Patterns in Gender Identity Stress Experiences of Transgender and Nonbinary Persons of Color Living in the United States: Relationship with Mental Health and Substance Use

Background and Purpose: Transgender and nonbinary (TNB) persons of color (POC) experience mental health and substance use disparities compared to their White and cisgender counterparts. Intersectionality theory, Gender Minority Stress and Resilience Model (GMSRM), and Gender Affirmation framework alongside empirical literature links aforementioned disparities to disproportionally higher minority stress (e.g., discrimination, rejection) exposure among TNB POC. Literature has examined the role of individual minority stressors in the community as isolated phenomena, however, limiting researchers’ ability to explore the role of multiple interwoven stressors in the lives of TNB persons more holistically. We use a person-centered approach to examine how gender minority stressors may cluster among TNB POC, facilitating poorer mental health and substance use outcomes.

Methods: Data consisted of the POC subsample of the 2015 U.S. Transgender Survey (n=5,057). Most participants were multiracial (30.7%) or Latine/Hispanic (29.1%), with an average age of 28.5 years. Additionally, most identified as transgender men (31.9%) or nonbinary (assigned female at birth; 31.8%). Using mixture modeling, we created latent profiles of gender minority stressors. Four indices, discrimination (x̄=1.1; range 0-11), victimization (x̄=0.7; 0-22), rejection (x̄=0.9; 0-8), and gender non-affirmation (x̄=9.8; 0-17) were used as indicators. We compared nested models across four variance-covariance structures, and selected the final model using information criteria, entropy, and theory. Using a three-step approach, mental health (i.e., suicidal ideation, planning, and attempts, psychological distress) and substance use (i.e., cannabis, electronic/combustible cigarette, illicit substances/prescription misuse, and heavy episodic drinking) outcomes were regressed on profiles while controlling for age, gender, race, sexual orientation, education, employment, and household income. Analyses were weighted to be representative of the US TNB population. Bonferroni correction was used to account for multiple comparisons (p<0.006).

Our final model had a profile-invariant unrestricted variance-covariance structure (entropy=0.932) and three profiles: (1)Rejection-dominant (n=694/13.7%), marked by high rejection and non-affirmation and moderate discrimination and victimization levels, (2)Cumulative stigma (n=200/4.0%), marked by high levels of non-affirmation, victimization, and discrimination and moderate rejection, and (3)Non-affirmation-dominant (n=4,160/82.3%), marked only by high gender non-affirmation.

Findings: Compared to non-affirmation-dominant profile, rejection-dominant profile membership was associated with higher odds of past-year suicidal ideation (aOR=2.43) and planning (aOR=2.43) and past 30-day psychological distress (aOR=3.11). Cumulative stigma profile membership was associated with greater odds of past year electronic/combustible cigarettes use (aOR=3.61) and illicit substance use/prescription misuse (aOR=4.06) compared with non-affirmation-dominant profile membership.

Conclusions and Implications: This study is among the first to elucidate how multiple minority stressors may cluster among TNB POC in distinct ways, facilitating poorer mental health and substance use outcomes. While TNB POC experienced high gender non-affirmation across profiles, its coupling with high rejection or cumulative stigmatization is linked to greater mental health and substance use vulnerabilities, respectively. Importantly, longitudinal analyses are needed to rule out any alternative explanations. Nevertheless, findings suggest social workers should consider using tailored mental health and substance use-related assessments. Lastly, findings underscore the need for policies addressing growing stigmatization of TNB persons and cumbersome barriers to gender affirming resources.