Transgender Adolescents, Gender Congruence, and Substance Use

Background and Purpose: Though data is limited, transgender adolescents have been observed to use substances at elevated rates. There are no known studies on the relationship between gender congruence and substance use outcomes among transgender adolescents. Gender congruence is the degree to which individuals feel their gender expression is genuine, authentic and comfortably in-line with their gender identity. From a gender minority stress framework, it is hypothesized that gender congruence will act as a protective factor against elevated substance use outcomes among transgender adolescents. Methods: The Youth Risk Behavior Survey was administered using a two-phase cluster-randomized sampling design in 2013 resulting in a representative sample of 9-12 grade students in Los Angeles, CA. The survey assessed gender identity and presentation, sexual orientation, ethnicity, sex, age, and substance use histories including past 30-day cigarette use, binge drinking, and marijuana use, as well as lifetime cocaine use and other illicit substance use. logistic regression was used to assess for significant moderation of substance use outcomes by gender congruence while controlling for sociodemographic differences including sexual orientation.  Results: Nearly 60% of adolescents were Latino (n=951), half reported female sex (n=816), about 12% were non-heterosexual (n=192) and about 60% of the sample were age 16 years or younger (n=987). Regression analyses indicated that the main effect of gender congruence was significantly associated with binge drinking (OR=.70, p=.018) and cocaine use (OR=.67, p=.038) in our sample of transgender (n=96) and cisgender (n=1,398) adolescents. The main effect of transgender status was not associated with any substance use outcomes. However, the interaction between transgender status and gender congruence was associated with cigarette use (OR=.69, p=.022) and binge drinking (OR=.69, p=.013). The higher risk of transgender adolescents for engaging in cigarette use, and binge drinking was only seen for gender incongruent adolescents (n=34); gender congruent transgender adolescents (n=61) and all cisgender adolescents regardless of gender congruence showed lower risk. Additionally, lesbian, gay and bisexual identity was significantly associated with increased likelihood for cigarette use (OR=2.33, p<0.001), binge drinking (OR=2.33, p<0.001), marijuana use (OR=2.38, p<.001), cocaine use (OR=3.08, p<.001), and any illicit drug use (OR=3.09, p<0.001). Age was significantly associated with all five substance use variables, while ethnicity and sex were not. Conclusions and Implications: Findings indicate that gender congruence may be an important protective factor for transgender adolescents regarding certain types of substance use. More research is needed to better understand the effect of gender congruence on transgender adolescent health overall, as well as to explore potential interventions to support transgender gender non-congruent adolescents in abstaining from substance use while still affirming their gender presentations and expressions. It is important to note that while gender congruence may be related to substance use outcomes, there should not be an effort to ask young people to conform to society’s gender norms and binary. Rather, social workers should strive to better educate communities and support resilience in young people whose gender expression does not match expectations placed on them.