Gender Diversity, Substance Cognitions, and Alcohol, Nicotine/Tobacco, and Cannabis Use Among U.S. Youth

Background and Purpose: Initiation of substance use typically begins in childhood or adolescence. The most commonly used substances among adolescents in the United States (U.S.) are alcohol, cannabis, and nicotine/tobacco. An individual’s age at first substance use is associated with faster transition to heavier substance involvement, substance use disorder, and substance use-related challenges during later adolescence and into adulthood. Given that the brain is still developing during adolescence and is more susceptible to the harmful effects of substance use, identifying subgroups who may be particularly vulnerable to substance use can inform the enhancement of early prevention and intervention strategies.

Studies on substance use disparities among U.S. youth have shown that transgender youth have heightened risk of substance use relative to their cisgender peers. However, these studies often use a binary and cross-sectional conceptualization of gender identity. Consequently, information on substance cognitions (i.e., curiosity and intention to use) and substance use among gender diverse youth remains limited. Using a multidimensional construct of gender, we aimed to classify youth according to longitudinal, repeated measures of gender indicators and examine associations of gender subgroups with curiosity, intention, and use of alcohol, nicotine/tobacco, and cannabis, adjusting for sociodemographic factors.

Methods: We used data from the Adolescent Brain Cognitive Development (ABCD) Study (N=11,868 youth at baseline [ages 9-10, 2016-2018] through the year 4 follow-up [ages 13-14, 2020-2022] and their parent/caregivers across 21 research sites). We identified subgroups of adolescents using latent class analysis (LCA). Indicators for the LCA models included: gender identity, felt gender, gender expression, and gender non-contentedness. Multivariable logistic regression was used to examine associations of gender class with curiosity, intention, and use of alcohol, nicotine/tobacco, and cannabis.

Results: A four-class model of gender was selected based on model fit: transgender (2.5%), questioning (9.0%), naïve (36.3%), and cisgender (52.1%). Members of the questioning and transgender classes were more likely to report curiosity to use (adjusted odds ratio [AOR] range 1.68-2.45, p<0.001) and intention to use (AOR range 1.69-3.14, p<0.01) but not actual use of alcohol, nicotine/tobacco, and cannabis relative to cisgender members. Members of the naïve class were less likely to report curiosity to use, intention to use, and use of alcohol, nicotine/tobacco, and cannabis (AOR range 0.48-0.81, p<0.001) relative to cisgender members.

Conclusions and Implications: This study underscores the importance of assessing preadolescent youth’s substance cognitions and engaging in early prevention efforts—particularly among those who identify as transgender or are questioning their gender, as these subgroups may be more vulnerable to later alcohol, nicotine/tobacco, and cannabis use. The finding that youth in the questioning and transgender classes did not have significantly higher odds of reporting alcohol, nicotine/tobacco, and cannabis use relative to their cisgender counterparts suggests that the timing of prevention efforts may be ideal during this developmental period. A more nuanced understanding of gender among preadolescent youth and their heterogeneous risk for substance use is critical for the enhancement of early prevention services. Substance use prevention efforts targeting youth should consider gender-specific approaches to increase acceptability among these youth populations.