Needs Assessment for the Transgender Community Questionnaire.

Alcohol and Drug Use Treatment

This questionnaire is totally voluntary and anonymous.
Please do not put your name or any other identifying information on the questionnaire form. The information we collect will be used to assess the alcohol and drug treatment needs of the Transgender community. Please complete this questionnaire as soon as convenient for you. When you have completed this questionnaire please place it in the envelope provided and post it back to us. Thank you very much for your assistance. If you have any questions, or if you would like to see the results of the questionnaire, please contact Sandy Gauntlett at Regional Alcohol and Drug Services, 815 5830.

1. Do you currently drink alcohol?Yes  No
2. Do you currently use illegal drugs?Yes  No
3. Has your drug and/or alcohol use ever interfered with your social or work life? Yes  No
4. Do you consider your alcohol or drug use a problem? Yes  No
5. How often do you drink alcohol? (circle one)
      1. Every day
      2. Two or three times a week
      3. Once a week
      4. Less than once a week
6. When you drink, how much do you drink? (circle one)
      1. One drink only
      2. Two or three drinks
      3. Four to six drinks
      4. More than six drinks
Please tell us how often you use the following drugs: (circle one answer for each)
7.       Barbiturates (barbs)
      1. Once in the last year
      2. Two to three times in the last year
      3. Every month
      4. More than once a month
      5. Weekly
      6. More than once a week
8.       Amphetamines (speed)
      1. Once in the last year
      2. Two to three times in the last year
      3. Every month
      4. More than once a month
      5. Weekly
      6. More than once a week
9.      Poppers (amyl/butyl, "leather cleaner" "room odorisers")
      1. Once in the last year
      2. Two to three times in the last year
      3. Every month
      4. More than once a month
      5.Weekly
      6. More than once a week
10.      Benzodiazepines (tranqs or benzos)
      1. Once in the last year
      2. Two to three times in the last year
      3. Every month
      4. More than once a month
      5. Weekly
      6. More than once a week
11.       Cannabis (grass, pot)
      1. Once in the last year
      2. Two to three times in the last year
      3. Every month
      4. More than once a month
      5. Weekly
      6. More than once a week
12.      Cocaine in any form (coke, crack)
      1. Once in the last year
      2. Two to three times in the last year
      3. Every month
      4. More than once a month
      5. Weekly
      6. More than once a week
13.      Party drugs (Ecstasy, GHB, Liquid E, Fantasy, K, etc.)
      1. Once in the last year
      2. Two to three times in the last year
      3. Every month
      4. More than once a month
      5. Weekly
      6. More than once a week
14.      Opiates (heroin, opium, peth, morphine, methadone, temmies, bake)
      1. Once in the last year
      2. Two to three times in the last year
      3. Every month
      4. More than once a month
      5. Weekly
      6. More than once a week
15.      Solvents (glue, paint thinner)
      1. Once in the last year
      2. Two to three times in the last year
      3. Every month
      4. More than once a month
      5. Weekly
      6. More than once a week
16.      LSD (acid)
      1. Once in the last year
      2. Two to three times in the last year
      3. Every month
      4. More than once a month
      5. Weekly
      6. More than once a week
17.Have you ever injected drugs?Yes No
18.Have you ever shared equipment for injecting drugs?Yes  No
19.Has your drug use or alcohol use ever resulted in risk to yourself or others?Yes No
20. Are you on medically supervised hormone therapy?Yes  No
21.Are you using hormones without medical supervision?
      (for example, are you buying them on the street?)Yes No
22.Is your doctor regularly monitoring your health changes resulting from hormone use
      (for example, doing regular lab tests and physical examinations)?Yes No
23. Are you injecting hormones? Yes No
24. Have you ever received alcohol or drug treatment in New Zealand?Yes   No
      If No (please go to question 27)
25. If yes to #24,
       do you feel you were discriminated against in any way because of your transgender status?Yes No
      If No(please go to question 27)
26. If yes to #25, did you leave treatment because of that discrimination?Yes  No
27. In your opinion, do alcohol and drug services in Auckland cater for transgendered people? Yes No
28. In you opinion, could alcohol and drug services improve the services they offer to transgendered people? Yes   No
Please rate the following by how important they would be to you in accessing alcohol and drug services for yourself.
Use the following scale:
Not important 1 Somewhat unimportant 2 Somewhat important 3 Important 4
29. Access to a transgendered clinician 1 2 3 4
30. Access to a clinician sensitive to the needs of the transgender community,
regardless of the gender status of the clinician.		 1 2 3 4
31. That the programme provides a safe and supportive environment for transgendered people 1 2 3 4
32. That the programme has education for its staff about transgender issues and needs. 1 2 3 4
33. That the programme has education for clients about transgender issues and therapies 1 2 3 4
34. That the programme offers transgender health care needs as part of the treatment 1 2 3 4
35. That the programme offers referral to housing, employment and other
life skills programmes as a part of the treatment		 1 2 3 4
36. Flexible programme hours (operating outside of office hours for example) 1 2 3 4
37. Mobile clinics (for example, vans or buses) 1 2 3 4
38. What was your age on your last birthday?
      1. Under 20 years old
      2. 20-25 years old
      3. 26-30 years old
      4. 31-35 years old
      5. 36-49 years old
      6. Over 50 years old
39. How do you describe yourself?
      1. Male to Female (MTF) transgendered
      2. Female to Male (FTM) transgendered
      3. Transvestite dressing as a female
      4. Intersex (ambiguous genitals)
      5. Androgynous (neither, or both, male and female)
      6. Something else (please state)
40. How do you describe your sexuality
      1. Gay Male
      2. Lesbian Woman
      3. Bisexual
      4. Heterosexual
41. How do you describe your ethnicity or nationality? (please circle all that apply)
      1. NZ European
      2. NZ Maori
      3. Pacific Islander
      4. Asian
      5. Some other ethnicity or nationality (please state)
Thank you very much for your assistance. Please remember to place the questionnaire in the envelope provided and post it back to us. Thank you again!