined sponsorship.

Sponsors do not give advice, but “share their experience, strength and hope” to guide others on the path to recovery. Although selecting a sponsor is a personal decision, it is strongly encouraged as part of the recovery process. In treatment centers and outpatient therapy, they are often required by the treater. Same-sex sponsors are recommended to avoid any issues such as “13th stepping”, defined as a romantic relationship that can cause significant harm to the newly sober person. However, this guideline does not take into account the needs of LGBTQ members. Same- sex sponsors in the gay community can blur boundaries which can have a negative impact such as relapse, financial loss, sexual misconduct, emotional and psychological issues or the desire to leave the program. There are fewer trans members, making it difficult to find a sponsor who truly understands the trans experience such as gender dysphoria, internalized transphobia, misgendering, medical transition or an absence of legal protections.

NA is a program with similar principles and sponsorship is encouraged. "Sponsorship is a bridge between a new way of life and our daily lives. It is the way we keep what we have by giving it away." (NA Basic Text, n.d., Sponsorship Section). The primary focus is maintaining sobriety from all drugs, including alcohol. Many sponsors in NA will not work with a person who is on medication- assisted treatment such as Suboxone or Methadone. Socially, the term

110 “addict” carries a stronger negative connotation than “alcoholic,'” often evoking images of a homeless heroin user whereas drinking alcohol is socially accepted. In regard to the availability of LGBTQ sponsors, the same issue exists in NA.

Mixed experiences.

Transgender individuals often report a range of experiences with sponsors, reflecting both support and harm. The sponsor-sponsee relationship is central to recovery and can become complicated when the sponsor lacks awareness of trans-specific issues or reinforces binary or exclusionary norms. As a result, some trans individuals may delay finding a sponsor which is detrimental to achieving sobriety.

Koatie Andrews.

During early recovery, sponsorship served as Koatie Andrews’s critical support system.

His experiences varied with different sponsors, mostly positive, leaving a lasting impact on his journey. He noticed how their beliefs shaped the way they sponsored. Koatie Andrews’s first trans sponsor supported him during the early phases of his recovery. At the time, he was in an intensive outpatient therapy program (IOP) working through trauma. Rather than focusing on the Twelve Steps, his sponsor provided emotional support, helping him navigate this challenging period. Sponsor two was a 32-year-old straight female who sponsored Koatie Andrews for six months and they completed the steps together. Sponsor three, a gay man in his 70’s, worked with Koatie Andrews for six months. They went through the Twelve Steps and the Twelve traditions together. Sponsor four was a straight woman in her 70s and worked with Koatie Andrews for three months. Sponsor five was a straight man who sponsored Koatie Andrews for two years.

111 They did not work through the steps but explored different paths to sobriety. He invited Koatie Andrews to attend a group focused on men's healing. His approach was more spiritual than structured. Koatie Andrews’s current sponsor is a 64-year-old gay man. They worked through the steps using the NA workbook, which Koatie Andrews found very thought-provoking. Koatie discussed several sponsors and gave insight into the impact they had on his recovery.

Sponsor one helped me understand the program better, like being able to leave meetings if I was uncomfortable. My sponsor provided emotional support and encouraged me to go to meetings when I was struggling Sponsor two was a straight female new to sponsoring. In fact, I think I was her first one because someone else told me later that she was really excited that she had her first sponsee. I felt listening to her shares, I had a lot of the same emotions and things that she dealt with, and I just felt a connection. And I know she has some mental health issues too.

She was understanding when I shared about my trauma, reassuring me it wasn't my fault.

Sponsor three was kind of like, I mean, he was straight to the point. We met, we got it done and then that was it.

Sponsor four said I should not be on any anxiety medication, and she said she would no longer sponsor me if I continued. I kind of chuckle about it now because she's really the first person I ever said “no” to. And I didn't say the word “no”. I just told her, “I'm not going to do that. And I told her, “you do what you need to do, but I'm going to do what I need to do. And I was amazed that she didn't try to force me, which told me in my mind, I can tell people no. And it's okay to tell people no.

My current sponsor is very into spirituality and energy work, which has led to good conversations. The relationship has evolved from a traditional sponsor-sponsee dynamic

112 to more of an equal relationship. I feel comfortable challenging his perspectives when needed.

Jonah.

Jonah described his current sponsor as a "butch lesbian.” In prior years, he had a few other sponsors before sponsor one, but he couldn't remember their names. Jonah had a cisgender male sponsor, and he felt uncomfortable as he was worried the sponsor might ask invasive questions about his medical history as a transgender man. Jonah preferred a female sponsor and expressed significant discomfort and caution around cisgender men, both as potential sponsors and in general interpersonal interactions, due to his past experiences and desire to feel emotionally safe in his recovery. He is hypervigilant of his physical and emotional safety after the physical attack that left him with neurological problems.

That cis guy was my first sponsor, but I was uncomfortable with some of the stuff he was asking me to do. He wanted me to come to a meeting. I'm like, I'm not driving in a hard freeze, dude. I'll do a Zoom meeting. He's like, oh, the disease will kill you faster than the snow or whatever. I'm like, no, dude. No faster than the ice. No, I was like, bad vibes. So, I told him, you know what? This is not going to work out." I felt "emotionally unsafe" with him as a sponsor and got "weird vibes" from him.

My current female sponsor is not a Christian, which I was initially hesitant about, but realized it's beneficial to have a different perspective. I said, you know what? No, you're stuck with me because I want to hear a different perspective. You're probably going to show me things in the big book that I wouldn't have seen before. Maybe at some point, if for some reason I need to get a new sponsor, if that person happens to be of the Christian

113 faith and looks at the big book as literature like I do, that could be cool. But if I find I am not growing, then it wouldn't be helpful.

Remy.

Remy recently sought out a sponsor for the first time, choosing Libby, a trans woman with 20 years of sobriety. Although Libby does not attend meetings or work the steps, Remy was drawn to her strong belief in God. Remy also appreciated her openness about her schizophrenia and mental illness. Remy mentioned a time when her sponsor referred to Remy as the “big brother she never had.” This made Remy sad, but she accepted it because “I have very strong facial features and people judge a book by its cover unfortunately, but I don’t.”

She tells me how she controls herself. And she's not a religious fanatic per se, but she believes and that's why I chose her. I feel that Libby’s experience with mental illness and long-term sobriety make her a good sponsor, even though some people were skeptical about the pairing. We'll see how that goes.

Hannah

.

Hannah had one sponsor and described their relationship.

My NA sponsor is an older gay man in his mid-thirties. He has been great. He is very patient. He is kind and I consider myself to be good friends with him. I was going to Gulf Coast Club and a lot of the crowd there is kind of people that you wouldn't really pick out as being very accepting of LGBTQ people and stuff, a rougher crowd. And Shane was kind of the first gay dude that walked through the door essentially. And yeah, I was like,

114 okay, he won't be weird about me being trans. I can probably be cool with him. I didn't have many options at the time.

Alexia.

Alexia has had three different sponsors in her recovery journey. Currently, Alexia does not have a sponsor and does not plan to seek one out. She stated the relationship with the first sponsor was not productive, and so she stopped talking to her. With her second sponsor, issues arose when Alexia wanted to work on Step Four with someone else instead of going over it with her. Alexia did not trust her and felt unsafe.

I did not feel comfortable going over Step Four because I didn't fully trust that sponsor. I know that people relapse, and I didn't want to have my sponsor at the same club that I go to because I still worry about telling people things, just because of the family I grew up in, they take a little bit of truth.

The third sponsor still gives me support, but she's not real pushy though either. And I like that because the second sponsor also wanted me to do more service work, and sometimes I feel like the service work is abuse. I don't see that doing it exactly their way is the right way if it doesn't fit me. Sometimes sponsors, I think that it's their way or no way, and everybody's their own person.

Boundaries.

In AA and NA, boundaries in sponsorship are crucial to ensuring a safe and supportive recovery community. A boundary defines acceptable behavior. When newly sober individuals attend AA or NA meetings, they are learning to navigate boundaries—both their own and those

115 of others. The Twelve Steps are a guide on how to create and enforce healthy boundaries with friends, family and work colleagues. While traditional sponsorship encourages same-gender sponsorship, trans individuals have the autonomy to choose a sponsor with whom they feel comfortable, whether same or opposite sex. The sponsor teaches the sponsee boundaries regarding physical space, emotional wellbeing, and within interpersonal relationships. However, the sponsors can be the biggest violator of boundaries, and the harm they cause can have profound lasting consequences.

Koatie Andrews.

Koatie Andrews had a very difficult childhood, suffering from significant abuse at a young age by his father. As a result, Koatie Andrews developed apprehension toward authority figures, perceiving them as having power over him. He is a self-described “people pleaser” and does not want to disappoint anyone including his sponsor. Koatie Andrews has had multiple sponsors with different challenges. Koatie Andrews discussed an important boundary he was able to enforce with one of his sponsors.

This one person was like, 'oh, no, you shouldn't do that.' I ended up having to set a boundary and basically getting him out of my life, which was the first person really I've ever done that with. I used to think I didn't have a choice. Anything anybody told me, I did, which was not good.

Our relationship (current sponsor) has started changing more into equals, and there were times where... It's really been hard for me. Again, it's that authority figure type deal for me. He has always been respectful of me and he knows the issues I have with authority.

116 He also understands more of my trauma and what I've been through on jobs. And like I said, it's on a different level now. It's no longer like a sponsor/sponsee.

Jonah.

Jonah was hypervigilant regarding boundaries. In September 2018, after leaving a bar in Boston, he was physically assaulted. He woke up in the hospital with a fractured skull, brain bleeding, and permanent loss of his sense of smell. His recovery took over a year and he was in a facility for physical rehabilitation. Although this experience was lifechanging, he initially decided to have a cis male sponsor and later changed to a female sponsor. He had a balanced approach with boundaries and he tried “not to take things too personally.” He seemed to have a good understanding of when to assert boundaries and when to let certain things go.

The week we had that hard freeze, my sponsor wanted me to come to a meeting. I'm like, I'm not driving in a hard freeze, dude. I'll do a Zoom meeting. He's like, oh, the disease will kill you faster than the snow or whatever. I'm like, no, dude. No faster than the ice.

No, I was like, bad vibes. So, after that weird day, when he asked me to come up here despite an ice storm, I'm like, nah, nah, bro, this ain't going to work. I just felt emotionally unsafe.

Remy.

Remy has been sober four months and she did not have a history in AA/NA. Libby was her first sponsor. She has worked through the first eight steps on her own, using notes and resources like AI to help study the Big Book. Her relationship is not a traditional sponsor-

117 sponsee dynamic and AA/NA would frown on this approach. As a result, boundaries can be blurred and the work to achieve sobriety has been diluted.

I give Libby all my love and I see her as someone she can call if she needs to talk, rather than necessarily working the steps with her. She would never, never drink – Libby is completely committed to her sobriety.

Hannah.

Hannah had worked with her NA sponsor since January 2023 and he was very supportive. She chose this sponsor because he was one of the few openly gay men in the NA meetings she attended, and she felt he would be accepting of her transgender status. Hannah described Shane as a "great" sponsor who was "very patient and kind.” She considered him a good friend and felt their relationship had healthy boundaries. The only issue she mentioned was a time Shane made insensitive remarks and exhibited some racial biases, but not directly towards Hannah. Hannah was able to set a boundaries and she did not feel unsafe doing so. She described feeling comfortable challenging this behavior from her sponsor.

Occasionally he starts talking like he's black, with a blackscent and I'm like, I called him out on it once and I noticed he stopped doing it. And then I remember he was a manager at this restaurant and he said something about how he got in trouble for adding gratuity onto ghetto tables or ghetto looking tables or something like that. It’s racial profiling.

Alexia.

Alexia preferred sponsors who were not "real pushy" and would allow her to work the program that was applicable to her journey. Alexia explained that her hesitance with some

118 sponsors was rooted in past trauma and a desire to feel safe and comfortable, rather than having to explain or defend herself. Alexia mentioned "vibes" from some sponsors, indicating they may have acted in ways that made her feel unsafe or uncomfortable. Her experiences with sponsors had left her wary of the process and a healthy boundary for her was not to engage a sponsor.

I just didn't feel comfortable with the sponsors, because sometimes sponsors, I think that it's their way or no way, and everybody's their own person.

It’s not what they say, it's the way that they act. That was one of the big things was just me feeling safe. I didn't feel comfortable sharing deeply with sponsors out of fear of my information getting spread around. They made me feel unsafe, even if they didn't explicitly say anything inappropriate.

Super-Ordinate Theme IV: Finding “God” The Twelve Steps of AA/NA are rooted in religious and spiritual teachings with the term “higher power,” “God” and “God as we understood him” spoken throughout meetings, literature and sponsorship. Spirituality is a core part of the recovery process, and AA/NA does not impose any specific religious beliefs. This may or may not be true depending on the city, state, group, meeting or political climate. South Texas as well as many parts of Houston are heavily religious. Atheists and Agnostics are welcome, but they find it difficult to be a part of Twelve Step programs due to the heavy religious content. Lambda is more lax and some members suggest an open-ended approach, allowing each person to define their own understanding of a Higher Power. For example, GOD “Group of Drunks” indicates the fellowship itself can serve as a higher power. This flexibility allows trans individuals to seek a higher power that aligns with their identity and experiences. “Good Orderly Direction”

119 emphasizes structure, guidance, and values in recovery.” “Gift of Desperation” is the idea of “rock bottom” can lead to surrender and growth. Some of these ideas are provocative especially to older people in sobriety who adhere to the rigid and strict teaching of AA/NA with no room for flexibility.

Religious trauma.

Transgender people have a history of religious trauma that can cause depression, anxiety, suicidality, and posttraumatic stress disorder (PTSD). Emotional and psychological distress results from harmful religious experiences, often rebuffing AA/NA due to the heavy religious and spiritual component. Shame, humiliation, and fear is common and often require intense work with a sponsor and outside therapy. Fundamentalist beliefs promote fear of eternal damnation, rejection, and manipulation from religious communities and leaders. Entering into AA/NA can feel similar, with a heavy emphasis placed on the “authoritarian” sponsor and Twelve Steps. In juxtaposition, some trans people are strong in faith, and they use their faith as a source of healing. Houston has an LGBTQ church and progressive religious community that reinterprets faith to affirm trans identity. Others choose to attend other recovery options such as SelfManagement and Recovery Training (SMART Recovery), that teaches cognitive behavioral therapy, or Refuge Recovery, inspired by Buddhist principles.

Koatie Andrews.

Koatie Andrews had significant religious trauma and distrust stemming from his upbringing, which made it very difficult for him to engage with the spiritual aspects of Twelve Step programs. As a child, he suffered severe abuse from his father, who instilled fear which led

120 to him questioning his beliefs. Religious trauma played a significant role in his struggles with self-acceptance and trust, and he worked tirelessly to overcome these challenges through his recovery process.

The religion I grew up in, it was - all against the LGBT, and I didn't like when religious beliefs were enforced or me. When I started exploring my transgender identity, I was scared to tell my therapist at first because of the religious beliefs instilled in me from a young age.

Jonah.

Jonah was raised in a conservative Latino Mexican Baptist household, where discussing LGBTQ identity was not acceptable. This created internal conflict as he grappled with his sexual and gender identity from a young age. In high school, Jonah struggled with the conflict between the fundamentalist Christian teachings and his sexual identity. He explained what it was like to study Christianity in high school.

I remember going to a Christian student union meeting after school. I must've been in 10th or 11th grade since I was driving at the time. So yeah, I was definitely over 16 driving mom's car. I drove it to my friend's house and had our little Bible study and stuff. I sat in the car before I drove the five minutes home and I started bawling, bawling, crying, thinking, and I'm praying. I'm like, okay, God. And at the time, again, I'm female presenting lesbian. I knew in my heart I was a lesbian then. And I remember praying to God going, if it's not okay for me to be gay, then why did you make me this way?

121 Remy.

Remy grew up in a very religious, Catholic family that was intolerant of homosexuality and LGBTQ identities. When she was younger and exploring gender identity, her family was not accepting. Strict gender norms and the conservative environment of Remy's upbringing contributed to her rejecting religion, becoming an atheist for approximately a year before joining AA. Remy described many impactful comments by her family.

My aunties, they quilted and they asked me, what color do you want your quilt? Pink, they said, and they were laughing and said, boys are blue, girls are pink. And I started crying. I remember that. That was so traumatic.

My redneck cousins. My redneck family. Wow. They were always being homo bashers.

And we were always taught to grow up and hate homosexual people. I grew up Catholic and I tell people, I'm a recovering Catholic.

Hannah Hannah was raised Baptist by her grandmother and she would go to church when forced.

At age 11, her grandmother started attending a mega church, which Hannah didn't seem to enjoy or connect with their teachings. Hannah stated she did not experience any religious trauma but described the dynamic within her family when discussing religion. She was still trying to figure out if she believes in God. I was raised a Baptist Christian. My grandma went to a mega church. I became a very staunch, very annoying, preachy atheist. I wanted to piss off my grandma. Me and my grandma were always arguing and stuff.

122 Alexia.

Alexia experienced significant religious trauma and rejection from her Southern Baptist upbringing, which had a lasting impact on her spiritual beliefs, self-image, and relationships with family. She grew up in an intolerant, controlling religious environment that made her feel damned, isolated, and blamed for the family's problems simply for being true to her identity. God became distorted after her experience with church. Religious trauma had been a major factor in her struggles with addiction and recovery. Alexia stated she is more spiritual and believes in God. She still has issues with the Bible because it was written by a man.

The church I grew up in was very racist, homophobic. They didn't shy back from using words in the pulpit. And I really thought that if I came out, I was destined for hell. So, it scared me. So, it distorted my view of a higher power for a long time because I was like, how can there be a God who hates me? My mom had heart conditions from diabetes and she died of COVID, but my family said her heart got bad because of the stress from me being transgender, so they said I killed her.

Religion versus spirituality.

In AA and NA, the distinction between religion and spirituality can be confusing. The traditional concept of God follows moral rules and may have an exclusive approach to truth that often alienates the trans population. Spirituality, in AA/NA, is about finding a connection to something greater than oneself—whether that’s a traditional God, the universe, nature, inner strength, or the collective wisdom of the group. The program encourages people to define their own definition of "Higher Power," making room for religious and non-religious individuals, even atheists and agnostics. While some meetings throughout Houston may lean more religious, others

123 emphasize spirituality. It depends on the location and principles of the meeting. This allows people of different backgrounds, including those with religious trauma, to engage in recovery without feeling pressured to conform.

Koatie Andrews.

Koatie Andrews had a lot of anger towards Christianity and he felt many people who use the "Christian" label don't actually understand what it means. Koatie Andrews was involved in an evangelical, charismatic type of Christianity at one point, even experiencing speaking in tongues and intense prayer. Since he has been attending AA/NA meetings, he had to separate Christ from the name of Christian in order to be more open-minded. He has moved away from rigid religious beliefs towards a spirituality that aligns with his transgender identity and life experiences.

I was dead set against God. I would be in a meeting and I would make myself stay in a meeting on God because I thought I had to. And my temporary sponsor, when I told her, Koatie Andrews, you don't have to stay in. Get up and leave.

I believe everybody is born in love. And I experienced real love for the first time. I knew from that point on, that's what I want to live in. Of course, you're not going to be in that all the time, but I have learned to get myself back into it.

Jonah.

Jonah departed from a strict religious upbringing and identified more with a personal sense of spirituality. He was focused on his own journey of self-discovery and acceptance, rather than “religious dogma.” Growing up as a lesbian, he was conflicted with religious teachings,

124 citing the church’s interpretations were often biased and flawed. As a result, Jonah did an extensive study of the Bible and different translations, realizing that words like "homosexual" were not in the original texts. This had allowed him to form his own understanding of God. He felt the community in AA fulfilled a similar purpose to church, where people could come together in God's name, even if they did not all believe the same thing. Jonah had not found a church he feels comfortable attending.

I was dead set against God. I had always had this religious idea of what God is.

Now, when I did go to the evangelical, charismatic type of Christianity, which was really odd because I got into prayer a lot, and I do believe in the baptism of the Holy Ghost with tongues, and I prayed a lot of times. However, I could never really pray for myself.

If I'm a girl and I like girls, well I'm gay. That was the identity I was struggling with what I was like, but I'm Christian, I can't do both. And I'd been struggling with that since I was little but didn't talk about it too much. If your religion teaches you to judge people and hate others, you're doing it wrong. If anything, AA has made my faith stronger. I now fully believe the people who work the program find God.

Remy.

In AA meetings, Remy had been an atheist and defined God as a fictional character to help people cope. Remy departed from organized religion towards a spiritual perspective such as higher power. This occurred when she had a near death experience during a surgery in which she

125 felt god and love in a profound way. She believed in a higher power or "God" in a more abstract, universal sense, rather than adhering to a specific dogma.

I left God, but God didn't leave me. Well, I never left God. I left religion. Let's say it that way.

Hannah.

Hannah was currently struggling with her beliefs in God and a higher power. She was working on the second step with her sponsor, which refers to believing in a "power greater than ourselves." Hannah explained that the concept of God in NA can be interpreted in different ways.

Her higher power had become a combination of people in NA and a path that aligns with her values. Hannah mentioned she had always been "somewhat spiritual" and the idea of God wasn't a big hurdle for her, though she knows it is a struggle for many others in the program. This reflected some of the contradictions in her previous statements, highlighting her struggle with God. I guess the concept of God, I have heard it shortened into GOD—group of druggies or good orderly direction. I guess I would say my higher power or whatever has become a mix of other people in NA. The fact of the matter is ten brains are more powerful than one.

Am I struggling at all? Not really. I have a less defined idea [of] God than I did in the past. So, I guess I am struggling because I was trying to look for a specific God that I could look at and define and be like, yeah, like this right here. And I'm trying to have, try to learn to be more vague, I guess, with it, which is odd.

126 Alexia.

Alexia grew up in a very conservative Southern Baptist church that was racist and homophobic. This distorted Alexia's view of a "higher power" for many years. Alexia had attended a more progressive, accepting church (Resurrection MCC) and liked “more spiritual" than a strictly religious view.

I'm more spiritual. I do believe in God. I still have issues with the bible though, because it's written by man and they go to a King James version. It's a king, it's a politician. Anything can be put in there. I still have my questions about it. For a long time, I was worried because why am I going to turn everything over to a God that hates me because I’m transgender? I had these issues with my family growing up.

Twelve Steps.

One of the most important foundations of AA/NA is the Twelve Steps. After the Twelve Steps are completed, the alcoholic/addict is meant to have a “spiritual experience,” and the desire to use substances is removed. Seven out of the Twelve Steps refer to God, Him, or spiritual experience, and believing in these concepts are integral to the recovery process. These religious teachings may create further stigma for the transgender community. Christianity rejects homosexuality and other gender diverse populations. Step One discusses the notion of powerlessness, not helplessness. Many people in the LGBTQ community have felt powerlessness throughout life. The meaning of powerlessness in AA/NA means you do not have control over the use of drugs or alcohol and life has become unmanageable. It does not mean

127 power over self and decisions is relinquished. However, many transgender people struggle with this concept as reflected in the Twelve Steps.

Koatie Andrews.

Koatie Andrews had a lot of anger and mistrust towards Christianity, stemming from his past trauma. With the help of his sponsor, Koatie Andrews started reading the Big Book and other Twelve Step literature in a way that resonated with him, highlighting the parts that were meaningful. Koatie Andrews initially had trouble connecting with the AA program and book, finding the language and tone too "harsh" for him. He had a lot of self-hatred and negative inner talk that made it hard to relate, therefore he felt the Twelve Steps of NA were more helpful. His temporary sponsor helped him understand he could "take what works and leave the rest." It wasn't until his fourth sponsor that Koatie Andrews was able to connect and work through the NA book, with the sponsor having him highlight passages that resonated.

It was with my fourth sponsor. He was in a meeting and I didn't know he was in there. I grabbed the NA book off the shelf and I was reading it. He came out and he saw me reading it, and he said, 'You like that?' And I said, 'Yeah.' Good, we are going to work out of that. What I want you to do is highlight anything that resonates with you and send it to me.

Over time, I have been able to connect more with the spiritual aspects of the program, even exploring things like energy work and breathwork. This has helped me feel a sense of trust and belonging.

Jonah.

128 Jonah worked the Twelve Steps in AA in a way that aligned with his personal faith and beliefs, without any bias or internalized transphobia. He used resources like the Life Recovery Bible to supplement the step work he had done with his sponsor. Jonah was able to decouple theology from God and separate anti-LGBTQ rhetoric he grew up with from his personal relationship with God. He continued to research and study faith to align with his transgender identity. Jonah follows the steps, however, he was intentional about how he worked the steps.

Believing in God versus surrendering are two completely different things. And that's the difference. Going through the steps, especially Steps Four and Five- taking a moral inventory, helped me gain deeper self-awareness about the role of my gender identity and trauma in my alcoholism.

Remy.

Initially, Remy was an atheist when she became sober. She started to work the AA steps by herself, which was not advised and a deviation from the Twelve Step program. This can cause isolation, absence of feedback, distortions, denial, and lack of accountability. Some steps, such as making amends (Step Nine), required discernment and wisdom. Members of AA/NA would view this lack of accountability as characteristic of someone who wanted to work their own program and not follow the rules of AA/NA. In turn, Remy was at risk of being shunned by AA/NA community. She explained her views on the steps.

The Twelve Steps is very God/religious oriented, and I had a hard time with that [way of] thinking; if it helps you believe in a fictional character, more power to you.

129 I have worked through the first eight steps on my own without a sponsor. I use a cheat sheet to go over the steps and try to understand them. Members can be very hardcore about sticking to the Twelve Step program exactly as written.

Hannah.

Hannah had struggled with the Twelve Steps of NA like most people in sobriety. Step Four is widely regarded as one of the most difficult phases of the Twelve Step process, wherein the individual engages in a structured written inventory to identify and discuss unresolved resentments, maladaptive coping skills, emotional conflicts, and responsibility. Relapse often occurs during this step because the individual is faced with the destruction they have caused others. Step five requires disclosing secrets to a sponsor, often reinforcing shame and regret.

Hannah previously had worked through the steps up to Step Four before relapsing. After a relapse, the steps start over. Hannah was currently working on Step Two, which involves finding a "higher power.” She mentioned struggling with this concept and trying to be more openminded.

I wouldn’t call myself any specific religion or anything. I’m not entirely sure if I believe in God, I’m actually working on that right now. I’m on the second step.

Alexia Alexia had difficulty engaging with Step One, admitting powerlessness over substances — it took her a long time to engage with this Step. She disclosed her most significant substance use experiences to a mentor rather than to her assigned sponsor. During Step Four, Alexia was fearful to share her moral inventory with her sponsor and chose to complete the Step with a

130 support person whom she identified as more trustworthy. She was working on Step Nine and was reluctant to make amends with certain individuals. She viewed Twelve Steps as helpful but not exclusive.

I didn't feel comfortable working the Steps with one sponsor who was "pushy" about doing it their way. I struggled with Step One because I didn’t quite want to do it. I didn’t feel comfortable. I’ve been powerless my whole life, I don’t want to be powerless again.

Super- Ordinate Theme V: Community AA/NA provided a structured peer-support system that created connection, accountability, and personal growth. Functions of the Twelve Step community included, offering a sense of belonging, a decrease in isolation, and discussion of shared experiences without judgment, to name a few. Accountability was through regular attendance, step work, and service work. The idea of volunteering and helping others in need promotes self-worth and community engagement. For example, the newly sober person is encouraged to make coffee, volunteer on committees, and help those less fortunate. This can include providing transportation, among many other tasks.

Since AA/NA lacks many transgender individuals, it is important to develop an additional support system in the community. This holistic approach is encouraged to maintain lasting sobriety. AA/NA is referred to as a “chosen family.”

Connection In AA/AA

131 Community is the core of recovery, and AA/NA provides emotional, social, and spiritual bonds in recovery to achieve long-lasting sobriety. If relapse occurs, the community is supportive and will rally around the struggling individual, to work toward common goals.

AA/NA is one of the only places in the world one can walk into a meeting and experience instant connection. We have one common goal—sobriety.

Koatie Andrews.

Koatie Andrews was surprised by the openness and acceptance of straight individuals at Lambda. He experienced a feeling of trust and having someone support him for the first time. He became more open about his gender identity, though he doesn't connect heavily with other transgender people in the program. Koatie Andrews does not know a lot of trans people that go to AA/NA. I haven't really connected a lot with trans people. I do know people who are trans, and people have come to me and asked, "Well, how did you do this?" or my experience in it.

And I share what I know and what I believe. And the main thing, and even with people who aren't trans, I try to get across is that we're all individuals. I mean, we may have similar experiences, but nobody's going to think exactly like I do. I've tended to lump one group into certain stereotype things, and you can't do that with trans people either.

There were times where I was struggling and just sitting in the bed and they (peers in recovery) would text me and ask me how I'm doing. And then they said, well get up, go to a meeting.

Jonah.

132 Jonah expressed feeling accepted by the AA community as a transgender man. Lasting friendships can be difficult to make due to the nature of addiction. There are people in AA that take advantage of others such as steal, manipulate and lie. This can be a difficult dance since early sobriety often results in cognitive impairments leading to bad decisions.

I had a hard time making friends, but I'm organically making a few here and there that I'm comfortable with. I have met amazing people. I'm still friends with a couple of people I met at Lambda that don't live in the area anymore.

As hard as it was for me to reach out for help yesterday to ask for rides, I got those offers, so I know that my tribe is there. I just have to open my eyes to see my people. And not everyone's going to be our cup of tea. I get that. The main thing for me about the AA is the community, because it does help. It's other people that have the same issues.

Remy.

Remy described her experiences in the AA/NA community, stating the group was accepting of her, despite initial reactions to her trans status. This is contradictory to earlier statements she made regarding lack of acceptance by the community. This experience, previously described on page 124, also illustrates how transgender participants are continuously assessing safety and belonging in gendered AA/NA spaces.

As Remy shared, this moment not only reflects her fear of rejection but also highlights the theme of seeking affirmation in unfamiliar or exclusionary recovery environments.

I walked into another women's meeting over at Spring Branch, and this time I walked in, I said, hi, I'm Remy and I'm trans, Am I welcome here? People turned around, some of

133 their mouths dropped, like I knew I wasn't welcome there. And the other girl said, Hey Remy, we're glad to see you here. Join the group.

Hannah.

Hannah has found the NA community to be an important and meaningful part of her recovery, although it took time to feel fully connected. The diversity and younger demographic of NA compared to AA was a better fit. Hannah attended various NA meetings until she found a group. She explained two different groups she attended.

I have been going to the NA meeting there more often. I'm starting to actually talk to some of the people there and stuff, and it just took me a while of going there, but it wasn't immediate. [AA] wasn't really my thing. It was only a few people and it is just, the connection wasn't really there.

Alexia.

Alexia identified the sense of community in AA as the most beneficial aspect, specifically noting the value of being surrounded by others with shared experiences. This connection has been highly supportive in her recovery. She has experienced lack of openness in larger AA meetings, and she feels more comfortable in smaller, more intimate meetings.

I could tell that they weren't too accepting. It was very cliquish. Lambda was good.

Nobody judged, but you can still be kind of cliquish there though too. I think the main thing for me about AA is the community, because it does help. But sometimes I still struggle.

134 Friends.

There is a benefit to having friends outside the program of AA and NA. People in recovery strive to have a healthy balance of people who are supportive and understanding.

Friends in the program can often have a shared understanding and acceptance, creating a more authentic relationship. Friends outside of the program may be understanding, however, because they are not in recovery, they have difficulty understanding the complexities of addiction. One problem that often occurs in AA/NA is some people become overly dependent on the friendships they make in the program. This can cause difficulties if a disagreement occurs between friends, and there becomes a divide in meetings. Often people will pick sides, and this can create tensions often leading the person to leave the group and find another one.

Koatie Andrews.

Koatie Andrews discussed important friendships he had developed in AA. He had a few other friends not in recovery. He stated not all gay people are accepting of trans people.

That's where all my friends are. I don't really have a lot of friends outside of AA. I haven’t really connected with a lot of trans people. I do know people who are trans in AA.

Jonah.

Jonah formed meaningful connections within the recovery community prior to initiating his own sobriety. He began attending AA in 2010 while accompanying a girlfriend who was seeking recovery. In 2024, he reconnected with a few sober friends he met in 2010. Jonah had a trans friend who recently became sober, however, they don't attend the same meetings.

135 I'm making friends slowly. What's funny is that now that I'm sober, I'm not as gregarious as I was in my drinking days, so I've had a hard time making friends, but I'm organically making a few here and there that I'm comfortable.

Remy.

Remy had some close friends inside AA/NA and attended various recovery meetings and interacted with a range of people, including those struggling with mental health issues and homelessness. Remy had found community and connection with other transgender individuals in AA meetings. She reported having other friends outside of the program, such as employees and customers she described as loyal. Remy disclosed her trans status, and they were accepting and supportive. Remy valued her friendships and the support they provided.

When I came out as trans my friends said, “you are who you are, I accept you for who you are.”

Hannah.

Hannah’s main social circle was people she had met through NA meetings, including her sponsor. She mentioned meeting a few other trans people through NA, though she stated there is a lack of connection. Outside of NA, her social circle is primarily made up of trans women; however, they drank and used drugs, and they are not part of the recovery community. Hannah felt that going to bars and clubs was risky, and she was afraid of relapsing because it has happened before.

They drink. Smoke weed and stuff. They are not addicts or anything. I had to learn to not feel the need to go out to the bars with 'em and stuff, just because I fear of missing out. I

136 relate more to cis women than I do to cis men. I don't really see myself the same as the cis woman.

Alexia.

Alexia lost friends when she transitioned and acknowledged those friendships were more about having substances in common rather than true friendship. She had difficulty conversing with younger people and felt more comfortable at the smaller AA meetings. Many of the younger trans people were absorbed with politics and Alexia did not find discussing political topics helpful. She preferred to attend groups that are older and in the suburbs.

I do have a few transgender friends that aren't in AA that I get along with really well.

And it's also a little bit of me, the meetings get so overwhelming that I'm really shy and I don't reach out and I don't put myself out there.

Career.

A career can be an accomplishment of self-expression, financial stability, and personal growth. Transitioning while in the workplace may be inclusionary or exclusionary depending on the climate of the organization. Many of the participants in this study have worked hard to maintain a sense of self-worth identified through their career. However, some had faced discrimination through harassment, misgendering, exclusion, or lack of protections. For instance, trans employees may face pressure to resign based on their identity or be denied promotions, contributing to addiction and mental health disorders. However, there are also supportive environments that can be helpful for lifting the person up.

137 Koatie Andrews.

Koatie Andrews makes dentures for a living and he takes pride in his work. Over his career, he had experienced mixed reactions in the workplace by superiors and peers. He explained how his transgender status in the workplace had affected his use of substances.

At one job, a coworker asked me to have sex with him, and other coworkers started making assumptions I was gay or transgender. At another job, coworkers would make comments and try to out me as transgender. My recent job, I believe the company was trying to get me fired and did push me out once they found out I was transgender.

I almost had a nervous breakdown. My sponsor there really, really helped me out with that. They did end up offering to pay my insurance for 90 days, which is really what I needed for my top surgery. I contacted the EEOC. They did try to stop me from getting unemployment.

Jonah.

Jonah had been a teacher on and off since 2006. He had taught students as young as sixth grade who had identified Jonah as transgender. Most of his students had been accepting and supportive, with a few exceptions. One student initially said she was uncomfortable calling Jonah "Mr.” Another student's religious parents had an issue with Jonah being transgender, but this was no longer an issue. Jonah was cautious about how he discussed his transgender identity with open-minded students, only going as far as they felt comfortable. He doesn’t want to be accused of "indoctrinating" the children. Jonah’s career was recently awarded Best Teacher for the 2024-2025 school year. Jonah’s career was very important to him and, although he had some challenges with recent DWI arrests, his school had been supportive.

138 I’ve been a teacher off and on since 2006, kids have known I’m either queer, lesbian, or whatever. Some of my students as young as six grade have figured out I’m trans, and they for the most part don’t care… Governor Greg Abbott wants to throw trans teachers out of the classroom, that’s cute.

Remy.

Remy owns a successful company but she has faced challenges with her drinking impacting her work. Remy had initially worried her trans status would cost her business, but she was surprised customers were accepting when she came out.

I thought for sure I was going to lose customers. I didn't, they all were on board with me.

I'm like, wow, this is so fucking great. One customer said, "you are who you are. I accept you for who you are."

Hannah.

Hannah was currently working at a restaurant and she had been working there for approximately eight months. She experienced some intentional misgendering while at work. She was able to resolve the situation after her manager intervened and mediated the disagreement with a coworker.

I got into it with one of my coworkers a while back. And all of a sudden, I think I was asking him a question like, oh, where are the potatoes? And he is like, I don't know, SIR. He look at me dead in the eye, clearly trying to get a rise out of me. And yeah, I'm like, what the fuck, why are you fucking with me right now?

139 Alexia.

Alexia's original career was in the chemical industry, before her addiction issues and health problems interfered with her ability to maintain the job. After her fourth DWI, she faced 20 years in prison and she decided to go to treatment. After successfully completing the alcohol and drug program, she decided to go back to school to become a Licensed Chemical Dependency Counselor (LCDC). She was embarking on a new career and wanted to work in the field of substance abuse.

Transgender people have their own issues when it comes to employment too. They’re very discriminated against and when it comes to employment and especially a lot of younger ones. And I feel a lot of them need guidance on how to go about things.

Summary of the Themes The purpose of this study was to explore the lived experiences of transgender individuals within AA/NA. Interpretative Phenomenological Analysis was the methodology used to deeply explore this phenomenon. This researcher interviewed six participants and one was later excluded from the study because she identified as non-binary and thus did not meet the research study criterion. During the interview process, all participants were encouraged to engage in freeflowing dialogue. Analysis of the results included identifying the recurrent themes that emerged from the initial sorting of the data, building a coding scaffold to support idiographic and interpretative analysis, and establishing emergent themes into primary categories. Emergent themes started to develop, resulting in five Super- Ordinate themes described in detail in this chapter: Intersection of Identity and Recovery, Safety and Acceptance, Sponsor Roulette, Finding “God” and Community. Theme one, Intersection of Identity and Recovery, emerged as the

140 participants described both embracing their trans identity and the vulnerability of walking into a meeting space. Theme two, Safety and Acceptance, were central to the discussion as participants navigated environments marked by both inclusion and rejection, highlighting the importance of physical and psychological safety. Theme three, Sponsor Roulette, reflected the mixed experiences of sponsorship identifying difficulties with boundaries and the sponsor/sponsee relationship. Theme four, Finding “God,” discussed religion, religious trauma and spirituality while working through the Twelve Steps of AA/NA. Finally, Theme five, Community, was an important element, as participants sought belonging within recovery, friends and careers.

Consistent with the methodological principles of Interpretative Phenomenological Analysis (IPA), theoretical frameworks were not utilized during data collection or initial analysis. Instead, the analysis remained grounded in participants’ narratives, allowing themes to emerge. Only after patterns and meanings were identified did this researcher turn to theoretical lenses, including attachment theory, self-psychology, and minority stress theory. The following chapter builds on the findings by integrating emergent themes with existing literature and the aforementioned theoretical lenses.

141 Chapter V Discussion

“It is impossible to have authentic and vulnerable relationships with people in their addiction, “we don’t have relationships; we take hostages” (Anonymous saying, n.d.).

Introduction: This study was developed from this researcher’s interest in the experiences of transgender individuals within Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). Curiosity was fueled after noticing an absence of transgender meetings. Several years ago, a transgenderfocused meeting was created but had low attendance and it was discontinued. Since then, no one has taken the initiative to start a new one.

The previous chapter introduced five participants who were given semi-structured interviews with open-ended questions. All interviews were conducted in person, face-to-face, except for the second interview with participant three, which was held via video due to a suspended driver’s license. In-person interviews allowed for “real time observations of nonverbal communication by participants that cannot be observed during telephonic and some video communications, given the point of view of the camera” (Patton, 2015). After each interview, this researcher utilized reflective journaling, taking notes of thoughts, insights, and wonderings.

Participants were encouraged to freely discuss meaning around being transgender and their experiences in AA/NA. This chapter provides a discussion of the results from the five Super- Ordinate themes that emerged: Intersection of Identity and Recovery, Safety and Acceptance, Sponsor Roulette,

142 Finding “God” and Community. In addition to the Super-Ordinate themes, associated component themes emerged. It should be noted that theoretical lenses were not initially discussed in the first three chapters of this study and prior to interviewing participants. This is consistent with Interpretative Phenomenological Analysis (IPA) methodology, which “remains open to theoretical insights, but are used post-analysis to deepen interpretation rather than drive theme development.” (Eatough & Smith, 2017, p. 195). After the specific themes emerged, this researcher decided to use theoretical frameworks such as attachment theory, self-psychology, and minority stress theory. This approach aligns with IPA’s methodological flexibility, permitting theories to inform interpretive meaning-making of the study’s participants.

Throughout this chapter, each theme is discussed in depth while weaving in the aforementioned theoretical frameworks. The final section of this chapter reflects on how these findings inform clinical social work practice and future research relating to transgender populations in recovery settings.

Theoretical Framework: Understanding the recovery experiences of transgender individuals in AA and NA requires a diverse theoretical approach. The findings that emerged from the data are discussed through the lenses of attachment theory, self-psychology, and minority stress theory in order to provide a comprehensive understanding of the lived experiences of transgender individuals in AA/NA. Together, these theories highlight how early relational patterns, the need for affirmation and supportive selfobjects, and the impact of stigma and discrimination intersect to shape recovery journeys within Twelve Step communities.

143 Building on this specific knowledge base and set of concerns, this discussion began by reflecting on what it meant to transgender individuals in AA/NA that secure attachment develops when caregivers are consistently responsive and support emotional regulation (Fonagy, 2012).

Insecure attachments include anxious attachment (fear of abandonment, need for reassurance), avoidant attachment (emotional distance, resistance to help and disorganized attachment, are often seen in cases of caregiver mental illness, addiction, or maltreatment (Mikulincer & Shaver, 2007). Attachment theory provides an understanding of how participants navigate safety, trust, and boundaries, especially within AA/NA meetings and sponsor relationships (Bowlby, 1988).

This is crucial in explaining how early childhood experiences set the stage for relationships and recovery in AA/NA. Family dynamics and attachment wounds surface during sobriety, and corrective experiences are necessary to achieve lasting recovery (Flores, 2004; Fonagy, 2012).

Early attachment experiences shape the capacity for a secure base and supportive relationships in recovery settings, while insecure attachment complicates efforts to establish safety, trust, and healthy boundaries (Schindler et al., 2005; Bowlby, 1988). Looking at attachment from this vital lens can explain challenges in a Twelve Step community.

While the previous paragraph emphasized potential challenges, Kohut (1971) defined the self as the “central structure of personality, striving for cohesion, stability, and continuity.” There is a need for selfobject functions such as mirroring, idealization and twinship in order to develop a healthy self (Kohut, 1977). The absence of these self-objects creates maladaptive coping skills such as substance use (Budge et al., 2013). AA/NA provides reparative experiences from early childhood attachment disruptions through fellowship. Budge et al., (2013) states “transgender individuals may find recovery meetings to be spaces where mirroring and twinship occur through shared identity and language.” At the same time, these opportunities for connection also present

144 challenges, creating spaces where growth and struggle occur. AA/NA reflects self-psychology in that these groups meet the needs for connection and stability of the self.

Minority Stress Theory (Meyer, 2003) offers a relevant theoretical framework for understanding how stigma, prejudice, and discrimination create an unwelcome and stressful social environment that leads to mental health disparities for marginalized individuals. This theory is particularly relevant for transgender individuals in recovery, as they may face compounding stressors related to gender identity, substance use stigma, and systemic exclusion from affirming treatment environments. The chronic stress associated with navigating these overlapping forms of marginalization can significantly impact one's ability to access and sustain recovery support systems such as AA and NA (Meyer, 2003).

Findings: Given the limited literature on the lived experiences of transgender individuals in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), this researcher was motivated to contribute to this underexplored area. As a member of AA at an LGBTQ club, this researcher had access and insight into the language, norms, and dynamics of the fellowship that was inaccessible to the general public. These are the findings of this study. 

Intersection of Identity and Recovery



Safety and Acceptance



Sponsor Roulette



Finding “God”



Community

145 Intersection of Identity and Recovery The intersection of identity and recovery theme emerged, highlighting how participants’ experiences of gender and recovery were linked to their engagement with recovery spaces. The literature states, “most recovery treatment was developed by white heterosexual males for white heterosexual males, so there is a disconnect for gender and sexual minorities” (White, 2009).

Although AA/NA preaches inclusivity, it can be difficult for transgender individuals to fully feel accepted when walking into AA and NA meetings around Houston.

Trans individuals face minority stress not only from addiction, but also from gender identity (Hendricks & Testa, 2012). All of the participants indicated their transgender identity was connected to their recovery. Hannah and Jonah explained they were unable to separate their transness from their addiction, Hannah stated, “I used because I didn’t feel like I could exist” and Jonah echoed “being trans is not a detail—it’s the context.” In conjunction, all participants suffered from early childhood trauma that led to heavy use of substances starting in early adolescence. These early injuries due to caretaker unpredictability, resulted in the participants lacking “the internalized capacity to regulate affect, a function that ideally emerges from early secure attachment” (Fonagy & Target, 2003). Flores (2004) states addiction is an attachment disorder and until substance users “surrender their insecure or dysfunctional attachment styles, they will forever remain vulnerable to all addictions.” The 2015 U.S. Transgender Survey found that transgender individuals were nearly four times more likely to use substances use at an early age compared to their cisgender peers (James et al., 2016). This was exacerbated by high rates of childhood abuse, neglect, and family rejection that is strongly associated with early onset substance use and long-term addiction (Grant et al., 2011). In order to have healthy relationships,

146 the person must be substance free and detach from drugs or alcohol so they can start to attach to sobriety and community (Flores, 2004).

Recovery can feel terrifying when your sense of self is challenged. For many substance users, the act of sobriety reveals pain and confusion about identity. From a self-psychology perspective, Kohut (1977) stated, that when identity is invalidated, selfobjects go unmet resulting in a fragmented self. Remy stated she never saw herself as a male growing up, and when she challenged gender norms from childhood, she was met with a non-empathetic response. She overidentified with her biological gender and became promiscuous with women outwardly until her transition a year and a half ago. Remy presented with authenticity, but her external grandiosity may be an unconscious attempt to seek validation from others. Kohut (1977) explained that unmet needs of mirroring and idealization in early development by caretakers fragment a sense of self. Her desire to be accepted at women’s meeting combined with her bold statements of “I’m trans, am I accepted here?” can be defined as an attempt to defend against feelings of internal vulnerabilities. This comparison of outward and inward self leads to shame and unmanaged emotions quelled by substances (Khantzian, 1997; Tangney & Dearing, 2002).

For many, embracing their gender identity becomes a vital part of their sobriety and sense of wholeness. Acceptance and healing provided a foundation required for long lasting recovery, especially in the trans community. While all individuals required this foundation for recovery, transgender individuals can often experience these needs as difficult to reach.

Safety and Acceptance

147 A central theme that emerged across participants’ narratives was the profound need for safety and acceptance. In addition, Maslow’s hierarchy of needs identifies safety as essential for survival (Maslow, 1943). All participants in this study experienced some form of childhood trauma that disrupted their ability to feel safe and develop secure attachments. Koatie Andrews shared that he never felt safe from childhood into adulthood. It wasn’t until years of therapy and sobriety that he began to recognize that not everyone in AA/NA meetings were dangerous.

Through healing, he was able to trust others, feel comfortable expressing his needs, and rely on others to meet those needs. For example, meetings that offered safety, consistency and inclusion functioned as a secure base, which allowed individuals to disclose and trust. In contrast, AA/NA mirrored a family, and enactments could occur causing relational harm and traumatization. This included verbal abuse, misgendering, or sexual harassment. This researcher had witnessed several incidents in AA where other members yell, scream, and name-call in the middle of meetings. This mirrored a dysfunctional family system that can retraumatize an individual.

For Remy, several occurrences were noted in her history that disrupted her development for a secure attachment. For example, she started to use alcohol at family gatherings and no one noticed, she was invisible. Often dismissed by family members who were steadfast in their belief of gender norms, she remembered her aunt responding to Remy’s wish for a pink object stating, “boys are blue, girls are pink.” Her caregivers were consistently unresponsive, and dismissive, constantly rejecting Remy’s emotional needs. She lacked attunement and validation from caretakers that caused her to feel unsafe and misunderstood (Tolpin,1971). These interactions were a failure of selfobject functions, undermining Remy’s developing sense of self and contributed to feelings of isolation and shame (Kohut, 1971).

148 Although Remy stated she has been openly trans for the past year and a half and she was “out and proud,” she continued to feel rejected and misgendered in some AA/NA meetings.

Unsafe spaces triggered attachment-related avoidance and anxiety. Reopening of attachment wounds almost always occurred in AA/NA because interpersonal dynamics were always at play.

Stressors such as rejection from women’s meetings were overwhelming and this can trigger past traumas (Flores, 2004; Schindler et al., 2005). This highlighted the ongoing nature of attachment and the potential for past experiences to impact current emotional well-being and sense of self.

When people feel unseen or invalidated, their self remains fragmented. Conversely, feeling safe and respected was essential mirroring that stabilizes a sense of self.

Koatie Andrews, Jonah, Hannah, and Alexia discussed “perceived rejection” from people in AA/NA when in fact, it was something they identified as “made up” within themselves. Each had mixed experiences when attending various meetings, and they generally found people be accepting whether they attended gay or straight meetings. Alexia preferred straight meetings in the suburbs and Hannah preferred NA meetings at a local community center. Koatie Andrews, Alexia, and Jonah were all in their 40s-50s and they have developed ego strength to examine perception versus reality. Hannah was in her 20s and she struggled with gender dysphoria. This incongruence often led to her distress and discomfort, challenging her sense of self (American Psychiatric Association, 2022; Bockting et al., 2016). Hannah had difficulty presenting as fully female and she was often unintentionally misgendered. She dressed in primarily black male clothes, which created misgendering. Her core sense of self was challenged by the outside world, fragmenting her sense of self (Bockting, 2014; Testa et al., 2015).

In regard to emotional safety, Koatie Andrews discussed his therapist as a mother figure.

He described feelings of love and warmth and appreciated another adult respecting him and

149 creating the first safe environment he ever experienced. There were times he felt rejected, but he was able to reach out to his therapist and receive validation that she still cared about him and she was there for support. This corrective experience shaped Koatie Andrew’s view on cisgender individuals, that not all people were like his parents. He internalized the safety he experienced changing the trajectory of repeated harmful patterns. Throughout sobriety, he was able to carry out and strengthen his relational patterns in work, AA, and community.

Sponsor Roulette Sponsor relationships within the Twelve Steps are considered the foundation of AA/NA programs. Sponsorship is a supportive and intimate relationship between a more experienced member and a newcomer to recovery. The sponsor provides trust, guidance, shares personal experience, and offers accountability. From a self-psychology lens, these relationships model a primary caregiver role and provide selfobject functions such as mirroring, idealization, and twinship (Kohut, 1977).

Koatie Andrews, Jonah, and Alexia all stated they had mixed experiences with sponsorship, including setting boundaries. Koatie Andrews had six sponsors that were a mix of gay men and straight females. Some of these sponsors provided emotional support and some were rigid, leading to a changes of sponsors. Koatie Andrews discussed his relationship with his first sponsor as “affirming and providing emotional support.” Through consistent emotional attunement, the sponsor provided a mirroring selfobject function. The sponsor validated his experiences that helped stabilize his fragmented sense of sense in early recovery (Kohut, 1971; Wolf, 1988). The new selfobject (sponsor) replaced the alcohol, leading to a reparative caregiving experience for the sponsee. Being held in sobriety mirrored being held by your

150 mother for the first time. It is a common occurrence in AA/NA meetings to hug each other even if you meet someone for the first time. This can sometimes lead to an activation of a past trauma or a sense of holding. In addition, “newcomer meetings” are a place where the newly sober alcoholic/addict is rallied around after the meeting ends. Sober members physically circle around the person as a family.

The atmosphere of the meetings, whether accepting or rejecting, can integrate or fragment the sense of self (Flores, 2004). Alexia and Koatie Andrews stated spirituality and religious beliefs of sponsors, both in AA and NA, played a significant role in how the steps were approached. Some sponsors emphasized the role of God or spirituality, which influenced the journey through the programs. Alexia experienced trust issues with her sponsors, which made it difficult for her to fully engage in the Twelve Steps, particularly with the Fourth Step (making a searching and fearless moral inventory of oneself). As a result, Alexia did not have a sponsor but used a trusted “mentor” in the community to discuss trans issues in recovery. She was cognizant of reopening old attachment wounds from childhood and chose to protect her sense of self.

Jonah had worked with several sponsors, starting with a male but eventually switched to a female sponsor because he felt safer. He was highly intelligent and he stated he needed someone with an open mind. He had found value in having a sponsor who challenged him and supported his growth. His current sponsor had over 35 years of sobriety and he idealized her sobriety. This selfobject function helped him strive for what she represented, a mirroring of healing and a life worth living. For Jonah, the purpose of sponsorship was about identifying with someone who understands his trans identity in a recovery space. Magura (2007) stated “idealization, whether the sponsor, the group, higher power, is in evidence when members tell of feeling bolstered by identification with some greater source of strength and wisdom (p. 113).”

151 Sponsorship can be challenging for trans individuals, and they often work with multiple sponsors over the course of sobriety. Finding the right fit can be frustrating and rewarding, contributing to a rich recovery experience.

Finding “God” Finding God emerged as a significant part of all participants’ recovery journeys, highlighting the importance of idealized selfobjects. Spirituality appeared to play a critical role in AA/NA allowing for a sense of belonging. All participants grew up with religious beliefs, however, some initially felt uncomfortable with the religious aspects of AA/NA. Alexia stated she was “wary” of turning her life and her will over to a God she felt had hated her growing up.

The church I grew up in was very racist, homophobic. They didn't shy back from using words in the pulpit. And I really thought that if I came out, I was destined for hell. So, it scared me. So, it distorted my view of a higher power for a long time because I was, how can there be a God who hates me?

Self-psychology suggests that individuals may idealize a higher power or God, seeing them as all powerful, which helps stabilize a fragmented sense of self (Kohut, 1971). However, when this idealized image of God is ruined by experiences of rejection, it can lead to a spiritual crisis or loss of sense of self. For instance, Hannah struggled with the idea of turning her will over to a God she believes might hate her for being transgender, contributing to her gender dysphoria. When a child’s emerging gender identity is not affirmed by caregivers and society, the individual may experience alienation from their authentic self––leading to fragmentation, shame, and inner conflict, which are core features of gender dysphoria (Ehrensaft, 2011; Lev, 2004). In contrast, Alexia was able to separate spirituality from traditional religious teachings,

152 which helped her connect with AA in a way that felt more personal. She was able to “take what I needed and leave the rest behind.” This common statement in AA/NA, allowed for the individual to internalize parts of the program that helped and discarded parts that were not helpful. These types of responses for trans individuals with minority stress often leads to deficits in selfobject experiences; they grow up with a lack of idealizing figures or positive mirroring (Kohut, 1971; Flanagan, 2011; Meyer, 2003). The need for integrative responses suggest these deficits have always been present, and the responses are geared toward repair rather than the cause of the deficits. Jonah shared that believing in something bigger gave him a sense of peace and direction. God as an idealizing selfobject function provides a sense of safety, coherence, and strength that can be internalized during the vulnerable early phases of recovery (Kohut, 1977).

He grew up in a religious household, and his faith morphed over time, but he never fully abandoned God. Finding or redefining God, and working the Twelve Steps, gave participants a sense of comfort and belonging that felt genuine. The search for meaning and connection with a higher power could offer comfort and in turn, a positive recovery experience.

Community All participants indicated community inside and outside of AA/NA was important for recovery such as friends, family, sponsors, peers and work colleagues. Alexia found it difficult to locate an AA group where she felt fully accepted, but once she did, she felt safe and now considers the meeting her home group. Kelly (2020) states “community support plays a critical role in fostering long-term recovery by offering connection, belonging, and shared purpose” (p.

3). For transgender participants, finding genuine community within AA and NA can be both

153 empowering and challenging. The purpose of AA/NA was to create a safe, comfortable and soothing "holding environment,” a function the group provided collectively. An example of “shared purpose” included engaging in simple tasks such as making coffee for meetings, taking out the trash, and giving rides to newcomers (Alcoholics Anonymous World Services, 2001; Narcotics Anonymous World Services, 2016). This “service work” fostered a sense of purpose and responsibility that were not modeled to participants in childhood but are taught in adulthood.

Remy stated she has participated in leadership roles within meetings and groups. This involvement had not only supported her own recovery, but also contributed to the AA/NA community.

Mirroring occurs in groups and community, looking to elders to help guide sobriety. A popular AA phrase, “if you have decided you want what we have and are willing to go to any lengths to get it—then you are ready to take certain steps” (Alcoholics Anonymous, 2001, p. 58).

In simple terms, do what we are doing. As children, Koatie Andrews and Remy were left to their own devices a majority of the time, looking to alcohol or drugs to fulfill selfobject needs they were missing from early caretaker experiences. As teens, they reported feeling alone and isolated, trying to fit in, often finding themselves socializing with addicts. Their heavy substance use developmentally arrested them at an early age. Both lacked problem solving skills - looking to substances to answer to life’s challenges. While many of these challenges resembled similar recovery experiences, the specific ways they are compounded by stigma and exclusion, underscored the need for specialized understanding and affirming counseling.

Embedding into an AA community does not only require attending meetings and seeking sponsorship, but other service related functions. During Thanksgiving and Christmas holidays, meals are prepared for community enjoyment. Other activities such as plays, drag shows,

154 fundraising and birthday are celebrated as a group. The notion of “family of choice” is heavily communicated to those who have been excommunicated from biological families due to their LGBTQ identity. (Weston, 1991). There are additional activities such as AA retreats and worldwide conferences focusing on recovery workshops and speaker meetings creating fellowship, belonging and connection. Most recently, AA sponsored the yearly International Convention in Vancouver, Canada and NA sponsored the International Convention in Washington, DC. One barrier that may prevent fully integrating into a recovery community can be attributed to minority stress. Disparities experienced by individuals who belong to marginalized or stigmatized groups, such as sexual and gender minorities can create increased prejudice and social stress that led to them leaving an AA/NA community (Myer & Frost, 2013).

This study highlights, the participants’ strength and resiliency, despite exposure to early childhood abuse and neglect, substance abuse, workplace harassment, bullying, and marginalization. These stories illustrate how internal and external stressors are managed through sustained emotional and physical regulation, despite chronic minority stress. Participants displayed cognitive flexibility by attending meetings, obtaining a sponsor, and working the Twelve Steps of AA/NA. Changing past behaviors require a level of ego strength, which participants internalize through connection and meaning making of their lived experiences. The participants achieve sobriety as they navigated work family, and for some, even transitioning.

Limitations

155 Within qualitative research, there are always limitations to a study. One limitation in this study was this researcher is not a member of the transgender community, and the position as an outsider could have affected participants’ comfort or willingness to share. However, this did not emerge as a significant issue, as all participants reported feeling comfortable and were engaged throughout the process. This researcher was also aware this might unintentionally create fear or power dynamics, but participants expressed gratitude for being included in the study.

Subjectivity in Interpretative Phenomenological Analysis (IPA) means that my interpretations are shaped by my own experiences and background, which can introduce bias.

Different researchers may interpret the same data differently. To address this, reflexive practices such as bracketing, memoing, and peer debriefing were implemented. The nature of IPA research is also time and resource intensive (Smith & Osborn, 2019). Managing interviews and analysis within a set time frame (for example, conducting five to six interviews over six to eight weeks) helped minimize participant dropout and loss of data, but still presented scheduling challenges. If there is too much time in between interviews, there is a risk of forgetting the data or participants dropping out.

An additional limitation of this study is that it excluded transgender individuals with long-term sobriety who no longer attend AA or NA meetings, due to criteria requiring attendance at least biweekly. Three transgender individuals with sustained recovery wished to participate, but reported no longer attending AA/NA. Their perspectives could have revealed crucial information of AA/NA group culture and added additional information on engagement and retention among transgender people, highlighting the ongoing barriers that may drive individuals away from peer support.

156 Another limitation is the small sample size. Although small samples are a strength in Interpretative Phenomenological Analysis (IPA), they also limit the generalizability of findings to broader populations (Smith, Flowers, & Larkin, 2009).

Finally, unlike quantitative research, this qualitative study does not provide statistical data to prove or disprove a hypothesis (Tuffor, 2017). Instead, it offers in-depth insight into individual lived experiences and captures the meaning and richness within the human experience.

Researcher Assumptions and Reflexivity At the outset of this study, this researcher had several assumptions shaped by both clinical training and personal experiences working in addiction and recovery settings. It was assumed that transgender individuals who attend AA or NA would describe their experiences primarily through a lens of marginalization, focusing on exclusion or harm within these groups.

Although the participants experiences were not all positive, they all stayed connected to AA/NA despite challenges. All participants expressed gratitude for the structure and support found in AA/NA, acknowledging these programs are the foundation of their way of life today. Rather than rejecting the program in times of struggle, many described adaptive strategies for staying engaged such as looking to other members and to their sponsor for guidance and support. This challenged my initial belief that transgender individuals primarily experience AA/NA as alienating due to poorly behaved sponsors and religiosity. In summation, AA/NA has been the foundation for all participants in sobriety.

Implications for Clinical Practice

157 This study is important because transgender individuals often encounter unique barriers when seeking help, such as discrimination, a lack of knowledgeable providers, and unsafe or inappropriate referrals. Many clinicians do not fully understand the needs of transgender clients, particularly regarding substance use treatment and recovery groups like AA or NA. By exploring these challenges, this study aims to raise awareness and improve clinical practices, ultimately helping transgender people receive safer, more effective, and affirming care.

Clinical social workers and other mental health professionals are employed across a range of settings. The quality of training varies across MSW programs, clinical supervision, and ongoing educational opportunities. Remaining current with emerging research and maintaining high ethical standards is essential to professional practice. Ongoing professional development enables LCSWs to expand their expertise and deliver high-quality, evidence-based care to diverse and marginalized populations. Continuing education is mandated by state licensing boards for licensure renewal, with required coursework in areas such as cultural competence, human trafficking, and suicidality, ensuring effective and ethical clinical practice. There is an absence in gender identity and substance abuse education specifically AA/NA. Recommendations that would be helpful for social workers moving forward to meet the needs of adult transgender individuals in AA/NA suggest: 1. Require MSW programs to include topics on substance abuse intervention and special populations, including transgender individuals.

2. Educate social workers to use inclusive language (ongoing CEU’s) and bring awareness to minority stress including physical assaults and violence.

3. Display the trans flag within agencies that suggest a safe place.

158 4. Have a designated list of vetted LGBTQ referrals for social services and maintain the list yearly.

5. Promote identity affirming care across all treatment settings 6. Advocate for policy reform and inclusivity.

Future Research There is a need for expertise in transgender issues in the social work profession.

Reaching out to professional transgender associations such as WPATH to gain further education is available and recommended. Future research should include the following: 1. Include participants who no longer attend AA/NA. 2. Expand research to include other recovery programs such as SMART Recovery, Refuge Recovery, or other peer based programs.

3. Expand research to include harm reduction models.

4. A mixed method study would be helpful in identifying additional information such as biopsychosocial problems.

5. Including the community, peers, and social workers in future research would help gain additional perspectives 6. Expand research to larger geographical areas in the United States.

7. Any clinician who actively and publicly shames transgender individuals should be disciplined by the board, including revocation of license.

8. Include minors in a study to identify early intervention strategies to prevent marginalization.

159

Conclusion This study explores the lived experiences of transgender individuals participating in AA/NA, offering insights into how gender identity intersects with recovery in traditional peersupport environments. Each participant's journey was emotional, and common themes emerged around patriarchal language, spiritual belonging, visibility, and authenticity. This research contributes to sparse literature that highlights the value of addressing the largest peer-based recovery programs in the world, along with addressing the needs of transgender individuals. As the field of social work emerges, this study serves as a call to action for social workers, healthcare professionals, and AA/NA to reevaluate how they meet the needs of transgender individuals. With the changing landscape affecting transgender reversal of rights, such as gender markers changes on driver’s licenses, the social work community more than ever, can benefit from additional training.

Many clinical social workers are taught to diagnose, treat, and prevent mental, emotional, and behavioral disorders in various practice settings. As a therapist, people come willingly to address their problems, which becomes the main focus of treatment. When the strength based perspective is lost in the room, this can reinforce marginalization by diminishing the capacity for recovery in oppressive environments. This affects agency, resilience and psychological growth as required in the program of AA/NA. Throughout these narratives, this researcher approached participants’ stories from the lens of the deficit model, focusing on risk factors, problems, and maladaptive coping skills. Over time, it became evident this conceptualization did not fully represent the participants’ meaning making and experiences. For example, Jonah’s experience of a hate crime left him with cognitive

160 and physical impairments, was viewed from a trauma lens. Although viewed as traumatic, Jonah’s resilience gave him the ego strength required to graduate with a master’s degree from Harvard. Focusing on chronic individual minority stress as “the problem”, minimizes ongoing systematic failures that creates true marginalization. This study is about identity, belonging, and connection. Hopefully, the insights offered in this study will inspire future research, enhance clinical training, and shift professional and peer-based recovery systems.

For transgender individuals, physical and emotional safety are foundational to achieving and sustained sobriety. Without safety, Recovery is impossible. This researcher approach the interview as a relational space in which prior experiences of rupture may shape participants expectation of being seen, heard or judge. Focusing on chronic individual minority stress as “the problem”, minimizes ongoing systematic failures that creates true marginalization. This study is about identity, belonging, and connection. Hopefully, the insights offered in this study will inspire future research, enhance clinical training, and shift professional and peer-based recovery systems.

161

APPENDIX A

162

163

164 Initial Screening and Script

"Hello, my name is Andrea Moorer and ____________ gave me your number. Did they tell you I would be calling?

If yes, can you tell me if English is your first language. If yes, proceed to “wonderful, is this a good time to talk?”

If no, he did not tell me: “I was hoping he would. I am in the program, and I was hoping you could help me out with some research I am conducting on the lived experiences of transgender individuals in AA/NA.” If yes or no: I am conducting my dissertation for the completion of a PhD in social work.” First and foremost, I am an ally of the LGBT community and I do not identify as transgender. Can we continue this conversation?

If no: “Thank you for your time, Goodbye.”

If we proceed after “yes”, the following will be stated.

I am not only a therapist but a member of AA and a friend of ___________. I attended Lambda for many years, and I am in recovery. Everything we talk about is confidential and protected by HIPAA. I want to know how it has been for you as a transgender man/woman in AA/NA. Does this sound like something you would want to participate in?

If yes, then we proceed with semi structured interview questions.

165

Interview Questions

1.Can you tell me what it is like to be in a Twelve Step program of recovery, and do you connect your experience to your transgender status?

2. Can you tell me about your history with substances?

3. Have you been in treatment before or/and have attended any Twelve Steps groups?

4. Have you ever been to AA/NA? How do you feel when attending an AA/NA meeting?

5. Do you have a sponsor, and have you worked on any of the Twelve Steps?

6. How do you feel about the heavy religious component of AA/NA? Why or why not?

7. Have you ever felt unwelcome by the LGB population in AA/NA and how did you handle it?

8. What does AA/NA need to do to better serve the transgender population?

166 Leave box empty - For office use only

DO NOT DELETE BOX

Institute for Clinical Social Work

Research Information and Consent for Participation is Social Behavioral Research

I,_____________________________________, acting for myself, agree to take part in the research entitled “Transgender people’s lived experience in AA/NA Twelve Step programs in Southern Texas”.

This work will be carried out by Andrea Moorer, LCSW-S, LCDC under the supervision of John Ridings, Ph.D. This work is being conducted under the auspices of the Institute for Clinical Social Work; At St. Augustine College, 1345 W. Argyle St., Chicago, IL 60640; (773)935-6500.

Purpose The purpose of this study is to understand the meaning transgender individuals make of their lived experience in Twelve Step substance recovery programs, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) in Houston, Texas. This researcher wants to address the experiences of transgender people during the process of recovery from substance use disorders, while exploring how transgender individuals are treated in heterosexual AA/NA groups versus LGBTQ groups. This study attempts to deepen the understanding of what it is like to be transgender in a Twelve Step program that relies heavily on God and spirituality. The study results will be used to create dialogue and contribute to the sparse research regarding the substance use among transgender individuals and what barriers need to be addressed to feel safe while attending AA/NA. In addition, this study will help mental health professionals understand a marginalized population that is often misunderstood.

Procedures used in the study and duration As soon as the first interview is scheduled, you will receive a demographic study to complete and return to this researcher. This demographic information will come from a confidential patient portal called Simple Practice. There will be two semi structured interviews that are required.

Each will last approximately 60-90 minutes at a confidential location to be determined. Each interview will be audio recorded and transcribed. Any recordings will be destroyed after the

167 completion of the research and any data will be password protected. You will receive a $20.00 Gift card at the completion of each interview, total $40.00.

Benefits There are potential benefits for participation in this study. Some benefits: 1) contribute to the research 2), address large gaps in research within the trans population, 3) may increase awareness and understanding of a marginalized population, 4) This research could give a voice to the trans population, 5) may increase understanding of Twelve Step programs such as AA/NA, 5) help mental health providers better understand what programs are appropriate when referrals are made, and 6) teach appropriate transgender and substance use language to providers.

Costs There are costs associated with travel such as gas, bus fare, light rail fare, uber, Lyft, and cab expenses. Other costs are travel time and time spent for interviews throughout the research. This researcher will work to reduce your time and travel if possible. For example, meeting in a mutually agreed upon location where you live.

Possible Risks and/or Side Effects There are risks associated with your participation in this study. One risk is physical safety from potential violence if gender is questioned or made public. Although every step will be addressed to maintain confidentiality and anonymity, there is always a chance someone may discover you are trans and/or attend AA/NA. There is a risk of verbal attacks from others, discrimination, increased stress, anxiety and depression. Some trauma may also be activated. If you start to have discomfort and need mental health services, this researcher will provide a referral to three therapists specializing in transgender issues. At any time, you have the right to refuse participation or withdraw from the study. If needed, this researcher will make a referral for you for ongoing support if it’s warranted.

Privacy and Confidentiality Privacy with data will be de-identified such as using fictitious names or codes and excluding identifying data such as ages, address, email or phone numbers. This researcher has an ethical duty of confidentiality to protect information from unauthorized access, use, disclosure, modification, loss or theft” this researcher will securely store and manage password protected data to protect participants' information. This includes safeguarding digital and physical records by enclosing documents in a locked safe and following IRB regulations.

Subject Assurances By signing this consent form, you agree to take part in this study. You have not given up any of your rights or released this institution from responsibility for carelessness.

You may revoke this consent and refuse to continue in this study at any time without penalty or loss of benefits. Your relationship with the staff of ICSW will not be affected in any way, now or in the future, if you refuse to take part, or if you begin the study and then withdraw.

168 If you have any questions about the research methods, you can contact Andrea Moorer at 713205-8117/ andreamoorerlcsw@gmail.com. your phone number/email address) or (John Ridings, Ph.D. at dissertation chair’s name) at Jridings@icsw.edu.

If you have any questions about your rights as a research subject, you may contact Dr. John Ridings, Chair of Institutional Review Board; the Institute for Clinical Social Work; At St. Augustine College, 1345 W. Argyle St., Chicago, IL 60640; (773)935-6500.; irbchair@icsw.edu.

Signatures For the Participant I have read this consent form and I agree to take part in this study as it is explained in this consent form: Participant Name (please print): ___________________________________ Participant Signature:__________________________________________ Date: _____________ 1. Would you like a summary of the results of this study?

Yes: ____ No: ____ For the Primary Researcher I certify that this researcher has explained the research to _________________________ and believe that they understand and that they have agreed to participate freely. This researcher agrees to answer any additional questions when they arise during the research or afterward.

Researcher Name (please print): ___________________________________ Researcher Signature:__________________________________________ Date: _____________

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