Full length articleSubstance use and treatment of substance use disorders in a community sample of transgender adults
Introduction
The term transgender describes people whose gender expression or identity differs from that traditionally attributed to their assigned natal sex (Mayer et al., 2008). Nearly 1 million American adults currently identify as transgender (Stroumsa, 2014). Studies examining substance use disorders (SUDs) among transgender people are rare, and reporting of gender identity data (e.g., transgender status) in SUD-related research is limited (Flentje et al., 2015). In the few studies that exist, transgender people have significantly elevated prevalence of alcohol and illicit drug use compared with the general population (Benotsch et al., 2013, Clements-Nolle et al., 2001, Herbst et al., 2008, Kecojevic et al., 2012, Reback and Fletcher, 2014, Santos et al., 2014).
A biopsychosocial model of illness (Engel, 1980) is often applied to understand SUDs, including consideration of the relationship of demographic, gender-related, mental health, and socio-structural risk factors to substance use and SUD treatment (Cheatle and Gallagher, 2006, Chermack and Giancola, 1997, Comfort and Kaltenbach, 1999, Griffiths, 2005, Marlatt, 1992). To our knowledge, however, no reports have comprehensively examined these factors in substance use and SUD treatment utilization among transgender adults. Indeed, the association between demographic characteristics and substance use among transgender people has not yet been well characterized. Studies have often focused on youth rather than the entire adult lifespan (Garofalo et al., 2006, Kecojevic et al., 2012, Rowe et al., 2015). In addition, gender differences in SUD treatment utilization between transgender people on the male-to-female spectrum (MTF/transgender women) vs female-to-male spectrum (FTM/transgender men) have not been described, as existing reports have focused primarily on substance use among transgender women in the context of HIV risk (Nemoto et al., 2004, Nuttbrock et al., 2014b, Reback and Fletcher, 2014, Rowe et al., 2015, Santos et al., 2014). Moreover, reporting of non-binary gender identity (i.e., gender identity which is not defined as either male or female, and may be defined as “genderqueer” or “gender variant”) in published substance use research is minimal (Flentje et al., 2015), and differences in substance use and SUD treatment between transgender people with binary vs non-binary gender identity have not been investigated.
Based on sexual minority (Meyer, 2003) and gender minority (Hendricks and Testa, 2012, Reisner et al., 2014a, Reisner et al., 2014d) stress theories, SUDs among transgender people are increasingly viewed as downstream consequences of internalized and enacted transphobia (Nuttbrock et al., 2014b). Transgender people are at high risk for verbal, physical and sexual victimization (Garofalo et al., 2006, Operario and Nemoto, 2010, Stieglitz, 2010, Stotzer, 2009). A national study of more than 6000 transgender people found that 63% had experienced a serious act of discrimination (e.g., medical service denial, eviction, bullying, or physical/sexual assault; Grant et al., 2011). Transgender people who, due to physical attributes that reveal their transgender status, are unable to “pass” (i.e., to be societally affirmed in the gender with which they identify) may be particularly vulnerable to victimization (Grant et al., 2011, Nemoto et al., 2004, Operario and Nemoto, 2010). Experiencing psychological or physical abuse as a result of one's nonconforming gender expression or identity is associated with a three- to four-fold higher odds of alcohol, marijuana, or cocaine use, as well as an 8-times higher odds of any drug use, among transgender women (Nuttbrock et al., 2014b). Among MTF transgender youth, gender-related discrimination is associated with increased odds of alcohol and drug use (Rowe et al., 2015). Research suggests that substance use may be a means of coping with discrimination, as a national study found that 35% of transgender people who experienced school-related verbal harassment, physical assault, sexual assault, or expulsion reported using substances to cope with transgender- or gender nonconformity-related mistreatment (Grant et al., 2011).
In the context of such common interpersonal trauma, a recent report showed that posttraumatic stress disorder (PTSD) symptoms are associated with increased odds of drug use among MTF youth (Rowe et al., 2015). Previous research also indicates that transgender people have high prevalence of depression (Clements-Nolle et al., 2001, Reisner et al., 2015) and, among transgender women, gender nonconformity-related abuse has been associated with higher likelihood of major depression (Nuttbrock et al., 2014a). Moreover, depression has been shown to mediate the relationship of gender-related abuse to substance use (Nuttbrock et al., 2014b). Though the associations of violent victimization, PTSD, and depression to substance use and SUD treatment utilization are well characterized in non-transgender populations (Davis et al., 2008, Jacobsen et al., 2001), these relationships remain largely unstudied among both MTF and FTM transgender adults.
Transgender people are twice as likely to be unemployed as non-transgender people (Grant et al., 2011), as stigma and discrimination restrict access to employment and income (Grant et al., 2011). Some transgender people, particularly transgender women, engage in sex work (Garofalo et al., 2006, Nemoto et al., 2006, Operario et al., 2008, Sausa et al., 2007, Sevelius et al., 2009). Sex work has been linked to increased prevalence and frequency of substance use among transgender women (Nuttbrock et al., 2014b). Little is known, however, about the associations of poverty, homelessness, and sex work to substance use and SUD treatment utilization among both MTF and FTM transgender adults, though these relationships have been studied extensively in non-transgender populations (Bassuk et al., 1998, Fischer and Breakey, 1991, Nuttbrock et al., 2004, Robertson et al., 1997, Shannon et al., 2008).
Many transgender people seek out medical gender affirmation technologies, such as cross-sex hormone therapy or surgeries, to align their physical selves with their internal sense of gender identity or expression. The American Medical Association has deemed cross-sex hormone therapy and gender-affirming surgery necessary medical treatments for gender dysphoria, defined as extreme and persistent distress related to incongruence of gender identity and natal sex (American Medical Association, 2008). Nevertheless, transgender individuals face numerous barriers to receiving appropriate gender-affirming health care (Operario and Nemoto, 2010), including a lack of both competent providers and insurance coverage (Operario and Nemoto, 2010, Sanchez et al., 2009, Spicer, 2010, Stroumsa, 2014). The psychological stress of health care access disparities faced by transgender people is believed to contribute to worse mental health (Poteat et al., 2013), including disproportionate substance use as a coping strategy (Wilson et al., 2015). A recent study examined the relationship of gender-affirming medical services to recent alcohol and drug use among transgender women (Wilson et al., 2015), however, the sample did not include transgender men, and SUD treatment utilization was not assessed. Thus research exploring the specific relationship of cross-sex hormone therapy and/or gender-affirming surgery to substance use and SUD treatment utilization among diverse groups of transgender people is warranted.
Significant gaps exist in the literature regarding the association of demographic, gender-related, mental health, and socio-structural risk factors to substance use and SUD treatment among transgender adults. To address these gaps, the present study aimed to: (1) assess the prevalence and distribution of SUD treatment history and recent substance use in a community sample of transgender adults; and (2) examine the relationship of substance use and SUD treatment utilization to demographic, gender-related, mental health, and socio-structural risk factors in this understudied and highly vulnerable population.
Section snippets
Participants and sampling
Data were gathered through Project VOICE, a community-based sample of 452 self-identified transgender and gender-nonconforming Massachusetts residents, ages 18 to 75 years. Participants were purposively recruited using bimodal methods (online and in-person) from August to December, 2013 and asked to complete a one-time survey assessing demographics, experiences of discrimination and victimization, and health indicators. Participants provided informed consent before beginning the survey. The
Sample characteristics
Characteristics of the study sample are presented in Table 1. The mean age was 33.6 (SD = 12.8) years, with 20.6% of the sample identifying as people of color and 36.9% self-identifying as MTF. Overall, 10% reported a lifetime SUD treatment history, whereas 7.3% reported both lifetime SUD treatment and recent substance use. Binge drinking in the past 3 months (47.0%) was reported more frequently than marijuana use (39.6%) or non-marijuana illicit drug use (19.0%) in the past 12 months. Recent
Discussion
In this community sample of transgender adults, the prevalence of alcohol and drug use was found to be consistent with previous studies assessing substance use in transgender people (Benotsch et al., 2013, Clements-Nolle et al., 2001, Herbst et al., 2008, Kecojevic et al., 2012, Reback and Fletcher, 2014, Santos et al., 2014). The higher prevalence of lifetime SUD treatment mainly among participants with recent illicit use of prescription medications such as stimulants, downers, and painkillers
Role of funding source
This project was supported with funding from the Miller Foundation. Dr. Keuroghlian is supported by the Kraft Family National Center for Leadership and Training in Community Health. Dr. Reisner is partly supported by grant R01 MH094323 from the National Institute of Mental Health. Dr. Weiss is supported by grant K24DA022288 from the National Institute on Drug Abuse. Ms. White is supported by grants T32MH020031 and P30MH062294 from the National Institute of Mental Health.
Funding sources had no
Contributors
All authors contributed to the interpretation of the data and revising the manuscript for important intellectual content. ASK led the drafting of the manuscript and oversaw subsequent revisions. SLR and ASK conceived the data analysis plan. SLR undertook the statistical analyses. SLR and JMW were principal investigators for Project VOICE, which they helped conceive and design. RDW provided clinical guidance for the article and edited the manuscript.
Conflict of interest
No conflict declared.
Acknowledgements
The authors would like to thank the participants of Project VOICE for taking part in the study.
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