A Qualitative Study of Transgender Women and Cisgender Men Living Together in Two Recovery Homes

Oxford Houses (OH) are a peer-run sober living homes that are the largest network of recovery homes with over 2,000 in the US. They are self-run without any professional staff. The current study focused on better understanding the facilitators and barriers to OH entry for transgender individuals. The study explored ways in which transgender people found entry into the OHs and the experiences of transgender residents in OHs in comparison to cisgender residents. We conducted semi-structured interviews of 7 transgender women and 7 cisgender men, using grounded theory methodology. Participants reported fear and apprehensions upon entry into OH due to participants initially feeling that OHs may be similar to past settings that were not sensitive to their needs and gender identity. However, the participants reported diminished fear and comfort shortly after transitioning into OHs. Though discrimination was brought up, it appears that participants could work through minor issues by means of discussion and boundary setting. Both groups of participants followed similar paths in addiction and recovery. Salient themes including familial connections within the house are discussed.


Introduction
Research on the effectiveness of substance abuse recovery programs for transgender individuals is scarce [1,2]. The term transgender is used to describe individuals whose gender with which they identify differs from the sex to which they were assigned at birth, whereas the cisgender term is used to describe individuals whose gender identity aligns with the sex to which they were assigned at birth. Substance use is a health concern for transgender individuals across various regions of the US [3][4][5][6][7][8][9][10]. Service provider insensitivity may serve as barriers to transgender people seeking service and provision for their addictions [11]. Among the few studies that have focused on transgender men and women with substance addictions [12], accessibility to sensitive substance use treatment is often difficult to achieve [13].
Specific research highlighting transgender individual's experiences in recovery settings is limited, but the efforts of Lyons, et al. [2] have uncovered issues related to stigma and inclusivity that transgender individuals in residential recovery settings may experience. This is consistent with research on transgender microaggressions that occur on both systematic and individual levels, in which transgender individuals report increased levels of vigilance within environments that are discriminatory. Microaggressions are seemingly commonplace instances of discrimination in which negative sentiments are communicated toward oppressed groups of people through for transgender residents from their cisgender roommates, how they are similar, and what intergroup dynamics occur in the homes, and what changes in social support network demographics occur after living with diverse groups. In summary, this preliminary study explored the experiences of transgender residents in comparison to cisgender residents living in OHs.

Method Sampling and recruitment
The research team established a purposive sample of transgender and cisgender residents at two Hawaiian OHs. These OHs were chosen because these were the only OH settings where there is a specific history of transgender and cisgender residents living together. These settings are unique because OHs are separated based on sex assigned at birth. An OH recruiter connected the research team with a resident of one of these OHs. The method of snowball sampling was used to recruit additional interviewees based on the recommendations of participants at the time of the interview. Participants were recruited in 2011 and 2012 via telephone and two initial letters sent to each house by the two DePaul based research assistants to explain the purpose of the interviews. Interviews were open to all individuals living in the OH. As an incentive for participating, the two participating OHs were given coffee makers worth $60. IRB approval was obtained from DePaul University.

Data collection
Participants were interviewed on a one-by-one basis by the research assistants following a semi-structured interview guide based on the research questions adapted from Alvarez, et al. [23] protocol for interviews conducted with Latino/a residents. The DePaul research team field tested a brief version of the protocol with a cisgender female and a homosexual, African American male from the Midwest who have resided in OHs. Based on these two pilot interviews, our final questions for the current study included: What was your support network like before you came to OH? What were your thoughts and feelings as you decided to join the house? What was your initial experience in OH like? How did you feel about transgender/cisgender individuals before you came to OH? How do you feel about transgender/ cisgender individuals now? What do you think are some of the reasons why transgender individuals may or may not be coming to OH?
Participants were explained the nature of the research, how the research would be used, and given informed consent at the beginning of each interview. Before the interview took place, participants were informed of the purpose of the research, how long the interview verbal, behavioral, or environmental cues [14]. Microaggressions for transgender individuals continue to consistently occur within health care settings, and often times transgender people seeking gender-affirming health care are met with further discrimination [15,16]. One study described microaggressions experienced by transgender people from police officers, health care workers and others, and methods of coping with microaggressions. The transgender participants often felt anger and betrayed, and this resulted in them being vigilant and cautious of their surroundings.
In the context of addiction recovery, many transgender individuals seek recovery programs after being incarcerated, and additional community-based supports need to be identified [17]. One potential community-based support is a network of more than 2,000 mutual-help residential recovery homes called Oxford House (OH). OHs are self-sufficient, democratically-run recovery homes, in which residents are responsible for management and housekeeping, and all residents must maintain sobriety and pay their share of house expenses. Past research [18,19] showing the effectiveness of OH has allowed the organization to be listed on The Substance Abuse and Mental Health Services Administrations National Registry of Evidence-based Programs and Practices [20].
OH research has found that people who live in an OH are less likely to relapse, be incarcerated, and be without employment as compared to individuals that are not provided OHs [21]. Recovering people from various backgrounds report positive experiences in OH, including: residents who live with both mental illness and substance abuse, Caucasians, African Americans, and both biological sexes [21,22]. In addition to studies on the effectiveness of OH, other research has explored mechanisms through which recovery is gained in these settings [19]. In addition, research has been conducted on Latino/a experiences in OH [23], Americans Indians in OH [24], and hearing impaired OH residents [22]. Still, less is known about individuals whose gender identities do not align with the sex they were assigned at birth in the OH experience.
The current study explored issues related to facilitators and barriers of entry to OH for transgender individuals, including: ways in which transgender people found entry into the OH; fears of transgender individuals entering OH; and whether discrimination occurs in OH directed toward transgender individuals. As such, the goals of this study are to understand the transgender resident's lived experiences by better understanding the barriers which may prevent access to recovery resources and to understand the role of OHs in assisting transgender individuals through their recovery. It is still unclear how the OH experience differs should take, what they would be asked if they agreed to the study, the risk, the benefits, and how their confidentiality would be protected. Participants were informed that they could discontinue the research at any time. The interviews lasted anywhere from an hour to two hours in length. All interviews were taped, recorded in English, and transcribed verbatim by members of the research team and undergraduate research assistants. All names of people and institutions involved were redacted to protect the identity of people living in the OHs. The analysis was conducted using methods described in Odo and Hawelu [25] in order to manage the analysis of the interview transcripts.

Data analysis
This study used a grounded theory methodology, which is a way to develop a model that emerges from the participant's experience and lived lives. Since our goal was to understand the significance among the participant's entries and OH experiences, analysis followed a more constructivist approach [26], which allows the process to unfold from the collection and interpretation of data, and the model to be directed and developed by the mutual experience of the participants and researchers.
Through an analysis of specific participant responses to the research questions, we developed a code book from emerging themes salient in the data. We initially began coding with a line-by-line analysis of the participants experiences in the OHs, and then we began naming concepts [26] based on the participants' responses, which then led to relationships between categories that emerged from the data. Next, researchers individually coded the responses of the participants using grounded theory techniques described above. We came to code book consensus by discussing the differences of our interpretation of the data, thus reaching common ground. The process of reaching agreement took using reflexivity [27] to understand our own experiences and the participants through becoming close to the data and doing our best to step outside our biases. Reflexivity was done by keeping written notes, gathering input from our team, and getting acquainted with the nuances of the participants' response style.

Results
The final sample included 7 transgender women and 7 cisgender men. The average age of the transgender women was 41.4, and the average age of the cisgender men was 39.0. Four of the transgender women had life partners and three were single. Likewise, 1 cisgender man had a life partner, 1 was divorced, 1 was separated, and 4 were single. Four of the transgender women had High School diploma/GED; 1 had a vocational degree; and 2 did not have a High School/GED diploma. Five of the cisgender men had a High School diploma/GED, 1 had an Associate's degree, and 1 had a Bachelor's degree. Three transgender women grew up in rural areas, 2 in suburban, and 2 in urban areas, and the distribution of where the cisgender men grew up was identical to that of the transgender women. The average stay of all participants in OH was approximately 12 months.

How do transgender individuals find entry into OH?
Participants reported being referred to OH. However, the source of referral was varied over our pool of participants; the referral most salient in our study was from drug treatment. Drug treatment in this study can be mandated (when individual is ordered by a collateral) or volunteer treatment (when individual goes on own will), but none-the-less their knowledge and influence to join OH came while in treatment for substance abuse. The following quotes from residents illustrate this point: When I was introduced in the Oxford Houses, I was in the drug treatment program.
Oxford House is very popular with some of the drug treatment programs because they feel comfortable that's why, and that's they wanna come and live here and I have a lot of phones calls from the ATS program, ATS is a Salvation Army program for um people coming out of jail or prison and they go inside there, or the people who want to get off drugs, they go get clean from over there and after they finish the program, they have to go look for housing, but they still have to report to the program, they have classes like twice a week, some of them once a week because they're already transitioning out of society from the program. That program is a pretty good program and you know the Oxford Houses, they deal with the Oxford Houses a lot as far as finding a place for clients that are transitioning out of the program.
I came through my treatment center.
[House name] is best house, all the programs, the drug treatment programs here in Hawaii, know this house has T-girls in it, a lot of the boys that transition out of the drug treatment program, you know they suggest to come to this house and live here.

Drug court
Around half of the participants indicated hearing about OH while involved with drug court; some reported drug court as a direct referral. Participants also talked about drug court as being related to their probation or parole status. This referral source typically represents mandated treatment. The following quotes from residents illustrate this referral: Um, actually, I was on probation. I was living at home with my mom, and, um, they terminated me from that we must, we needed to get into those houses or else we have to stay in the YMCA, I didn't wanna live in a YMCA. I wanted to live more in a house setting.
[The recruiter] goes to the treatment programs and recruits people when they come out of jail or some of them are finishing up treatment. He has a list of houses that are open bed space and the clients has to make, they have to go and call and find out if there's an opening, if they can get into that house, if they can get into and have an interview with the house, in order to get into that certain house.

What barriers do transgender individuals have as they try to access OH?
Another revealed theme was barriers that impede transgender people from moving into OH. Even though individuals were referred, they reported a belief that the OH may be similar to previous experiences at institutions that were not best suited for their needs. The following quote from a transgender resident illustrates the participant's experience: I think that a t girl, you know, really, doesn't come from a place where they're accepted, and the only place where they find acceptance is on the streets, unfortunately. And, you know, they start doing drugs, and you just get caught up in that lifestyle that you're out their all the time. And, they don't, the sad thing is they don't know anything better than that because that's where they feel accepted.

Fears and apprehension
All participants reported fears or apprehension while attempting to make the transition into OH. Individuals talked about being scared of living in a new environment compared to the way they used to live in active addiction. Quotes from residents illustrate this theme: Before I went in it (Oxford House) I was kind of scared because I was only twenty at that time.
I was kinda skeptical at the beginning because um, I never lived with drug addicts or alcoholics.
Um, some of them don't want to come into recovery, they're afraid.
Participants' reported being scared of living with strangers and the change of living apart from their family. For example, transgender residents stated: Cause I know, like, for the first time, of course, it's kind of scary, cause, you know, you don't know what's gonna happen or you don't know how they're gonna treat you and stuff.
I was scared shitless. I had no idea what it was going to be like living in a house full of total strangers. probation. They put me into drug court, and drug court placed me in this Oxford House.
I was in drug court back in 2000, and they referred me to a house. And because of that I went into the Oxford House, and then I also had a couple of relapses. And then I had to leave. And then I just figured out that I always come back here because I'm off of probation, and I don't need to be here. I'm not here by court, or I'm not here by anything.
I'm here on my own will, and it's because I like the comradery that we have here. You know, I like the support.
I'm on parole, and I definitely don't want to go back to my old ways or live in the street.

Transition from prison or jail
Participants in this study also indicated that they found OH through referral sources while incarcerated. Participants talked about the need for sober housing transitioning out from prison. They reported how OH has provided an environment that has allowed for a new start. The following quotes from transgender residents help speak to this transition process: A lot of t girls that come out of jail and go into drug treatment programs, they go to a house where the t girls live, they suggest that, or the counselors, or case managers suggested they come to this house because it's well known, with all the probation officers, paroling office, the drug treatment programs, their counselors, the case managers, it's well known.
There were girls that were coming out of jail, so I told them like, you know, just try and get in because it's the good, the kind sobriety and, you know. It's cheap. You can just do what you're doing. You don't have to worry about where you're gonna stay and stuff like that. Just abide by the rules. If you guys want a better life then stop using. Come to an Oxford House.
I needed a place because I'm transitioning out from prison.

OH recruiter
A common theme that emerged from our study was the involvement of the OH recruiter. Recruiters work under a grant from the state to recruit residents into OH. Along with recruiting, they have other responsibilities such as keeping track of how many residents move in or out of OH and for how long they stay. They also keep track of demographics such as ethnicity and age. Recruiters help get new houses started and aid in finding rental properties for OH residents. The following quotes from residents illustrate this theme: They told me these houses were given by [recruiter] and Houses and (cuts out) thing is when we do go to, like, um, chapter meetings, you know, they do kind of segregate.
Many of the participants talked about a barrier that exists between transgender individuals and the access to resources. When asked what was most positive in their in their transition experience to OH, many mentioned that it addressed this barrier. Transgender participants indicated that most OH residents harbored a spirit of inclusiveness and hospitality despite gender identity differences. Some transgender residents spoke in light of the economical utility that OH provided; and indicated that OH allowed them to have a comfortable and affordable place to live with roommates with similar goals such as being sober, getting a job, and going to college. This speaks to the concerns that transgender individuals have regarding access to resources. Here are some of the voices from our transgender participants reflecting how OH has helped: It's easy that I live here because the rent is cheaper than getting a place on your own or having to move in with roommates that are kind of sketchy.
While in the Oxford House I found a job. Now I don't need a financial support cause I'm able to take care of myself as far as food, groceries, etc. And getting a job has enabled me to continue on with my therapist, through my psychologist, and I haven't relied on very many people like in the past where I would've before because now I know the avenues to take, I know what roads to take and I don't need to rely on anybody. I'm pretty much self-sufficient.

OH rules
Participants also reported fear about adjusting to the rules of OH. Structure is a component of the day-in and day-out life of OH residents. They talked about being apprehensive about the structure that OH provided which required that residents stay sober, find a job, contribute to chores, and pay their fair share of rent; all of which can be intimidating rules for new residents. Paradoxically, participants indicated that after a week or two of becoming residents, they adapted to the rules and became grateful for the structure OH provided, as illustrated by the following quotes from residents. Additionally, al-I was kinda scared at first because, um, and me coming out of a family home and stuff and being put into jail and then coming out of jail and then having to go into a program, it was just, like, overwhelming, but I got over it.

Differences
Another concern discussed by transgender participants was the fear of gender "differences" in regards to having roommates that identified as cisgender, who may not understand their gender expression. The following quotes from transgender residents illustrate these concerns: Well, when I, when I found out that I had to come to the clean and sober house my initial thoughts were: I don't want to be here, I want to be at home with my family, kinda scared, didn't know what to expect, I didn't want to live in a house with thirteen other guys, um, yeah it was just a little, in the beginning it was a little overwhelming.
I was scared to come because, you know, living in a house full of men and being the way that I was, you know, it's kind of different.

Discrimination
Participants reported fear of being discriminated against in the OH based upon past experiences while incarcerated or while in other rehabilitative services such as substance abuse treatment programs. The following quote from a transgender resident illustrates this concern: Well, my experiences with living with straight guys would only be when I would be locked up in jail. Because you know, I used to get hit on all the time, I used to, you know, just, so that in itself is a mind trip. So, just, (cut out) of that, and just that playing that over and over in my head in a house setting where there are no guards, where there are no safe place for me to go it just kind of messed with me a little bit.
Transgender residents reported subtle discrimination in regards to their initial entry into OH, mostly in the form of micro-aggressions [14] when cisgender residents would refer to them as male. The following quotes from transgender residents illustrate these concerns: Um, the part that, you know, you're, you're, kinda like, forced to live with all these people and then you have to abide by the rules, and then, you know, you have some, sometimes there was kinda like, some people, like, in my first house were kinda homophobic I guess you can say. They wasn't OK with, um, transgenders.
I have, um, friends that are in drug court, and, you know, they're also in clean and sober, I mean, Oxford I knew I needed help and…so I tried to get myself into a treatment center.

Connectedness and helping others:
Transgender residents seemed to benefit from community connectedness within the transgender community in terms of connectedness and mental health. Mentoring/helping and experiencing mutual acceptance others was mentioned by several transgender individuals: We're all like a secondary family… A cisgender individual said: They are just like my sisters.

Discussion
Professional and mutual-help recovery programs exist to facilitate and maintain sobriety for those in recovery from these addictions, including the mutual-help recovery housing system of OH. However, little is known about minority cultures in these homes or even more broadly of transgender individuals in recovery from psychoactive substances. The current study provided a grounded theory inquiry of transgender and cisgender individuals living together in OH. The research examined the initial experiences of these individuals in OH, their ongoing experiences, their intergroup dynamics, and changes in the composition of their social support networks as a function of OH residency. Several emerging themes examined included their experience of entry into OH, fears and apprehensions, barriers, meeting basic needs and social support before and after entering OH though OH explicitly does not let members of opposite sexes assigned at birth live together, transgender residents feel comfortable referring to their home as co-ed: I just obey the rules. You know, do your chore, all this kind of stuff; I go to work every day. So, it's pretty easy.
I was kinda scared at first because, um, I had to abide by the rules.
Well, actually, like the second week that I was here and I got used to the Oxford rules, and, you know, becoming closer with my house mates, then it, then my view shifted, and I just, just had a different outlook on Oxford House. I call them family now, you know. The, it's, um, co-ed here now because we have the, you know, the transgenders and the, the, the men. So, the first thing is just to acclimate myself with the surrounding and know about the rules, especially the rules. You know, and to, I mean, to adhere to the rules because I don't want to get kicked out.

What are the benefits of oxford house for transgender individuals?
Sobriety is priority: For all residents of the house, sobriety was mentioned as a key part of living in the OHs, as indicated in the quote below by a transgender individual: We're all here to get sober. We're all here to do our footwork.
A cisgender individual commented: …we're all addicts so we all-you know-share the same problem and,…we call each other on our shit and…we help out each other whenever we can.
To maintain their sobriety, consequences were emphasized by transgender and cisgender residents as being of importance. As an example, one transgender resident said: …what has really kept me sober is just knowing that I could not fake being high in front of these people…".
A cisgender individual mentioned: …if I didn't get into trouble, I wouldn't be in this po-sition…".

Seeking a setting with normalcy and stability:
Seeking normalcy/stability also was mentioned by many, and one cisgender individual elaborated by saying: I already knew basically that there were gonna be rules and…I was just all up for it.
The following quotes were by transgender individuals: those who felt respected in treatment had positive experiences.
There are several limitations in this study. A test of reliability was not conducted. In addition, the small sample size and use of only Hawaiian houses limits the generalizability of the results, although we do not know of other OHs that service this group. Another limitation of this study relates to whether the results can be generalized to all the transgender people living in other recovery homes in the US. In addition, there is a need for more research regarding how gender plays a role in recovery as well as how gender plays a role in the OH environment and recovery efforts by individuals. We need more information about interactions between cisgender and transgender residents within the OH. For example, how initial experiences change over time, and how these interactions affect the relationships and social networks/support systems of cisgender and transgender individuals after leaving OHs. Finally, longitudinal data is needed to help us understand how intergroup/contact theory allows us to understand how this exposure affects established and new relationships for either cisgender or transgender OH residents.
Future research should not only address these limitations but also expand on answers to research questions posed in this study as well as unexpected themes. For example, additional inquiry could further illuminate ways in which past experiences of transgender residents in recovery might hinder entry into other systems as well as the role peers in diffusing apprehension and fears. Moreover, future studies should examine the potential influence of family roles in the recovery home environment. For homes with transgender residents, such inquiry should pay particular attention to gender-related roles. Lastly, comparative research should be conducted to compare family roles in gender segregated recovery homes to those in which gender is not segregated.
In conclusion, in response to the barriers that prevent transgender individuals from entering into treatment for substance abuse [5,6], a number of initiatives for equal rights have been instituted, and one of these involves recovery homes like OHs. It is important that the perspectives of transgender individuals are examined [11] and recovery homes like the ones profiled in this study might provide excellent recovery settings for transgender individuals. While there are limitations to the current study, it advances knowledge about a topic that scholarly inquiry has largely ignored-the experiences of transgender people in recovery from alcohol and other drugs. In particular, it identifies multiple pathways to entry that shape residents' fear-laden expectations, transgender residents prioritization of sobriety and stability, and family roles that may contribute to their experiences and outcomes.
(limited social support, lack of access for services, transient/street lifestyle). While our focus in this article was on the transgender experience, the attitudes of cisgender individuals were important to include in order to better understand their acceptance of transgender individuals in the OHs. Both cisgender and transgender participants expressed many similar themes regarding fears about entering the OHs and the support they experienced once they lived in these residences.
The findings of this study revealed that transgender individuals found their way into OH primarily through health and criminal justice systems. These include referral from drug treatment centers and mandated treatment such as drug court, probation, and from prison. OH recruitment efforts seemed to collaborate with the above agencies to recruit transgender individuals into OH. Participants reported hearing about OH from staff at the agency of referral and from mutual transgender individuals while receiving intervention services. Such referrals are particularly noteworthy given transgender residents' negative experiences with other health and criminal justice systems.
These experiences appeared to shape transgender participants' expectations of what their experiences in OH would be like. Transgender participants in this study approached the decision to enter OH with apprehensions and a number of fears, mainly regarding the fear of living in a new environment with strangers who might not understand their transgender identity. Prior to OH entry, transgender participants reported fear of discrimination based on their past experiences with other intervention organizations. Participants reported that past experiences with institutions, such as jail, were not sensitive to their identity and needs and feared OH may be similar.
However, this study found that once the participants were in OH, their gender identity was respected in most circumstances, and that discrimination occurred on a micro level, often not being intentional, and was worked out through discussions and boundary setting. Transgender women view the roles of women in society as being nurturers and communicators, and OHs may give them opportunities to reinforce those traits within the household. Our findings suggest that transgender women and cisgender men go through similar experiences in recovery. Both groups may benefit from living together in a structured environment. A sense of family within the home may lead to reinforcement of positive self-concept. This is compatible with findings from Lyons, et al. [2], who conducted semi-structured interviews with 34 transgender individuals. Those with prior addiction treatment had experiences that varied according to whether their gender identity was accepted. Those who experienced stigma left treatment prematurely whereas