The Binary Gender Of Addiction Screening Tools: Can Transgender People Benefit From Them?

by Krisoula Kotassidis 

A recent national US study found that transgender people 18-35 years old are more likely than cisgender people to be diagnosed with a substance use disorder10.Research shows that transgender people face additional stressors due to stigma, compared to the general population14 which explains their high rates of substance use. As a result, young transgender adults do not feel comfortable accessing medical and mental health care services, including substance use treatment7. This is why widespread awareness about transgender stress, and prevention of substance use disorders in these populations is crucial. However, existing prevention tools for substance use screening and treatment may cause more harm than benefit to transgender individuals, as they were designed with exclusively cisgender heterosexual people in mind10.

Photo credit: Juan Moyano, 2019
[Photo description: Person standing in the middle of a beach, shown from the chest and up. The transgender flag including the colours of blue, pink and white covers their head. At the background the sky is clear with only a few clouds].

Let’s talk labels first

Gender is pretty simple, right? You are born with male genitalia; therefore, you are a boy and your caregiver dresses you in blue. You are born with female genitalia; therefore, you are a girl and your caregiver dresses you in pink. This is a binary cisgender identity which assumes that your sex assigned at birth defaults to only one of two gender options. Individuals who feel happy and comfortable with such an identity and expression usually do not have to think about their gender; they just enjoy being accepted for who they are. Gender identity is your individual experience of being man, woman, both, something in between or something else. Gender expression is the way you communicate your gender identity to others through your clothing, behaviour, preferred pronouns etc.1

People who do not identify as neither a man nor a woman are non-binary. But, what about transgender people? Transgender is an umbrella term describing individuals whose gender identity or gender expression does not conform to the gender norms associated with the sex (female vs. male) they were assigned at birth6. In reality, there are many more ways in which people identify with or express their gender.

From minority stress to substance use to substance use disorders

Although research on transgender populations is extremely limited, the evidence about their poor physical and psychological well being is alarming. Transgender people face more discrimination, receive more threats about their safety, and are more likely to be victims of sexual and physical violence compared to non-transgender people 6. In the workplace, transgender people are more likely to get fired and be denied a job because of their gender identity and expression compared to non-trans folks. As a result, trans people are more likely to be homeless.14

Image by: NCTE
[Photo description: Activists on the street protesting for transgender rights. They are standing in front of a historical building and only their heads are depicted in the picture. One person, closest to the camera, holds a sign reading “We want to live free”. The rest of people are holding primarily transgender flags, and one person is holding the US flag].
This image has an empty alt attribute; its file name is K_Image3.jpg
Infographic made on Canvas by: Krisoula Kotassidis

Transgender people learn to expect such stressful events to happen, which makes them hide their gender identity to protect themselves from emotional and physical harm6. However, this often exacerbates their distress13. At the same time, transgender folks often agree with stigmatising beliefs about the way they identify with and present their gender (aka internalised transphobia) which hinders their ability to cope and accept themselves for who they are13.  To make things worse, transgender individuals are less likely to access available health care and report gender-based violence to the police 6. This is because transgender prejudice and discrimination is deeply rooted in social institutions, such as our education, healthcare, and law enforcement.12

All these experiences are traumatising to the transgender person who lives each day with fear because of the stigma they experience due to their minority status. As a result, trans populations are found with high rates of psychological disorders, substance use disorders, and suicide attempts.46

Screening & timely intervention: An example 

The Screening, Brief Intervention, and Referral to Treatment (SBIRT) model is a public health screening process used to identify individuals who use substances6. The goal of this process is to:

  • identify users who are at risk of developing a substance use disorder
  • intervene when the individual is engaged in high-risk substance use, and
  • refer individuals with severe use to a specialist. 
Image by: SAMHSA
[Image description: Four smaller pictures places next to each other creating a square and showing images of family, friends, and a hospital setting with a doctor standing in front of the camera having their hands crossed. On the right side the background of the image is in blue reading “SBIRT: Screening, Brief Intervention and Referral to Treatment”].

The model is usually used in clinical settings by doctors, nurses, social workers and other healthcare professionals6; however, there is evidence that the model is also beneficial in non-professional settings used by individuals with little or no clinical training6.   Plenty of research supports the effectiveness of this screening tool particularly with vulnerable populations such as racial minorities6, prenatal and parenting women, adolescents, and the elderly.6

Is SBIRT trans inclusive?

The answer is: no. In fact, this model uses screening tools supported by binary research using gender binary biological standards and language, without taking into account transgender-specific stressors and stigma 6. For example, the pre-screening questionnaire only refers to binary risk limits  for alcoholic drinks per day, by expecting individuals to choose only between the risk limits for men (5 or more/day) or women (4 or more/day) when answering the questions.7 However, these drinking thresholds are based on biological sex and only refer to biological females or males who also identify as women or men, respectively, in terms of gender. This may be harmful for trans folks because we do not even know how many drinks for them are too much, and also because of the non-affirming language being used.

Gender binary language also includes the use of only she/her and he/him pronouns without considering whether the individual feels comfortable with these pronouns. If you consider the gender-based emotional trauma that transgender folks have to live with, you can understand why language and representation in screening measures are important for them to feel safe in substance use screening and intervention settings. If the person does not feel accepted for who they are, they will be reluctant to receive any advice or treatment no matter how well intended it is.

Image by: Shutterstock
[Image description: Six people standing next to each other, all of different ethnicities wearing a pink, orange, yellow, green, violet, and purple clothing. They each have their preferred pronouns written on their tops].

What if SBIRT (trans)itions?

Just because something doesn’t work the way it’s supposed to doesn’t mean that we should give up on it.  Transgender focused research is almost non-existent, while there are very few transgender-specific substance use disorders healthcare professionals. But, transgender people are still struggling with substance misuse. Transgender people, especially those who are racialized, homeless or involved in sex work are overdosing 12.Therefore, we need to act fast by changing our already existing tools. Here is how SBIRT and the medical and mental health care field can change:

  • By giving priority to transgender healthcare professionals in developing and administering transgender-specific substance use prevention and treatment programs6.
  • By changing the language of screening questionnaires used in the interviewing process to include gender neutral pronouns 6.
  • By training healthcare professionals to be sensitive to the lived experiences of trans folks6 and aware of their other social identities, such as race and socioeconomic status without making binary assumptions about the individual 
  • By making use of effective peer support

How does peer support work?

According to research, peers helping each other is effective for HIV prevention, as well as, depression and substance misuse treatment.11 Therefore, some researchers believe that training transgender individuals to use tools like  SBIRT in transgender spaces could be effective, especially for those at higher risk for substance use19. Peer support can help with gender-based stressors and build resilience to cope with stigma by creating a non-judgmental environment, while preventing substance use or preparing those with heavy use for treatment6.

How you can help 

Be a transgender ally! You do not have to be transgender nor a healthcare professional to support transgender folks at risk of substance use disorders. Although there are available courses for SBIRT training online, you do not have to undergo training in order to help. Instead: 

Photo credit: John Keon, 2018
[Photo description: Portrait of writer and performance artist, ALOK. They are wearing a pink, blue, and light brown hair extension. Their make-up is in pink, white, and purple tone. They are also wearing long purple and white earrings and a navy blue and white striped, long sleeved top with gold buttons].
  • Learn more about transgender individuals through social media spaces. My favourite Instagrammer is ALOK. They have helped me so much in understanding gender. The best way to learn about transgender people and be an ally is to listen to them. It is the first big step in removing any  stereotypical thinking you might have adopted.
  • Remember the suggestion about SBIRT (trans)itioning? Well, you can do it too! You can change your language by using gender neutral pronouns when you feel ambivalent about one’s gender. Or even better: you can just ask the person what their preferred pronouns are. Trust me, they will very much appreciate it.
  • Call out (in a civilised manner) on transphobic jokes or other acts of discrimination against transgender people. If you actively show your allyship, a transgender person will feel more comfortable around you and even trust you in talking to you about their substance use. Take the first step to become an ally here.
  • Donate, donate, donate here. Even if you cannot donate, you can volunteer! Don’t have the time to volunteer? No worries! You can make the continuous effort to use the proper pronouns and simply accept transgenders for who they truly are. This is an important first step to allyship.

Dealing with substance use disorders is challenging, especially for transgenders who live with additional stressors because of their gender identity and expression. Be there for them, listen, and give them voice. Provide them with valuable peer support to identify those at risk and point them to trans-affirming treatment environments. Try it! You might save a life.


References

  1. American Psychological Association. (2014). Transgender people, gender identity and gender expression. Retrieved from: https://www.apa.org/topics/lgbtq/transgender
  2. Bavinton, B., Gray, J., & Prestage, G. (2013). Assessing the effectiveness of HIV prevention peer education workshops for gay men in community settings. Australian and New Zealand Journal of Public Health, 37(4), 305–310. doi: 10.1111/1753-6405.12076
  3. Candian Centre for Addictions. (2019). Addiction in the LGBTQ community: LGBTQ individuals tell their stories. Retrieved from: https://canadiancentreforaddictions.org/addiction-lgbtq/
  4. Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality, 51, 53–69. doi: 10.1300/J082v51n03_04 
  5. Day, J. K., Fish, J. N., Perez-Brumer, A., Hatzenbluehler, M. L., Russel, S. T. (2017). Transgender youth substance use disparities: Results from a population-based sample, Journal of Adolescent Health, 61(6), 729-735. doi: https://www-sciencedirect-com.ezproxy.lib.ryerson.ca/science/article/pii/S1054139X17303257
  6. Dentato, M. P., Ortiz, R., Orwat, J., Kelly, B. L., Gates, T. G. & Propper, E. (2019) Peer-based education and use of the SBIRT model in unique settings with transgender young adults, Journal of Social Work Practice in the Addictions, 19:1-2, 139-157, doi: 10.1080/1533256X.2019.1589884.
  7. Gilbert, P. A., Pass, L. E., Keuroghlian, A. S., Greenfield, T. K., & Reisner, S. L. (2018). Alcohol research with transgender populations: A systematic review and recommendations to strengthen future studies. Drug and alcohol dependence, 186, 138–146. https://doi.org/10.1016/j.drugalcdep.2018.01.016 
  8. Glynn, T. R., & van Den Berg, J. J. (2017). A systematic review of interventions to reduce problematic substance use among transgender individuals: A call to action. Transgender Health, 2(1), 45–59. doi:10.1089/trgh.2016.0037  
  9. Gonzalez, C.A., Gallego, J.D., Bockting, W.O. (2017). Demographic characteristics, components of sexuality and gender, and minority stress and their associations to excessive alcohol, cannabis, and illicit (noncannabis) drug use among a large sample of transgender people in the united states. J. Prim, 38, 419–445. doi:
  10. Hughto, J. W., Quinn, E. K., Dunbar, M. S., Rose, A. J., Shireman, T. I. & Jasuja, G. K. (2021). Prevalence and co-occurrence of alcohol, nicotine, and other substance use disorder diagnoses among US transgender and cisgender adults. JAMA Network Open, 4(2), e2036512–. doi: 10.1001/jamanetworkopen.2020.36512
  11. Kelly, J. F., & Yeterian, J. D. (2015). Outcome research on twelve-step programs. In M. Galanter & H. D. Kleber (Eds.), Textbook of substance abuse treatment (5th ed., pp. 579–595). Washington, DC: American Psychiatric Press.
  12. Laye, B. (2019). The Overdose Crisis Isn’t Gender Neutral. West Coast Leaf. Retrieved from: http://www.westcoastleaf.org/2019/08/07/the-overdose-crisis-gender/ 
  13. Martino, W., Kassen, K. & Omercajic, K. (2020) Supporting transgender students in schools: Beyond an individualist approach to trans inclusion in the education system, Educational Review, doi: 10.1080/00131911.2020.1829559
  14. Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36, 38–56. Doi: https://www-jstor-org.ezproxy.lib.ryerson.ca/stable/2137286?pq-origsite=summon&seq=1#metadata_info_tab_contents
  15. Meyer, I. H., Schwartz, S., & Frost, D. M. (2008). Social patterning of stress and coping: Does disadvantaged social statuses confer more stress and fewer coping resources? Social Science & Medicine, 67, 368–379. doi:10.1016/j.socscimed.2008.03.012
  16. SBIRT training. (2021). Retrieved from: https://sbirt.clinicalencounters.com/aboutus/ 
  17. Trans Pulse. (N/A). Drug use among transgender people in Ontario. Retrieved from: https://transpulseproject.ca/research/drug-use-among-transgender-people-in-ontario-canada-disparities-and-associations-with-social-exclusion/ 
  18. Trans Equality Canada. Retrieved from: https://www.transequalitycanada.com/background 
  19. Hughes TL, Wilsnack SC, Kantor LW. The Influence of Gender and Sexual Orientation on Alcohol Use and Alcohol-Related Problems: Toward a Global Perspective. Alcohol Res. 2016;38(1):121-32. PMID: 27159819; PMCID: PMC4872607. doi: https://pubmed.ncbi.nlm.nih.gov/27159819/ 

 Images & social media 

  1. CBC News. (2020). 4 Canadian transgender activists you should know. Retrieved from:https://www.youtube.com/watch?v=zbKXfme1Wkc&ab_channel=CBCNews 
  2. Moyano, J. (2019). Retrieved from: https://www.stocksy.com/3251846/covered-by-a-transgender-pride-flag 
  3. Keon, J. (2018). Retrieved from: https://www.alokvmenon.com/photo 

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