Differences in alcohol use and alcohol-related problems between transgender- and nontransgender-identified young adults

Highlights

• Heavy episodic drinking (HED) differs between transgender and nontransgender people.

• Sexual assault after drinking is higher for transgender than nontransgender people.

• Suicidality after drinking is higher for transgender than nontransgender people.

• For transgender people, sexual assault is associated with greater HED days.

• For transgender people, verbal threats are associated with greater HED days.

Abstract

Background

Little is known about differences in alcohol use and alcohol-related problems between transgender- and nontransgender-identified populations. Using data from a large-scale health survey, we compare the drinking patterns and prevalence of alcohol-related problems of transgender-identified individuals to nontransgender-identified males and females. For transgender-identified people, we examine how various forms of victimization relate to heavy episodic drinking (HED).

Methods

Cross-sectional surveys were completed by 75,192 students aged 18–29 years attending 120 post-secondary educational institutions in the United States from 2011 to 2013. Self-reported measures included alcohol use, alcohol-related problems, victimization, and sociodemographics, including 3 gender-identity groups: transgender-identified individuals; nontransgender-identified males; and nontransgender-identified females.

Results

Compared to transgender-identified individuals, nontransgender-identified males were more likely to report HED in the past 2 weeks (relative risk = 1.42; p = 0.006); however, nontransgender-identified males and females reported HED on fewer days than transgender-identified people (incidence-rate ratios [IRRs] ranged from 0.28 to 0.43; p-values < 0.001). Compared to transgender-identified people, nontransgender-identified males and females had lower odds of past-year alcohol-related sexual assault and suicidal ideation (odds ratios ranged from 0.24 to 0.45; p-values < 0.05). Among transgender-identified people, individuals who were sexually assaulted (IRR = 3.21, p = 0.011) or verbally threatened (IRR = 2.42, p = 0.021) in the past year had greater HED days than those who did not experience those forms of victimization.

Conclusions

Compared to transgender-identified people, nontransgender-identified males and females: have fewer HED occasions (despite nontransgender-identified males having greater prevalence of HED); and are at lower risk for alcohol-related sexual assaults and suicidal ideation. Experiences of sexual assault and verbal threats are associated with greater HED occasions for transgender-identified people.

Introduction

After systematically documenting the dearth of research on transgender populations, the landmark Institute of Medicine report on the health of lesbian, gay, bisexual, and transgender populations recommended expanding research on the health of transgender populations (Institute of Medicine, 2011). The term transgender is commonly used as an umbrella term for people whose gender identity or expression does not conform with the sex they were assigned at birth (Institute of Medicine, 2011, The GenIUSS Group, 2014). Transgender populations often face multiple forms of discrimination and victimization, including physical, verbal, and sexual assault (Institute of Medicine, 2011, Stotzer, 2009), which can negatively impact their wellbeing and may result in maladaptive coping, such as heavy alcohol use (Keyes et al., 2011, Meyer, 2003).

Few epidemiologic surveillance systems collect information about transgender status (Institute of Medicine, 2011, The GenIUSS Group, 2014), limiting information that compares the drinking behaviors of transgender people to their cisgender counterparts (i.e., people whose gender identity and expression match their assigned sex at birth). One study of United States youth (aged 13–18 years) found that transgender youth had higher odds of lifetime alcohol use than cisgender youth, but were no different in their prevalence of regular alcohol use (i.e., alcohol use at least monthly in the past year) (Reisner et al., 2014a). Another study of Massachusetts adults (aged 18–64 years) found no differences in the prevalence of past-month heavy episodic use between transgender and cisgender populations (Conron et al., 2012). The remaining few studies about transgender individuals’ alcohol use utilized convenience-based samples or lacked direct cisgender comparison groups (Bradford et al., 2013, Gilbert et al., 2014, Hotton et al., 2013, Reisner et al., 2013, Rowe et al., 2015). Therefore, we have incomplete knowledge about drinking differences between transgender and cisgender populations, especially among young adults, the age group most at risk for heavy alcohol use in the United States (Centers for Disease Control and Prevention, 2010b, Fryar et al., 2006, Substance Abuse and Mental Health Services Administration, 2011, USDHHS, 2009).

Alcohol use, especially heavy episodic drinking, can lead to acute problems—like blackouts, suicides, and sexual assaults (Darvishi et al., 2015, Perkins, 2002, White, 2003)—which contribute to multiple leading causes of death among young adults (Centers for Disease Control and Prevention, 2010a). In young adulthood, the prevalence of alcohol-related problems sometimes vary by gender (American College Health Association, 2012, Perkins, 2002). According to studies where transgender status was not assessed, males were more likely get into trouble with police, while females were more likely to experience sexual assault (Perkins, 2002). Meanwhile, blackouts and alcohol-related suicidality are equally common among males and females (American College Health Association, 2012, Perkins, 2002). Yet, little to no information exists about differences in alcohol-related problems for transgender people compared to their cisgender counterparts.

A burgeoning body of literature shows that, compared to cisgender people, transgender individuals have a higher risk of experiencing victimization (Grant et al., 2011, Institute of Medicine, 2011, Kosciw et al., 2012, Reisner et al., 2014a), which can induce psychological distress and lead to alcohol use as a way of coping (Keyes et al., 2011, Meyer, 2003). While this phenomenon has been shown in multiple empirical studies of alcohol use among transgender populations (Bradford et al., 2013, Gilbert et al., 2014, Hotton et al., 2013, Reisner et al., 2013, Rowe et al., 2015), there is a paucity of research about how certain forms of assault (i.e., physical, verbal, and sexual) are associated with heavy episodic drinking for transgender people. In studies where transgender status was not measured, different types of victimization have diverse effects on alcohol use (Begle et al., 2011, Tyler et al., 2012). For example, in a longitudinal study of adolescents, experiences of sexual and physical abuse predicted subsequent high-risk behavior (including alcohol use) for boys, and sexual abuse was the primary driver of subsequent high-risk behavior for girls (Begle et al., 2011). These results demonstrate how associations between victimization and alcohol use vary by gender, substantiating the need for a within-group analysis among transgender populations.

The purpose of this study was to examine alcohol use and alcohol-related problems for transgender young adult populations using data from a large epidemiologic surveillance system of college and university students in the United States. We examined differences in drinking behaviors and the prevalence of alcohol-related problems by gender identity, comparing transgender-identified people to their nontransgender-identified counterparts. We also examined how various forms of victimization were related to heavy episodic drinking among transgender-identified people.