Post Traumatic Stress Disorder (PTSD) As a Mediator of Child Sexual Abuse (CSA) and Substance Use Among a National Probability Sample of Transgender and Gender-Expansive (TGE) Adults in the United States

Background and Purpose: Transgender and gender-expansive (TGE) people experience an excess burden of child sexual abuse (CSA), mental health concerns, and risky substance use behavior compared to cisgender populations. Post-traumatic stress disorder (PTSD) has been found to mediate CSA and substance use behaviors in cisgender populations, but this pathway has not been previously examined among TGE adults.

Methods: A representative national probability sample of TGE adults (N=274) were sampled as part of the U.S. Transgender Population Health Survey (TransPop study). CSA victimization was measured using the Adverse Childhood Experiences (ACE) subsection for sexual abuse. Positive screening for PTSD was measured using criteria from the Primary Care-Post Traumatic Stress Disorder (PC-PTSD) DSM-IV screening tool. Substance use behaviors were determined by any lifetime reports of drug use or binge drinking, as well as recent drug use behavior measured by The Drug Use Disorders Identification Test (DUDIT). Baron and Kenny’s (1986) approach was used to assess PTSD as a mediator between reports of CSA and substance use behaviors. Parameter estimation used weighted complex samples logistic (CSLR) and general linear regression (CSGLR) models. All multivariable models included covariance adjustment for sociodemographic measures.

Results: Within our sample, a large minority of TGE adults reported a victimization history of CSA (40%) and positively screened for PTSD (42%). Over a third of TGE adults reported lifetime binge drinking (36%) and drug use (38%) behavior, and the average DUDIT score was 3.95. TGE adults who reported having experienced CSA had significantly higher odds of PTSD (aOR= 5.0, 95%CI: 2.6-9.8); lifetime binge-drinking (aOR= 2.0, 95%CI: 1.2-3.6) and drug use (aOR= 2.5, 95%CI: 1.4-4.4), as well as a higher mean DUDIT (𝛽=2.3, 95%CI: 0.7-3.9) compared to TGE adults without a CSA victimization history. Results from the mediation analyses were consistent with PTSD being a complete mediator between CSA and lifetime binge drinking and DUDIT scores as well as a partial mediator for lifetime drug use.

Conclusions and Implications: Additional research needs to explore CSA as a critical risk factor for negative mental health outcomes and substance use risk among TGE populations. Therapeutic interventions aimed at alleviating PTSD symptoms are likely crucial for addressing traumas related to CSA and co-occurring substance use problems among TGE adults.