A Systematic Review of Interventions to Reduce Problematic Substance Use Among Transgender Individuals: A Call to Action

A sex- and gender-based analysis of alcohol treatment intervention research involving youth: A methodological systematic review

BACKGROUND

While there is widespread consensus that sex- and gender-related factors are important for how interventions are designed, implemented, and evaluated, it is not currently known how alcohol treatment research accounts for sex characteristics and/or gender identities and modalities. This methodological systematic review documents and assesses how sex characteristics, gender identities, and gender modalities are operationalized in alcohol treatment intervention research involving youth.

METHODS AND FINDINGS

We searched MEDLINE, Embase, Cochrane Central Registry of Controlled Trials, PsycINFO, CINAHL, LGBT Life, Google Scholar, Web of Science, and grey literature from 2008 to 2023. We included articles that reported genders and/or sexes of participants 30 years of age and under and screened participants using AUDIT, AUDIT-C, or a structured interview using DSM-IV criteria. We limited the inclusion to studies that enrolled participants in alcohol treatment interventions and used a quantitative study design. We provide a narrative overview of the findings. Of 8,019 studies screened for inclusion, 86 articles were included in the review. None of the studies defined, measured, and reported both sex and gender variables accurately. Only 2 studies reported including trans participants. Most of the studies used gender or sex measures as a covariate to control for the effects of sex or gender on the intervention but did not discuss the rationale for or implications of this procedure.

CONCLUSIONS

Our findings identify that the majority of alcohol treatment intervention research with youth conflate sex and gender factors, including terminologically, conceptually, and methodologically. Based on these findings, we recommend future research in this area define and account for a spectrum of gender modalities, identities, and/or sex characteristics throughout the research life cycle, including during study design, data collection, data analysis, and reporting. It is also imperative that sex and gender variables are used expansively to ensure that intersex and trans youth are meaningfully integrated.

TRIAL REGISTRATION

Registration: PROSPERO, registration number: CRD42019119408.

Factors Associated with Sexual Victimization Among Transgender Emerging Adults

This cross-sectional study documented between-group differences in risk factors associated with sexual victimization histories in an ethnically and racially diverse sample of transgender emerging adults (N = 248, ageM = 22.61 years). The sample was recruited using the Internet-based CloudResearch platform to answer questionnaires assessing predictors for recent experiences of intimate partner violence (IPV). Participants were categorized into four groups based on cross-classified self-reports of child sexual abuse (CSA) and recent sexual IPV, prior to the use of multivariate analysis of variance to evaluate mean score differences for past-year substance use, minority stressor, and relationship functioning variables. Participants reporting sexual IPV reported higher scores for all substance use variables, while transfeminine participants reported significantly higher scores for alcohol use problems and negative consequences related to substance use. Participants reporting both CSA and sexual IPV also reported the highest scores for everyday discrimination. Participants who experienced sexual IPV also reported the highest scores for internalized sexual stigma. Sexual revictimization among transgender adults occurs in the context of harmful patterns of substance use and several minority stressors. Our findings have implications for healthcare or counseling services for transgender emerging adults who have experienced multiple forms of victimization, substance use problems, and minority stressors, including the importance of trauma-informed and integrated intervention services, and specialized training for service providers.

Combined Motivational Interviewing and Ecological Momentary Intervention to Reduce Hazardous Alcohol Use Among Sexual Minority Cisgender Men and Transgender Individuals: Protocol for a Randomized Controlled Trial

BACKGROUND

Sexual minority cisgender men and transgender (SMMT) individuals, particularly emerging adults (aged 18-34 years), often report hazardous drinking. Given that alcohol use increases the likelihood of HIV risk behaviors, and HIV disproportionately affects SMMT individuals, there is a need to test interventions that reduce hazardous alcohol use and subsequent HIV risk behaviors among this population. Ecological momentary interventions (EMIs), which use mobile phones to deliver risk reduction messages based on current location and behaviors, can help to address triggers that lead to drinking in real time.

OBJECTIVE

This study will test an EMI that uses motivational interviewing (MI), smartphone surveys, mobile breathalyzers, and location tracking to provide real-time messaging that addresses triggers for drinking when SMMT individuals visit locations associated with hazardous alcohol use. In addition, the intervention will deliver harm reduction messaging if individuals report engaging in alcohol use.

METHODS

We will conduct a 3-arm randomized controlled trial (N=405 HIV-negative SMMT individuals; n=135, 33% per arm) comparing the following conditions: (1) Tracking and Reducing Alcohol Consumption (a smartphone-delivered 4-session MI intervention), (2) Tracking and Reducing Alcohol Consumption and Environmental Risk (an EMI combining MI with real-time messaging based on geographic locations that are triggers to drinking), and (3) a smartphone-based alcohol monitoring-only control group. Breathalyzer results and daily self-reports will be used to assess the primary and secondary outcomes of drinking days, drinks per drinking day, binge drinking episodes, and HIV risk behaviors. Additional assessments at baseline, 3 months, 6 months, and 9 months will evaluate exploratory long-term outcomes.

RESULTS

The study is part of a 5-year research project funded in August 2022 by the National Institute on Alcohol Abuse and Alcoholism. The first 1.5 years of the study will be dedicated to planning and development activities, including formative research, app design and testing, and message design and testing. The subsequent 3.5 years will see the study complete participant recruitment, data collection, analyses, report writing, and dissemination. We expect to complete all study data collection in or before January 2027.

CONCLUSIONS

This study will provide novel evidence about the relative efficacy of using a smartphone-delivered MI intervention and real-time messaging to address triggers for hazardous alcohol use and sexual risk behaviors. The EMI approach, which incorporates location-based preventive messaging and behavior surveys, may help to better understand the complexity of daily stressors among SMMT individuals and their impact on hazardous alcohol use and HIV risk behaviors. The tailoring of this intervention toward SMMT individuals helps to address their underrepresentation in existing alcohol use research and will be promising for informing where structural alcohol use prevention and treatment interventions are needed to support SMMT individuals.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05576350; https://www.clinicaltrials.gov/study/NCT05576350.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/55166.

Causes of Death of Transgender and Gender Diverse Veterans

INTRODUCTION

Transgender and gender diverse (TGD) veterans face numerous challenges due to stigma and marginalization, which have a significant impact on their health and well-being. However, there is insufficient data on cause-specific mortality in TGD veteran populations in the U.S. The purpose of this study was to describe the leading causes of death in a sample of TGD veterans who received care from the Veterans Health Administration.

METHODS

A secondary data analysis was conducted using Veterans Health Administration electronic health record data matched with death certificate records from the National Death Index from October 1, 1999 to December 31, 2019. Using record axis codes from National Death Index data, the 25 most frequent underlying and all causes of death were summarized.

RESULTS

Deaths occurred in 1,415 TGD veterans. Ranking by any mention on the death certificate, mental and behavioral disorders due to psychoactive substance use (17.2%), conduction disorders and cardiac dysrhythmias (15.3%), chronic obstructive pulmonary disease (15.1%), diabetes mellitus (13.9%), and chronic ischemic heart disease (13.3%) were the top five causes of death. Three distinct methods of suicide appeared as the 7th (firearms), 17th (self-poisoning), and 24th (hanging) underlying causes of death for TGD veterans.

CONCLUSIONS

Targeted prevention efforts or interventions to reduce the frequency and severity of causes of death, particularly mental and behavioral health disorders and metabolic disorders, could prevent premature mortality among TGD adults.

Understanding the delivery of substance use treatment services to transgender and gender-diverse people: Findings from a mixed-methods study of healthcare professionals

BACKGROUND

Transgender and gender diverse (TGD) people who use drugs report barriers to accessing substance use treatment, including provider mistreatment. Little research has explored the multilevel factors that shape the capacity of substance use treatment professionals to provide gender-affirmative care (i.e., care that respects and affirms one's gender) to TGD people.

METHODS

From October 2021 to March 2022, substance use treatment and harm reduction professionals in Rhode Island were surveyed (N = 101) and qualitatively interviewed (N = 19) about the provision of substance use treatment-related services to TGD people. Quantitative data were analyzed descriptively; differences were examined using Fisher exact tests (p < 0.05). Qualitative interviews were coded and analyzed using thematic analysis.

RESULTS

Participants reported limited exposure to TGD people and lacked training on TGD health, which resulted in limited cultural and clinical competency and low self-efficacy in their ability to care for TGD people. Participants also highlighted structural factors (e.g., non-inclusive intake forms, limited availability of gender-inclusive ancillary community services) that restricted their ability to provide effective and affirming care to TGD people. Some participants also reported a "gender blind" ethos at their institutions- described by some as ignoring the potential impact of TGD peoples' unique experiences on their substance use and ability to benefit from treatment. While some perceived gender blindness as problematic, others believed this approach enabled substance use treatment professionals to consider all the identities and needs that patients/clients may have. Despite differences in treatment approaches, most participants agreed that their workplaces could benefit from efforts to create a safe and affirming space for people who use drugs, particularly TGD patients/clients.

CONCLUSION

Results underscore how structural, interpersonal, and individual factors contributed to barriers in the provision of gender-affirmative substance use-related care for TGD people. Findings can inform efforts to increase the capacity of providers to deliver gender-affirmative substance use-related services, which is essential to supporting the recovery goals of TGD people.

Detectable viral load associated with unmet mental health and substance use needs among trans women living with HIV in San Francisco, California

BACKGROUND

Substance use and mental distress are known barriers to HIV care engagement among trans women. Less is known about access and utilization of mental health and substance use care among trans women and the relationship between unmet behavioral health needs and HIV viral suppression. We examined the relationship between mental health and substance use on HIV viral load among trans women living with HIV. We also examined the relationship between mental health and substance use services needs with HIV care engagement and having a detectable viral load by comparing engagement in care cascades.

METHODS

Data are from a 2022 baseline assessment for an intervention with trans women living with HIV (n = 42) in San Francisco. Chi-Squared or Fisher's exact tests were conducted to determine associations between HIV viral load, mental health, and substance use. We also examine characteristics associated with each step in the HIV, mental health, and substance use care cascades.

RESULTS

Most participants were trans women of color (85.7%), 40 years of age or older (80.9%), with low income (88.1%), and almost half were unstably housed (47.6%). Of the 32 participants who screened positive for depression, anxiety and/or psychological distress, 56.3% were referred for mental health services in the past 12 months. Of those who were referred, 44.4% received mental health services. Of the 26 participants who screened positive for a substance use disorder, 34.6% were referred to substance use services in the past 12 months. Of those referred, 33.3% received substance use services in the past 3 months. Latina trans women had a low referral rate to meet their mental health needs (50%) and only 16.7% of African American/Black trans women who screened positive for a substance use disorder were referred for services, while trans women of other race/ethnicities had high referral and services utilization. No significant results were found between HIV viral load and screening positive for a mental health disorder. Methamphetamine use was statistically associated with having a detectable HIV viral load (p = 0.049).

CONCLUSIONS

We identified significant unmet mental health and substance use services needs and noted racial/ethnic disparities in the context of high HIV care engagement among trans women living with HIV. We also found that methamphetamine use was a barrier to having an undetectable viral load for trans women living with HIV. To finally end the HIV epidemic, integration of behavioral health screening, linkage, and support are needed in HIV care services for populations most impacted by HIV, especially trans women.

TRIAL REGISTRATION

NCT, NCT 21-34,978. Registered January 19, 2022.

Discrimination, gender dysphoria, drinking to cope, and alcohol harms in the UK trans and non-binary community

Transgender (trans) and non-binary people may be at increased risk of alcohol harms, but little is known about motives for drinking in this community. This study explored the relationship between risk of alcohol dependence, experience of alcohol harms, drinking motives, dysphoria, and discrimination within a United Kingdom sample of trans and non-binary people with a lifetime history of alcohol use. A cross-sectional survey was co-produced with community stakeholders and administered to a purposive sample of trans and non-binary people from 1 February until 31 March 2022. A total of 462 respondents were included-159 identified as non-binary and/or genderqueer (identities outside the man/woman binary), 135 solely as women, 63 solely as men, 15 as another gender identity, 90 selected multiple identities. Higher levels of reported discrimination were associated with higher risk of dependence and more reported harms from drinking. Coping motives, enhancement motives, and drinking to manage dysphoria were associated with higher Alcohol Use Disorders Identification Test scores. Social, coping, and enhancement motives alongside discrimination and drinking to have sex were associated with harms. The relationship between discrimination and risk of dependence was mediated by coping motives and drinking to manage dysphoria. Further to these associations, we suggest that reducing discrimination against trans and non-binary communities might reduce alcohol harms in this population. Interventions should target enhancement motives, coping motives and gender dysphoria. Social and enhancement functions of alcohol could be replaced by alcohol free supportive social spaces.

Systematic Review, Quality Assessment, and Synthesis of Guidelines for Emergency Department Care of Transgender and Gender-diverse People: Recommendations for Immediate Action to Improve Care

Introduction

We conducted this systematic review to identify emergency department (ED) relevant recommendations in current guidelines for care of transgender and gender-diverse (TGD) people internationally.

Methods

Using PRISMA criteria, we did a systematic search of Ovid Medline, EMBASE, and CINAHL and a hand search of gray literature for clinical practice guidelines (CPG) or best practice statements (BPS) published until June 31, 2021. Articles were included if they were in English, included medical or paramedical care of TGD populations of any age, in any setting, region or nation, and were national or international in scope. Exclusion criteria included primary research studies, review articles, narrative reviews or otherwise non-CPG or BPS, editorials, or letters to the editor, articles of regional or individual hospital scope, non-medical articles, articles not in English, or if a more recent version of the guideline existed. Recommendations relevant to ED care were identified, recorded, and assessed for quality using the AGREE-II and AGREE-REX criteria. We performed interclass correlation coefficient for interrater reliability. Recommendations were coded for the relevant point of care while in the ED (triage, registration, rooming, investigations, etc.).

Results

We screened 1,658 unique articles, and 1,555 were excluded. Of the remaining 103 articles included, seven had recommendations relevant to care in the ED, comprising a total of 10 recommendations. Four guidelines and eight recommendations were of high quality. They included recommendations for testing, prevention, referral, and provision of post-exposure prophylaxis for HIV, and culturally competent care of TGD people.

Conclusions

This is the most comprehensive review to date of guidelines and best practices statements offering recommendations for care of ED TGD patients, and several are immediately actionable. There are also many opportunities to build community-led research programs to synthesize and inform a comprehensive dedicated guideline for care of TGD people in emergency settings.

Are Cisgender Women and Transgender and Nonbinary People Drinking More During the COVID-19 Pandemic? It Depends

PURPOSE

This narrative review of research conducted during the first 2 years of the COVID-19 pandemic examines whether alcohol use among cisgender women and transgender and nonbinary people increased during the pandemic. The overarching goal of the review is to inform intervention and prevention efforts to halt the narrowing of gender-related differences in alcohol use.

SEARCH METHODS

Eight databases (PubMed, APA PsycInfo, CINAHL, Embase, Scopus, Gender Studies Database, GenderWatch, and Web of Science) were searched for peer-reviewed literature, published between March 2020 and July 2022, that reported gender differences or findings specific to women, transgender or nonbinary people, and alcohol use during the pandemic. The search focused on studies conducted in the United States and excluded qualitative research.

SEARCH RESULTS

A total 4,132 records were identified, including 400 duplicates. Of the remaining 3,732 unique records for consideration in the review, 51 were ultimately included. Overall, most studies found increases in alcohol use as well as gender differences in alcohol use, with cisgender women experiencing the most serious consequences. The findings for transgender and nonbinary people were equivocal due to the dearth of research and because many studies aggregated across gender.

DISCUSSION AND CONCLUSIONS

Alcohol use by cisgender women seems to have increased during the pandemic; however, sizable limitations need to be considered, particularly the low number of studies on alcohol use during the pandemic that analyzed gender differences. This is of concern as gender differences in alcohol use had been narrowing before the pandemic; and this review suggests the gap has narrowed even further. Cisgender women and transgender and nonbinary people have experienced sizable stressors during the pandemic; thus, understanding the health and health behavior impacts of these stressors is critical to preventing the worsening of problematic alcohol use.

A comparison of chronic conditions between transgender and cisgender individuals with recent incarceration and in the community in a United States county

Background: Transgender individuals are known to be at a higher risk for certain chronic conditions compared to cisgender individuals. Similarly, research also shows justice-involved individuals have a higher risk of chronic conditions compared to non-justice-involved individuals. Aim: This study aims to investigate the differences in chronic disease diagnoses between transgender and cisgender individuals who either utilized healthcare services provided by a US county health system or who were incarcerated in the same county's jail. Method: We leveraged electronic health record data from a United States county health system, including data from the local jail, to evaluate the difference in diagnosis of certain chronic conditions among transgender and cisgender individuals. We also compared individuals who experienced incarceration and those who did not. Results: We found transgender individuals experiencing recent incarceration were more likely to be diagnosed with substance use disorder, HIV/AIDS, and Hepatitis C than cisgender individuals. Transgender individuals not experiencing recent incarceration were more likely to be diagnosed with HIV/AIDS, seizure disorder, major depressive disorder, and bipolar disorder than cisgender individuals. Conclusion: These results highlight how transgender individuals may be disproportionately impacted by certain diseases within and outside carceral settings.

Alcohol reduction interventions for transgender and non-binary people: A PRISMA-ScR-adherent scoping review

INTRODUCTION

Transgender and non-binary people use more alcohol and report a greater need for help to reduce their consumption than their cisgender counterparts. They experience anticipated and enacted discrimination when seeking alcohol reduction healthcare. This study aimed to identify any alcohol reduction interventions for trans and non-binary people.

METHODS

A systematic scoping review was completed according to PRISMA-ScR guidelines. Following an extensive search across five databases, two independent reviewers carried out abstract screening, full-text screening, data extraction and quality assessment. Findings were synthesised narratively.

RESULTS

The search generated 1399 unique records. Ten texts were reviewed in full, and the final sample comprised six studies of moderate quality. Included records all reported adaptations of various psychosocial interventions including individual therapies, group therapy, a trans-affirmative clinical environment, and a specialist inpatient rehabilitation service. Four interventions resulted in alcohol reduction with modest effect size. However, the change in alcohol consumption was not statistically significant in two studies. Trans women were disproportionately investigated through the lens of HIV risk reduction.

CONCLUSION

Interventions developed for one population cannot be presumed effective in another, particularly those as heterogeneous as trans and non-binary communities. There is some suggestion that psychosocial interventions adapted for the needs of the trans community are effective in achieving alcohol reduction. However, it is unclear how these will fare with trans men and non-binary people and specialist interventions may be needed.

Transgender and gender diverse adults' reflections on alcohol counseling and recommendations for providers

Transgender and gender diverse (TGD) populations experience health disparities due to societal stigma that increases TGD individuals' sources of stress and decreases access to health protective resources. Research has linked experiences of stigma to risky alcohol use, yet there remains a dearth of culturally sensitive alcohol use interventions that meet the needs of TGD people. The present study was conducted to inform modifications to the content and delivery of an existing brief, telehealth, motivational intervention to decrease at-risk alcohol use among TGD adults. Individual semi-structured in-depth qualitative interviews were conducted with TGD adults who reported recent alcohol use (n = 18) to explore factors that facilitate positive interactions with health care providers and identify relevant information for alcohol use disorder treatment. Participants were recruited from an LGBTQ +-focused health center in Los Angeles, California. Two major themes and recommendations emerged: (a) A multicultural orientation of humility is important to develop productive therapeutic relationships with TGD clients when delivering motivational interviewing; (b) Due to insufficient appropriate data on alcohol use and health in TGD populations, feedback used in motivational alcohol counseling needs to be modified to better serve TGD clients. These findings show that counselors' philosophy and behavior, as well as session content, need to be considered when working with TGD populations within the context of alcohol counseling. These findings also have implications for intervention development, clinical treatment, and future research. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Disparities in health condition diagnoses among aging transgender and cisgender medicare beneficiaries, 2008-2017

INTRODUCTION

The objective of this research is to provide national estimates of the prevalence of health condition diagnoses among age-entitled transgender and cisgender Medicare beneficiaries. Quantification of the health burden across sex assigned at birth and gender can inform prevention, research, and allocation of funding for modifiable risk factors.

METHODS

Using 2009-2017 Medicare fee-for-service data, we implemented an algorithm that leverages diagnosis, procedure, and pharmacy claims to identify age-entitled transgender Medicare beneficiaries and stratify the sample by inferred gender: trans feminine and nonbinary (TFN), trans masculine and nonbinary (TMN), and unclassified. We selected a 5% random sample of cisgender individuals for comparison. We descriptively analyzed (means and frequencies) demographic characteristics (age, race/ethnicity, US census region, months of enrollment) and used chi-square and t-tests to determine between- (transgender vs. cisgender) and within-group gender differences (e.g., TMN, TFN, unclassified) difference in demographics (p<0.05). We then used logistic regression to estimate and examine within- and between-group gender differences in the predicted probability of 25 health conditions, controlling for age, race/ethnicity, enrollment length, and census region.

RESULTS

The analytic sample included 9,975 transgender (TFN n=4,198; TMN n=2,762; unclassified n=3,015) and 2,961,636 cisgender (male n=1,294,690, female n=1,666,946) beneficiaries. The majority of the transgender and cisgender samples were between the ages of 65 and 69 and White, non-Hispanic. The largest proportion of transgender and cisgender beneficiaries were from the South. On average, transgender individuals had more months of enrollment than cisgender individuals. In adjusted models, aging TFN or TMN Medicare beneficiaries had the highest probability of each of the 25 health diagnoses studied relative to cisgender males or females. TFN beneficiaries had the highest burden of health diagnoses relative to all other groups.

DISCUSSION

These findings document disparities in key health condition diagnoses among transgender Medicare beneficiaries relative to cisgender individuals. Future application of these methods will enable the study of rare and anatomy-specific conditions among hard-to-reach aging transgender populations and inform interventions and policies to address documented disparities.

Examining the role of problematic drug use in the relationship between discrimination and sleep disturbance in transgender and nonbinary individuals

OBJECTIVE

Transgender and nonbinary (TGNB) individuals are a health disparity population at high risk for sleep disturbance (e.g., insomnia). Recent evidence suggests minority stress (e.g., discrimination) is associated with sleep disturbance in TGNB adults. However, investigators have yet to identify factors that might explain this relationship. In this study, we investigated the role of problematic drug use (PDU) in the relationship between discrimination and sleep disturbance in TGNB individuals.

METHODS

The study sample included 194 TGNB participants from Wave 5 (2021) of Project AFFIRM, a multi-site longitudinal study of transgender health. Discrimination, PDU, and sleep disturbance were measured using the Everyday Discrimination Scale, Drug Use Disorders Identification Test (DUDIT), and PROMIS Sleep Disturbance measures, respectively. Individuals were classified as having PDU using established DUDIT criteria that were applied based on sex assigned at birth. Regression analyses were used to estimate the associations of study variables, and subsequently, mediation analysis was used to determine whether PDU partially mediated the association between discrimination and sleep disturbance.

RESULTS

Nearly half of participants reported PDU, of which 83.2% reported cannabis use. Higher levels of discrimination were associated with worse self-reported sleep disturbance scores. Additionally, participants with greater discrimination were more likely to have PDU. Surprisingly, participants with PDU had lower sleep disturbance scores.

CONCLUSIONS

Our cross-sectional findings suggest that PDU partially suppressed the association between discrimination and sleep disturbance in TGNB people. Efforts to address PDU in TGNB adults may consider assessing sleep disturbance as a motivating factor for drug use and the potential role of discrimination in perpetuating PDU.

History of Sex Work Is Associated with Increased Risk of Adverse Mental Health and Substance Use Outcomes in Transgender Adults

Understanding factors influencing mental health and substance use in transgender and gender diverse people is critical to reducing disparities in this population. We sought to investigate whether a history of sex work was associated with increased prevalence of poor mental health, substance use, and a negative experience within drug and alcohol treatment facilities. We conducted a secondary analysis of the data of 25,204 transgender respondents of the 2015 United States Transgender Survey. We estimated multiple logistic regressions to assess the association between a history of sex work and adverse mental health and substance use outcomes. We then estimated mean prevalence of adverse outcomes by type of sex work. Finally, we performed chi-square analysis to explore differences in mistreatment at drug and alcohol treatment facilities. Respondents with a history of sex work were significantly more likely to have poorer psychological health, suicidality, and substance use after adjusting for covariates. Among those who visited drug and alcohol treatment facilities, those with a history of sex work were significantly more likely to report adverse experiences (26.34% vs. 11.63%). Our findings highlight the increased risk of adverse outcomes in transgender sex workers and emphasize the need for interventions targeting this subgroup of transgender people.

Prevalence and correlates of substance use and associations with HIV-related outcomes among trans women in the San Francisco Bay Area

BACKGROUND

Trans women face tremendous social inequities as well as disproportionate rates of HIV and substance use, yet disaggregated substance use data specific to trans women remain limited.

METHODS

We conducted a secondary analysis of baseline data from the Trans*National Study (2016-2017) surveying trans women in the San Francisco Bay Area (n = 629). Multivariable logistic regression was used to analyze socio-demographic and environmental correlates of substance use, and bivariate associations between substance use and HIV-associated outcomes are presented alongside prevalence data.

RESULTS

Over half (52.9%) reported using substances in the prior year, most frequently marijuana, methamphetamine, and crack/cocaine. Those with unmet gender-affirming health care needs, lack of insurance, or a history of experiencing racial violence, transphobic violence, adult housing instability, or extreme poverty had higher odds of substance use. Sex work and condomless anal sex were also independently associated with substance use.

CONCLUSIONS

Among this sample of trans women, substance use and substance use concurrent with sex were highly prevalent, and associated with a number of socioeconomic and health care needs. These findings corroborate the need for holistic and intersectional efforts to reduce substance use and HIV risk.

Differences in Alcohol and Other Drug Use and Dependence Between Transgender and Cisgender Participants from the 2018 Global Drug Survey

Purpose: The purpose of this study was to compare five gender groups (cisgender women, cisgender men, transgender women, transgender men, people with nonbinary/other identities) on measures of use of and dependence on seven substances. Methods: A two-stage approach to assessing gender allowed 126,648 participants from the 2018 Global Drug Survey (GDS) to be classified to one of these five gender groups. Participants were asked to disclose use of each substance in the preceding 12 months. The Alcohol Use Disorders Identification Test and the Severity of Dependence Scale were used to assess dependence. Multivariable logistic regression generated odds ratios (ORs) to measure the association between gender and each substance use/dependence outcome, with cisgender women as the reference group. Results: The sample comprised 43,331 cisgender women, 81,607 cisgender men, 215 transgender women, 254 transgender men, and 1241 people with nonbinary/other identities. Relative to cisgender women, nonbinary/other participants reported greater odds of last 12-month use of all substances (adjusted odds ratio [AOR] = 1.66-2.30), except alcohol (lower odds; AOR = 0.42), and greater odds of dependence on cannabis (AOR = 2.39), 3,4-methylenedioxymethamphetamine (AOR = 1.64) and alcohol (AOR = 3.28), adjusting only for age (all p < 0.05). Conclusion: Transgender 2018 GDS respondents, particularly those with nonbinary/other identities, had greater odds of reporting most substance use outcomes than cisgender women. These findings suggest that a nuanced approach to gender reporting in surveys and treatment centers is required to understand the needs of transgender people who use substances.

Prevalence of social and economic stressors among transgender veterans with alcohol and other drug use disorders

Transgender persons have high rates of alcohol and other drug use disorders (AUD and DUD, respectively) and commonly experience social and economic stressors that may compound risk for adverse substance-related outcomes. National VA electronic health record data were extracted for all outpatients in each facility with documented alcohol screening 10/1/09–7/31/17. We describe the prevalence of eight individual-level social and economic stressors (barriers to accessing care, economic hardship, housing instability, homelessness, social and family problems, legal problems, military sexual trauma, and other victimization) among transgender patients with and without AUD and DUD (alone and in combination), overall and compared to cisgender patients in a national sample of VA outpatients. Among 8,872,793 patients, 8619 (0.1%) were transgender; the prevalence of AUD, DUD, and both was 8.6%, 7.2%, and 3.1% among transgender patients and 6.1%, 3.9%, and 1.7% among cisgender patients, respectively. Among all patients, prevalence of stressors was higher among those with AUD, DUD, or both, relative to those with neither. Within each of these groups, prevalence was 2–3 times higher among transgender compared to cisgender patients. For instance, prevalence of housing instability for transgender vs. cisgender patients with AUD, DUD, and both was: 40.8% vs 24.1%, 45.8% vs. 36.6%, and 57.4% vs. 47.0%, respectively. (all p-values <0.001). Social and economic stressors were prevalent among patients with AUD, DUD, or both, and the experience of these disorders and social and economic stressors was more common among transgender than cisgender patients in all groups. Further research regarding experiences of transgender persons and influences of stressors on risk of AUD and DUD, substance-related outcomes, and treatment uptake are needed. Routine screening for social and economic stressors among patients with substance use disorders (SUDs) could improve equitable substance-related care and outcomes. Treatment of SUDs among all persons should consider social and economic risk factors.

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Social and economic stressors are understudied in transgender persons with SUD.

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Social and economic stressors were greater in persons with SUD than those without.

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Concurrent stressors and SUD were 2–3x higher for trans-than cis-gender patients.

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Transphobia may be a fundamental cause of disparities in SUD and stressors.

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SUD treatment should address social and economic stressors.

Promoting a gender-affirming environment in research: implications for research nurses

Background: Approximately 25 million people around the world identify as transgender, and the numbers are growing. While visibility of transgender communities has increased, significant healthcare disparities remain. Transgender individuals report being less inclined to share their sex assigned at birth due to fear of stigmatization and mistrust of the medical community. The mistrust and inequity experienced by transgender individuals are not limited to clinical care and may extend to clinical research as well. Aim and method: The aim of this paper is to start a conversation about barriers to participating in research and the role of research staff, specifically the Clinical Research Nurse, in promoting engagement of transgender individuals in clinical research trials. Discussion and conclusions: A discussion of safety considerations, data integrity, and implications for data management is included. Because disparities may result in large part from lack of education and knowledge on best practices for providing care for this population, recommendations for fostering a culture of competence and gender-affirming care among research professionals featuring the role of the research nurse will be discussed.

Complementary therapies in substance use recovery with pregnant women and girls

Objectives:

Supporting women and girls who are pregnant and experiencing substance use challenges is a high priority for researchers, clinicians, and policymakers. Complementary therapies (CTs) can be effective forms of treatment in some contexts and populations; however, research on the use of CTs in substance use recovery with pregnant women and girls is scarce. To fill this gap, we conducted a mixed methods study using survey data collected at a women’s recovery center in Canada. Our objectives were to describe CTs provided at the program; identify what CTs are perceived by participants as most/least positive; and explore factors that may impact participant experiences with CTs.

Methods:

We analyzed feedback responses from 255 women and girls ( Mage = 27.5 years, range 15–64) using Pearson chi-square tests, logistic regression, and inductive content analysis.

Results:

The most frequently provided CTs were yoga, energy-related activities (e.g. reiki, reflexology), and meditation. Among the most common CTs, participants provided the highest endorsements for massage and physical activity, and the lowest endorsements for yoga and drumming. Across CTs, whether participants looked forward to an activity contributed significantly to whether they found it helpful, would like to do it again, and planned to continue engaging in the activity after leaving the program. Four broad contextual factors were identified that may impact experiences and perspectives about CTs: (1) goodness of fit, (2) self-awareness, (3) growth, and (4) healing and holistic wellbeing.

Conclusions:

This study provides novel evidence on the potential impacts of CTs in substance use treatment for pregnant women and girls, and important contextual factors to consider when implementing these approaches.

Uptake, Retention, and Adherence to Pre-exposure Prophylaxis (PrEP) in TRIUMPH: A Peer-Led PrEP Demonstration Project for Transgender Communities in Oakland and Sacramento, California

BACKGROUND

TRIUMPH (Trans Research-Informed communities United in Mobilization for the Prevention of HIV) was a community-led, transgender-specific pre-exposure prophylaxis (PrEP) demonstration project at 2 community-based clinical sites in California. TRIUMPH used peer health education, community mobilization, and clinical integration of PrEP with hormone therapy to promote PrEP knowledge and acceptability. The goal of this study was to evaluate PrEP uptake, retention, and adherence among TRIUMPH participants and examine site-based differences.

METHODS

Eligible participants were adult transgender and gender diverse people interested in PrEP. Participants were seen at baseline and at 1, 3, 6, 9, and 12 months for PrEP provision, clinical visits, and HIV testing. PrEP uptake was defined as dispensation of PrEP, PrEP retention was defined as proportion of expected visits completed among those who initiated PrEP, and PrEP adherence was assessed by measuring tenofovir diphosphate concentrations in dried blood spots. Logistic regression models quantified the association of variables with PrEP outcomes.

RESULTS

TRIUMPH enrolled 185 participants; the median age was 28 years (interquartile range: 23-35), 7% was Black, and 58% was Latinx. PrEP uptake was as follows: 78% in Oakland and 98% in Sacramento; 91% among trans women, 96% among trans men, and 70% among nonbinary participants. Almost half (47%) rarely/never believed about HIV, and 42% reported condomless sex act in the past 3 months. Participants who reported higher numbers of sex partners were more likely to be retained and adherent; other predictors of adherence included not having a primary partner and not experiencing violence in the past 3 months.

CONCLUSIONS

This community-led, trans-specific PrEP demonstration project documents high levels of PrEP initiation in a young transgender and gender diverse cohort at risk of HIV acquisition.

Transphobia and gender identity: social representations of trans women from Brazil and Colombia

The present research aimed to identify and discuss the social representations of trans women related to gender identity and transphobia in Brazil and Colombia. In this study participated 43 Trans women, 22 from Brazil, aged between 18 and 55 years (M=29.09, SD=8.53) and 21 from Colombia, aged between 21 and 41 years (M=28.19, SD=7.63). This study adopted a qualitative approach in which semi-structured interviews were used. The data were analyzed by the Iramuteq software, which identified the social representations in classes. The results showed what the participants understood about transphobia and how they regarded their experiences with this gender identity. The participants presented negative social representations, aiming at their personal experiences related to their social context. Themes related to violence, discrimination, prejudice, denial of rights and family support emerged from both the Brazilian and Colombian sample. Implications for Tran´s quality of life are discussed.

What does gender affirmation mean to you? An exploratory study

PURPOSE

Gender affirmation lessens mental health disparities among transgender and gender nonbinary (TGNB) persons. However, the concept of what it means to be affirmed in one's gender has not been fully explored, nor has the impact of gender affirmation on other health indicators been determined. The purpose of this study was to explore the meaning of gender affirmation among a sample of TGNB persons.

METHODS

This qualitative, narrative inquiry study consisted of individual, in-depth, semi-structured interviews with a convenience sample of 20 TGNB persons. Descriptive content analysis was conducted to discover themes.

RESULTS

This study identified salient themes regarding the multiple levels of affirmation (including internal, external and societal) needed to achieve the overall goal of living an optimal life described as "being seen, heard and even celebrated" as TGNB.

CONCLUSION

Results of this study have clinical, educational, research, and policy implications. Future research should explore the impact of gender affirmation on important health indicators in the TGNB community, differences in the experiences and needs among subgroups of TGNB persons, and the potential impact of nurses on the health experience of TGNB persons across the spectrum of transition.

Postoperative Pain and Opioid Use after Facial Feminization Surgery

The objective of this study is to characterize surgical pain after facial feminization surgery (FFS) and delineate postoperative opioid usage. It is a retrospective cohort study. It was performed in a multicenter integrated health care system. Electronic medical records were reviewed for patient demographic characteristics, medical history, pain medication prescriptions, and responses to a postoperative pain survey. Student's t-test and the Mann-Whitney U-test were used for bivariate analysis. Fisher's exact tests were used for categorical data. Seventy-four patients who underwent FFS were included. The mean (standard deviation) reported "average" postoperative pain score was 4.3 (2.3) out of 10. A total of 58% of patients reported pain lasting 5 or fewer days after surgery. The severity and duration of postoperative pain was similar between patients who underwent partial-FFS or full-FFS. A total of 68% of patients required fewer than 15 opioid tablets. There were no significant differences in the quantity of opioids prescribed or used between patients who underwent partial-FFS or full-FFS. Older age and premorbid mood disorder did not correlate with greater severity/duration of pain or number of opioids used after surgery. Most patients required fewer than 15 opioid tablets after surgery and experienced less than a week of postoperative pain. Patients undergoing full-FFS did not appear to experience significantly greater pain than those undergoing fewer procedures. Older age and premorbid mood disorder were not predictors of worse pain outcomes or greater opioid utilization.

Alcohol interventions for LGBTQ+ adults: A systematic review

INTRODUCTION

Gender and sexual minority populations are more likely to drink excessively compared to heterosexual and cisgender people. Existing reviews of alcohol interventions focus on specific subgroups within the lesbian, gay, bisexual, trans*, queer, questioning or otherwise gender or sexuality diverse (LGBTQ+) population and neither identify their theoretical basis nor examine how interventions are tailored to meet the needs of specific subgroups.

METHODS

This systematic review includes published studies reporting the effectiveness of interventions to reduce alcohol use in LGBTQ+ people. The review followed PRISMA guidelines. Quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool.

RESULTS

The review includes 25 studies, with the earliest published in 2005. The majority (n = 20) focused on men who have sex with men; only two included sexual minority women and three included trans* people. Most studies were conducted in the USA (n = 21) and used a randomised design (n = 15). Five studies were assessed to be of strong quality, seven moderate and 13 weak. Interventions were mainly delivered face-to-face (n = 21). The most common approaches used to inform interventions were Motivational Interviewing (n = 8) and Cognitive Behavioural Therapy (n = 8). Nineteen studies reported a significant reduction in alcohol consumption.

DISCUSSION AND CONCLUSIONS

This review suggests that for interventions to be effective in reducing alcohol consumption in LGBTQ+ people, they need to be informed by theory and adapted for the target population. Alcohol interventions that focus on sexual minority women, trans* people and people with other gender identities are needed. The findings have implications for professionals who need to identify when gender and/or sexuality are peripheral or central to alcohol use.

Opioid pain medication misuse, concomitant substance misuse, and the unmet behavioral health treatment needs of transgender and gender diverse adults

BACKGROUND

Limited research has explored risk factors for opioid pain medication misuse, concomitant substance misuse, and the unmet behavioral health treatment (BHTx) needs of transgender and gender diverse (TGD) adults.

METHODS

In 2019, TGD adults (N = 562) in Massachusetts and Rhode Island were purposively recruited and completed a psychosocial and behavioral health survey (95 % online; 5% in-person). Multivariable logistic regression was used to examine factors associated with past 12-month opioid pain medication misuse and unmet BHTx needs.

RESULTS

Overall, 24.4 % of participants were trans women; 32.0 % trans men; and 43.6 % were non-binary. Past-year substance misuse included: marijuana (56.8 %), hazardous drinking (37.5 %), hallucinogens (9.8 %), benzodiazepines (8.2 %), and opioid pain medication (8.0 %). Among participants with past-year substance misuse and BHtx need (n = 326), 81.3 % received BHtx and 18.7 % had unmet BHtx needs. Being a trans woman, having HIV, stigma in healthcare, and number of substances misused were associated with increased odds of past-year opioid pain medication misuse; high social connectedness was associated with decreased odds of opioid pain medication misuse (p-values<0.05). Younger age, stigma in healthcare, and misusing opioid pain medications were associated with increased odds of unmet BHTx needs; post-traumatic stress disorder and family support were associated with decreased odds of unmet BHtx needs (p-values<0.05).

CONCLUSIONS

Addressing disparities in opioid pain medication misuse among TGD people requires systematic improvements in healthcare access, including efforts to create TGD-inclusive BHtx environments with providers who are equipped to recognize and treat the social and structural drivers of TGD health inequities, including opioid pain medication misuse.

International clinical practice guidelines for gender minority/trans people: systematic review and quality assessment

OBJECTIVES

To identify and critically appraise published clinical practice guidelines (CPGs) regarding healthcare of gender minority/trans people.

DESIGN

Systematic review and quality appraisal using AGREE II (Appraisal of Guidelines for Research and Evaluation tool), including stakeholder domain prioritisation.

SETTING

Six databases and six CPG websites were searched, and international key opinion leaders approached.

PARTICIPANTS

CPGs relating to adults and/or children who are gender minority/trans with no exclusions due to comorbidities, except differences in sex development.

INTERVENTION

Any health-related intervention connected to the care of gender minority/trans people.

MAIN OUTCOME MEASURES

Number and quality of international CPGs addressing the health of gender minority/trans people, information on estimated changes in mortality or quality of life (QoL), consistency of recommended interventions across CPGs, and appraisal of key messages for patients.

RESULTS

Twelve international CPGs address gender minority/trans people's healthcare as complete (n=5), partial (n=4) or marginal (n=3) focus of guidance. The quality scores have a wide range and heterogeneity whichever AGREE II domain is prioritised. Five higher-quality CPGs focus on HIV and other blood-borne infections (overall assessment scores 69%-94%). Six lower-quality CPGs concern transition-specific interventions (overall assessment scores 11%-56%). None deal with primary care, mental health or longer-term medical issues. Sparse information on estimated changes in mortality and QoL is conflicting. Consistency between CPGs could not be examined due to unclear recommendations within the World Professional Association for Transgender Health Standards of Care Version 7 and a lack of overlap between other CPGs. None provide key messages for patients.

CONCLUSIONS

A paucity of high-quality guidance for gender minority/trans people exists, largely limited to HIV and transition, but not wider aspects of healthcare, mortality or QoL. Reference to AGREE II, use of systematic reviews, independent external review, stakeholder participation and patient facing material might improve future CPG quality.

PROSPERO REGISTRATION NUMBER

CRD42019154361.

Minority stress and drug use among transgender and gender diverse adults: A daily diary study

BACKGROUND

Transgender and gender-diverse people are at higher risk for drug use and drug use disorder than their cisgender peers. Theory and research have suggested that external minority stressors (e.g., discrimination, violence, and rejection) and internal minority stressors (e.g., internalized transphobia) may contribute to this health disparity. However, few studies have examined the proximal (e.g., same-day) association between minority stress and drug use.

METHODS

The present study tested the same-day association of external and internal minority stressors with use of drugs in a sample of 38 transgender and gender-diverse participants residing in two Southeastern cities. Participants reported their previous day's experiences with minority stress and drug use over the course of 30 days. A total of 836 daily surveys were collected (73.3 % compliance rate).

RESULTS

Multilevel modeling revealed that external minority stress (i.e., violence, harassment, discrimination, rejection), but not internalized stigma, was associated with increased odds of drug use on a given day, while controlling for time, same-day depressive affect and cognition, same-day gender dysphoria symptoms, demographics, and baseline levels of drug use.

CONCLUSIONS

These findings suggest that external minority stress is associated with drug use on the same day. Future empirical and theoretical work may examine factors that could moderate these associations. Clinicians working with transgender and gender-diverse individuals should assess for minority stress and possible related drug use behavior.

Prevalence and minority-stress correlates of past 12-month prescription drug misuse in a national sample of transgender and gender nonbinary adults: Results from the U.S. Transgender Survey

BACKGROUND

Prescription drug (PD) misuse, particularly opioid misuse, is a major US public health concern. While transgender and gender nonbinary (TGNB) individuals experience numerous health disparities, including substance use disparities, little research has focused on PD misuse in this population.

METHODS

Data for this secondary analysis come from the US Transgender Survey (N = 26,689). First, we examined bivariate differences in past 12-month PD misuse among binary transgender women, binary transgender men, nonbinary individuals assigned-female-at-birth (AFAB), and nonbinary individuals assigned-male-at-birth (AMAB). We then used multivariable logistic regression (separately based on sex-assigned-at-birth) to examine the relationship between gender-identity related discrimination and PD misuse.

RESULTS

PD misuse was significantly more common among binary transgender men (17.3 %), nonbinary AFAB individuals (18.7 %), and nonbinary AMAB individuals (18.0 %); compared to binary transgender women (13.5 %). In multivariable analyses, nonbinary identity was associated with higher odds of PD misuse among TGNB AFAB individuals (OR = 1.121; 95 %CI 1.021-1.232) and AMAB individuals (OR = 1.315; 95 % CI 1.133-1.527). Controlling for overall health status and psychological distress, public accommodations discrimination was associated with PD misuse among TGNB AMAB individuals (OR = 1.578, 95 %CI 1.354-1.839). Among both groups, healthcare discrimination was associated with PD misuse (AFAB OR = 1.388, 95 %CI 1.255-1.534; AMAB OR = 1.227, 95 %CI 1.073-1.404).

CONCLUSION

In this national sample of TGNB individuals, nonbinary individuals were at greater risk for PD misuse than binary individuals, possibly due to less societal affirmation. Similar to other TGNB health disparities, discrimination based on gender identity/expression was associated with PD misuse. This highlights the importance of interventions to reduce discrimination against TGNB individuals.

Prevalence and Co-occurrence of Alcohol, Nicotine, and Other Substance Use Disorder Diagnoses Among US Transgender and Cisgender Adults

IMPORTANCE

Substance use disorders are a major source of morbidity and mortality in the United States. National data comparing the prevalence of substance use disorder diagnoses (SUDDs) among transgender and cisgender individuals are lacking in the United States.

OBJECTIVES

To investigate the prevalence of SUDDs among transgender and cisgender adults and to identify within-group and between-group differences by age, gender, and geographic location.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used the OptumLabs Data Warehouse to analyze deidentified claims from approximately 74 million adults aged 18 years or older enrolled in commercial or Medicare Advantage insurance plans in 2017. A total of 15 637 transgender adults were identified based on a previously developed algorithm using a combination of International Classification of Diseases, Tenth Revision (ICD-10) transgender-related diagnosis and procedure codes and sex-discordant hormone prescriptions. A cohort of 46 911 cisgender adults was matched to the transgender cohort in a 3:1 ratio based on age and geographic location.

MAIN OUTCOMES AND MEASURES

SUDDs, based on ICD-10 codes, were assessed overall and compared between transgender and cisgender cohorts and by geographic region (ie, Northeast, Midwest, South, and West); age groups (eg, 18-25, 26-30, 31-35 years), and gender (ie, transfeminine [TF; assigned male sex at birth, identify along feminine gender spectrum], transmasculine [TM; assigned female sex at birth, identify along masculine gender spectrum], male, and female).

RESULTS

In this study of 15 637 transgender adults (4955 [31.7%] TM) and 46 911 cisgender adults (23 247 [50.4%] men), most (8627 transgender adults [55.2%]; 51 762 cisgender adults [55.2%]) were aged between 18 and 40 years, and 6482 transgender adults (41.5%) and 19 446 cisgender adults (41.5%) lived in the South. Comparing transgender to cisgender groups, significant differences were found in the prevalence of a nicotine (2594 [16.6%] vs 2551 [5.4%]; P < .001), alcohol (401 [2.6%] vs 438 [0.9%]; P < .001), and drug (678 [4.3%] vs 549 [1.2%]; P < .001) SUDDs. Among transgender adults, cannabis was the most prevalent drug SUDD (321 [2.1%]), followed by opioid SUDD (205 [1.3%]) and cocaine SUDD (81 [0.5%]), whereas among cisgender adults, cannabis and opioid SUDDs were equally prevalent (cannabis, 186 [0.4%]; opioid, 207 [0.4%]), followed by cocaine SUDD (59 [0.1%]).

CONCLUSIONS AND RELEVANCE

In this study, the prevalence of SUDDs was significantly elevated among transgender adults relative to their cisgender peers. These findings underscore the need for culturally tailored clinical interventions to treat substance use disorder in transgender populations.

Prevalence and correlates of substance use among transgender adults: A systematic review

INTRODUCTION

Minority stress theories suggest that high rates of discrimination experienced by transgender people are precipitants of substance use. This risk is likely exacerbated by an inadequate provision of trans-inclusive substance misuse services. However, the exclusion of transgender people from the general substance misuse literature makes it difficult to determine the extent to which transgender status influences substance use. A systematic review was undertaken to better understand the prevalence, patterns and correlates of substance use among this group.

METHODS

In accordance with the PRISMA guidance, a literature search was conducted to 29th May 2019 on PubMed, PsycINFO, Embase and Global Health databases. Primary quantitative studies, published in English, that reported the prevalence, patterns or correlates of substance use by transgender people were included, with no restriction on methodological design.

RESULTS

653 unique records were identified, and 41 studies were included. Half the studies reported on both transgender men and transgender women and half transgender women only. There was high and excess prevalence of substance use among transgender compared with cisgender people, but insufficient evidence to estimate prevalence or quantify the risk for substance use. Correlates of substance use included transphobic discrimination or violence, unemployment and sex work, gender dysphoria, high visual gender non-conformity and intersectional sexual minority status.

CONCLUSIONS

The sparse findings lend support to the minority stress model. However, the overreliance of the literature on disproportionate investigation of transgender women with multiple intersectional disadvantages, means there are significant gaps regarding the wider transgender community. To ensure substance use treatment services are inclusive, gender identity should be recorded and targeted interventions available. Clinicians should be aware of the multiple, complex drivers of substance use and be prepared to ask about substance use and offer support. Given the high prevalence of trauma experienced by transgender people, trauma-informed psychosocial interventions may be useful in the management of problematic substance use in transgender adults.

Socially distant and out of reach: Unintended consequences of COVID-19 prevention efforts on transgender and gender non-binary populations in Puerto Rico

Substance use disorders in the United States disproportionately affect minorities and socially vulnerable populations, particularly those at the intersection of racial and sexual minority status. Preceded by over a century-long subjugation to the U.S. government, a recent financial crisis, the devastating hurricanes of 2017, and a string of earthquakes at the end of 2019 and early 2020, the current COVID-19 pandemic is only the most recent disaster to disrupt the local health care system in Puerto Rico. However, the effects of the current emergency and imposed social distancing measures have only exacerbated the underlying vulnerabilities of the transgender and gender non-conforming (GNC) population made bare during these other recent disasters. Clinics and providers who treat patients with opioid use disorder (OUD) in Puerto Rico have had to develop their own safety protocols to limit the spread of the virus while trying to optimize current treatment protocols to maintain the stability of their patients. Despite these measures, we have observed a reduction in the ability of local organizations to outreach to already disconnected transgender and GNC individuals with OUD. For example, due to the government-imposed curfew that began March 15, 2020, some providers engaged in outreach with transgender and GNC sex workers have eliminated nighttime outreach completely. Additionally, a research project surveying all buprenorphine prescribers in Puerto Rico has found that few have received training in treating this vulnerable population, and even fewer report that they are currently providing treatment for transgender or GNC individuals. If Puerto Rico is to address this problem of gross under-representation of a population known to be disproportionately affected by substance use disorders, Puerto Rico must address structural factors to prevent this disparity from widening further during the inevitable future disasters our health care system will face.

Screening, Counseling, and Shared Decision Making for Alcohol Use with Transgender and Gender-Diverse Populations

At-risk alcohol use occurs among transgender and gender-diverse (TGD) populations, yet current alcohol use screening tools and guidelines do not distinguish between sex- and gender-related characteristics, having been developed without accounting for natal sex-based physiology, effects of gender-affirming medical care, and gendered drinking behavior among TGD people. More research on how sex- and gender-related factors independently influence alcohol use can help validate gender-inclusive screening protocols and develop evidence-based guidelines meaningful for people of all genders. In the interim, clinicians must be mindful of gender diversity and engage in transparent, collaborative discussions when screening for and counseling about alcohol use.

Studying physical and mental health status among hijra, kothi and transgender community in Kolkata, India

Individuals with diverse sexual orientation and gender identities have historically experienced the major share of stigma, discrimination, and marginalization among all the LGTBIQ+ communities in India. Transgender, intersex, or queer individuals are deprived of their basic rights, self-dignity, bodily autonomy, and healthcare leading to significant negative health status. Recent legal reforms such as the decriminalization of Section 377 of the Indian Penal Code (prohibited same-sex activity) and amendments to the Transgender Persons (Protection of Rights) Bill may improve their health. In this context, the study has the following objectives: 1) to measure the physical and the mental health status of hijra, kothi, and transgender (HKT) individuals using the Short Form 12 (SF-12) questionnaire; 2) understand the variation in their health status by social determinants; and 3) identify spatial patterns of HKTs general, physical, and mental health. Data was collected using a Bengali version of SF-12 (N = 98). We calculated physical (PCS) and mental (MCS) health composite scores and conducted relevant statistical and spatial analysis. Findings revealed that HKT individuals had poor mental health (mean MCS = 42.3) compared to their physical health (mean PCS = 49.0). ANOVA tests showed statistically significant variation of PCS and MCS among HKTs by their age and income. Participants with both poor and good health conditions were evenly distributed in the study area, with no significant spatial clustering. This study was the first attempt to assess the health-related quality of life among the HKT individuals using SF-12, not previously adapted to gender-diverse communities in India. Results clearly indicate that there is a pressing need to address both physical and mental health among gender-diverse communities by not only improving awareness of their healthcare rights but by also removing social and structural barriers to health programs, increasing targeted health interventions, grassroot level activism, and government advocacy.

Association of transphobic discrimination and alcohol misuse among transgender adults: Results from the U.S. Transgender Survey

BACKGROUND

Alcohol misuse remains a leading preventable risk factor for morbidity and mortality in the United States. Evidence suggests that alcohol misuse is more prevalent among transgender populations. This study examined the association between transphobic discrimination and alcohol use/misuse among a large sample of transgender people.

METHODS

Using the 2015 U.S. Transgender Survey (N = 27,715), logistic regression models were conducted to estimate the adjusted odds ratios (AOR) and 95 % confidence intervals (CI) of current alcohol use, past-month binge drinking (≥1 occasion of consuming ≥5 alcoholic beverages within the past month), and past-month frequent binge drinking (≥5 occasions of binge drinking within the past month) among transgender people.

RESULTS

Of the respondents, 60.4 % reported current alcohol use, 24.3 % reported past-month binge drinking, and 8.5 % reported past-month frequent binge drinking. The majority (70.1 %) had experienced some form of past-year transphobic discrimination. Experiencing 3+ forms of transphobic discrimination was significantly associated with past-month binge drinking (AOR = 1.49, 95 % CI = 1.37-1.62) and past-month frequent binge drinking (AOR = 1.57, 95 % CI = 1.37-1.79) than individuals who did not experience transphobic discrimination. Persons who cross-dress showed higher odds of current alcohol use (AOR = 1.52, 95 % CI = 1.32-1.74), past-month binge drinking (AOR = 2.51, 95 % CI = 2.21-2.85), and past-month frequent binge drinking (AOR = 4.13, 95 % CI = 3.45-4.94) than transgender women. Discrimination within public spaces and housing domains had the most robust associations with alcohol misuse.

CONCLUSIONS

Experiencing transphobic discrimination increased the odds of alcohol misuse among transgender people. Stakeholders and providers should be cognizant of the multifaceted nature of transphobic discrimination as unique social stressors that many transgender persons experience.

Prevalence and Risk Factors of Nonmedical Prescription Opioid Use Among Transgender Girls and Young Women

IMPORTANCE

Nonmedical prescription opioid use is a pressing public health issue in the United States. Transgender youth, including adolescent girls and young women who were assigned male at birth and currently identify as women, female, transgender women, or another diverse gender identity along the transfeminine gender spectrum, are more likely than their cisgender peers to report illicit substance use and meet diagnostic criteria for substance use disorders. However, relatively little is known about the experiences of these populations in the current era of opioid addiction and misuse.

OBJECTIVE

To report the prevalence of and risk factors associated with lifetime nonmedical prescription opioid use in a high-risk community sample of transgender adolescent girls and young women who are sexually active.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used 2012 to 2015 baseline data from Project LifeSkills, a randomized clinical trial of a behavioral intervention to reduce the risk of HIV acquisition and transmission among a diverse sample of transgender adolescent girls and young women recruited from Boston, Massachusetts, and Chicago, Illinois. A total of 297 transgender girls and women aged 16 to 29 years who were sexually active were included in this analysis. Data were analyzed from June 2019 to August 2019.

EXPOSURES

Transgender woman identification.

MAIN OUTCOMES AND MEASURES

Self-reported lifetime nonmedical prescription opioid use.

RESULTS

Among 297 transgender adolescent girls and young women (mean [SD] age, 23.4 [3.5] years), 145 (48.8%) identified as non-Hispanic/Latinx black, 76 (25.6%) identified as non-Hispanic/Latinx white, 37 (12.5%) identified as Hispanic/Latinx, 7 (2.4%) identified as non-Hispanic/Latinx Asian, and 32 (10.8%) identified as multiracial or other race/ethnicity. Thirty-five participants (11.8%) reported lifetime nonmedical prescription opioid use. Young transgender women who smoked cigarettes monthly or less (adjusted odds ratio, 3.92; 95% CI, 1.10-13.89) and who smoked daily (adjusted odds ratio, 5.69; 95% CI, 1.87-17.33) had greater odds of nonmedical prescription opioid use compared with those who did not smoke. Additionally, participants who identified as a sexual orientation other than heterosexual, gay, lesbian, or bisexual had significantly greater odds of lifetime nonmedical prescription opioid use compared with those who identified as heterosexual (adjusted odds ratio, 3.69; 95% CI, 1.07-12.72).

CONCLUSIONS AND RELEVANCE

These findings suggest that transgender adolescent girls and young women have similar prevalence of lifetime nonmedical prescription opioid use compared with the US general population prevalence of 12.5%. These findings may serve as a call-to-action for public health surveillance studies and evidence-based interventions to be comprehensively tailored to examine and respond to specific trends of substance use, particularly opioid use disorder, among transgender populations.

Qualitative Study of the Processes of Transgender-Men Identity Development

OBJECTIVE

Describe and analyze the mental health service and medical needs of a group of transgender men from the point when they changed their gender identity to male.

MATERIAL AND METHOD

Transgender men volunteers who attended a specialized care center in Mexico City answered a qualitative semi-structured interview to explore their needs as well as the adversities they unnecessarily face due to the lack of information and care for their condition. Interviews were audio-recorded and transcribed for thematic analysis.

RESULTS

Respondents began to develop their transgender identity in childhood; however, during that time, almost none of them had any helpful contact with a health professional. Those who did receive some form of care received mistreatment rather than positive feedback. It was not until adulthood that they obtained facts about a specialized care center.

CONCLUSION

It is necessary for health professionals to have information about sexual diversity and be trained to meet the needs of transgender children, in order to have information on places and professionals who accompany them and advise on available treatments such as hormone blockers or treatments. The study includes a small but important sample. However, the currently hostile, discriminatory environment, significantly exposes transgender people to developing mental health problems.

The Roles of Gender Affirmation and Discrimination in the Resilience of Transgender Individuals in the US

Transgender individuals face severe stigma-driven health inequities structurally, institutionally, and interpersonally, yielding poor individual-level outcomes. Gender affirmation, or being recognized based on one's gender identity, expression, and/or role, may be considered a manifestation of resilience. To provide intervention and policy guidelines, we examined latent constructs representative of gender affirmation (legal documentation changes, transition-related medical procedures, familial support) and discrimination (unequal treatment, harassment, and attacks), and tested their impact on mental, physical, and behavioral health outcomes among 17,188 binary-identified transgender participants in the 2015 US Transgender Survey. Confirmatory factor analyses revealed high standardized factor loadings for both latent variables, on which we regressed outcomes using structural equation modeling. Fit indices suggested good model fit. Affirmation was associated with lower odds of suicidal ideation and psychological distress, and higher odds of substance use, and past-year healthcare use and HIV-testing. Discrimination was associated with higher odds of suicidal ideation, psychological distress, substance use, and past-year HIV-testing. Affirmation and discrimination interaction analyses showed lower odds of past-year suicidal ideation, with affirmation having a significant moderating protective effect against discrimination. Gender affirmation is paramount in upholding transgender health. Clarification of affirmation procedures, and increases in its accessibility, equitably across racial/ethnic groups, should become a priority, from policy to the family unit. The impact of discrimination demands continued advocacy via education and policy.

Gender expansive youth disclosure and mental health: Clinical implications of gender identity disclosure

Some healthcare providers work with gender expansive youth, and preliminary evidence notes that many of these youth do not disclose their gender identity to all of their healthcare providers. No previous research focused on youth has explored gender identity disclosure to healthcare providers, nor linked youth disclosure to negative mental health outcomes (e.g., symptoms of depression). Data were drawn from the LGBTQ National Teen Survey in order to test the relationship between gender identity disclosure, symptoms of depression, and self-esteem among 5,637 13- to 17-year old (M _age = 15.6) participants who identified as transgender boys, transgender girls, non-binary youth who were assigned female at birth (AFAB), or assigned male non-binary youth who were assigned male at birth (AMAB). Transgender boys reported the highest symptoms of depression and the lowest levels of self-esteem in comparison to other groups. Among the full sample, 66.8% had not disclosed their gender identity healthcare providers-non-binary AMAB youth were least likely to disclose (77.6%). Symptoms of depression were the highest and self-esteem was the lowest for transgender boys with mixed levels of disclosure. Transgender girls reported the lowest symptoms of depression - these youth had also disclosed their identities the most. Findings suggest that mixed disclosure to healthcare providers is problematic for gender expansive youth, especially transgender boys. Findings suggest a need to better prepare health professionals to understand not all gender expansive youth may feel comfortable disclosing their gender identities in medical contexts. Future research should explore gender affirmative healthcare as a potential protective factor in combatting negative mental health outcomes.

Understanding predictors of improvement in risky drinking in a U.S. multi-site, longitudinal cohort study of transgender individuals: Implications for culturally-tailored prevention and treatment efforts

OBJECTIVE

While transgender people report higher rates of risky drinking than the general population, no studies have examined transgender alcohol use longitudinally. This study investigated minority stress and identity development predictors of improvement in risky drinking among transgender individuals.

METHODS

Data come from a multi-site, longitudinal cohort study of U.S. transgender individuals (N = 330) and include measures of enacted stigma, felt stigma, identity development, and risky alcohol use. Theory-driven, hierarchical multivariable logistic regression was used to investigate the hypothesis that minority stress and identity development factors are related to improvement in risky drinking between baseline and 1-year follow-up.

RESULTS

Baseline risky drinkers (n = 106; 37.1%) were younger and more likely to have female sex assigned at birth. At 1-year follow-up, 68 baseline risky drinkers (64.2%) reported persistent risky drinking, while 38 (35.8%) reported improved drinking. Controlling for demographics and study site, female sex assigned at birth and enacted stigma were associated with lower odds of improved drinking. Non-white/Hispanic race/ethnicity, felt stigma, change in gender role/expression for 1-5 years, and diffuse-avoidant identity style were associated with higher odds of improvement.

CONCLUSIONS/IMPORTANCE

This is the first study to identity predictors of improvement in risky drinking among transgender individuals. Compared to trans-feminine individuals (assigned male at birth), trans-masculine individuals (assigned female at birth) were more likely to report risky drinking at baseline and had lower odds of improvement at 1-year follow-up. Improved drinking may be facilitated by preventing anti-transgender discrimination. Felt stigma and diffuse-avoidant identity style may lower alcohol risk via avoidance of drinking venues. Further research is needed to explicate these relationships and to inform culturally-tailored alcohol interventions for this at-risk population.

Day-Level Associations Between Substance Use and HIV Risk Behavior Among a Diverse Sample of Transgender Women

Purpose: Transgender women in the United States face elevated rates of HIV and of substance use. Studies measuring overall or aggregate levels of substance use have linked use to increased HIV transmission risk behavior (TRB). Although intensive longitudinal studies in other populations have found day-level links between substance use and TRB, no study has yet explored such links among transgender women. This study aimed to fill this gap in the literature. Methods: Utilizing survey and 60-day timeline follow-back interview data from a sample of 214 transgender women in New York City, we tested whether day-level heavy drinking, marijuana use, and/or nonprescription stimulant use were associated with odds of engaging in any sex (vs. no sexual activity) or engaging in TRB (vs. sex without TRB), adjusting for overall levels of use. Results: Multilevel models showed that each of the three substance types was associated with greater odds of engaging in sex on a given day-and more strongly so for heavy drinking among those with higher rates of heavy drinking, and for stimulant use among those with lower rates of stimulant use. Only marijuana use was associated with greater odds of TRB on a given day, but only among those with higher rates of use. Conclusion: These findings substantiate day-level links between substance use and engaging in sexual activity among transgender women, and importantly, between marijuana use and greater likelihood of TRB on a day when sexual activity occurs. This highlights the importance of addressing substance use for sexual health among transgender women especially focusing on marijuana use.

TransAction: A homegrown, theory-based, HIV risk reduction intervention for transgender women experiencing multiple health disparities

HIV vulnerability among transgender women is symptomatic of numerous syndemic psychosocial and structural co-factors that attribute to and exacerbate HIV risk. From February 2010 to December 2017, 514 transgender women enrolled in a 'homegrown' theory-based, HIV risk reduction program, TransAction, specifically designed to intervene with trans women who experience numerous co-occurring health disparities. Increased attendance in TransAction intervention sessions was associated with significant reductions in the number of male sexual partners (coef. = -0.20), anonymous male sexual partners (-0.30), exchange male sexual partners (-0.25), engagement in drug/alcohol use (-0.37), engagement in injection drug use (-0.20), engagement in unmonitored injection hormone use (-0.55), engagement in sex while high (-0.23), and engagement in sex work (-0.20; all coefficient estimates p ≤ 0.05). Results demonstrated that the homegrown HIV risk reduction intervention was successful in working with transgender women who experience multiple co-occurring syndemic conditions. Given that there has been a dearth of evidence-based interventions for this population that are designed to be delivered in resource limited settings, TransAction can serve as a model HIV risk reduction program for guiding public health departments and community-based organizations.

Alcohol research with transgender populations: A systematic review and recommendations to strengthen future studies

BACKGROUND

There is a recent and growing research literature on alcohol use and related harms among transgender and other gender minority populations; however, current definitions and measures of hazardous drinking do not consider the complexity of physiological sex characteristics and socially constructed gender, raising doubts regarding their validity, applicability, and use with these populations. To address this, we reviewed current research on alcohol-related outcomes in transgender populations and critically summarized key issues for consideration in future research.

METHODS

We conducted a systematic review of transgender alcohol research in English language, peer-reviewed journals, published 1990-2017, and extracted key details (e.g., sample composition, alcohol measures, results).

RESULTS

Forty-four studies met all inclusion criteria for the review, the majority of which were conducted in the United States. The prevalence of hazardous drinking was high; however, estimates varied widely across studies. We noted frequent methodological weaknesses, including few attempts to differentiate sex and gender, poor attention to appropriate definitions of hazardous drinking, and reliance on cross-sectional study designs and non-probability sampling methods.

CONCLUSION

Given findings that suggest high need for ongoing public health attention, we offer recommendations to improve future alcohol studies with transgender and other gender minority populations, such as being explicit as to whether and how sex and/or gender are operationalized and relevant for the research question, expanding the repertoire of alcohol measures to include those not contingent on sex or gender, testing the psychometric performance of established screening instruments with transgender populations, and shifting from descriptive to analytic study designs.