Glynn T.R., van den Berg J.J.
Transgender Health: 2017, 2(1), p. 45–59.
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Part review, part ‘call to action’, the featured paper highlights the lack of awareness of evidence-based interventions for transgender people, and advocates for ‘culturally-sensitive’ approaches embedded in both general and specialised substance use programmes.
Summary Nearly two decades ago, the need for specialised substance use services for lesbian, gay, bisexual, and transgender (LGBT) people was proposed to remedy shortcomings, discrimination, and bias in general treatment programmes. Following this, the US-based Substance Abuse and Mental Health Services Administration published a policy highlighting LGBT-specific issues in substance use treatment to researchers and treatment providers.
‘Transgender’ is an umbrella term for people who do not identify with the sex they were assigned at birth:
• A transgender woman (or trans woman) is someone who was assigned or designated male at birth but identifies and lives as a woman.
• A transgender man (or trans man) is someone who was assigned or designated female at birth but identifies and lives as a man.
The term transgender also includes people who are ‘non-binary’. Someone who is non-binary feels that their gender identity cannot be defined by the expected binary terms of either ‘man’ or ‘woman’, or ‘male’ or ‘female’; they experience their gender in another way.
Transgender people are more vulnerable to substance use problems than the wider population, and exhibit more severe drinking and drug use patterns. Yet today there remains a lack of consensus about evidence-based substance use interventions for this group. The featured review was the first to attempt to identify and summarise available evidence on interventions for reducing problem substance use among transgender people, and to synthesise treatment recommendations from the literature.
Only two studies met criteria for being included in the review. Of the 44 potentially relevant papers screened, only one could be retained for review – the majority needing to be excluded because they did not specifically evaluate an intervention (26), failed to report outcomes (7), or did not report separate outcomes for transgender participants (5). An additional study from the same research group, identified through consultation with experts in transgender health, was retained for review. This had been presented at a conference but not yet published in a peer-reviewed journal.
Both studies aimed to reduce substance use and the risk of contracting HIV among transgender women over the age of 18, who were living or working in San Francisco – a population showing some of the highest rates of HIV, substance use, and mental health problems among all groups at risk. The interventions were facilitated in both English and Spanish by health educators, all of whom were transgender women.
Between October 2001 and September 2003, 206 transgender women (out of an eligible 359) enrolled in the TRANS programme. The intervention involved 18 weekly, one-hour, group workshops, which participants were encouraged to complete at their own pace, and covered three domains: (1) sex, relationships, and health; (2) reducing drug use and improving coping skills; and (3) general life needs.
The intervention space was designed to feel safe, welcoming and culturally sensitive, and included a living room area, shower facility, and a resource closet with donated clothing and accessories free to those in need.
Participants were assessed before starting the intervention, and again within two weeks of completing the intervention (ie, attending 10 or more of the 18 group sessions). Around half reported drinking and using illicit drugs at baseline. By the second assessment, there were significant reductions in perceived barriers to substance use treatment programmes, marginal reductions in drinking during the past 30 days [from 57% to 48%], and no changes in illicit drug use [remaining at 46%].
[The TRANS trial also found significant reductions in depression and the level of risky sexual behaviour (measured by determining whether participants were at no risk, low risk, or high risk) in the past 30 days, and considerable but non-significant reductions in participants reporting that they had engaged in unprotected receptive anal sex in the past 30 days.]
The TEAM-I study focused exclusively on transgender African American and Latina women who reported drinking alcohol almost every day or using drugs more than three days a week in the past six months. In contrast to the TRANS programme ( above) delivered in group workshops, TEAM-I sessions were delivered to individuals.
Between March 2011 and August 2012, 114 participants were recruited and randomly allocated to one of three groups:
• Motivational enhancement therapy (up to six, two-hour sessions) based on motivational interviewing, and informed by the ‘stages of change’ [see Effectiveness Bank hot topic]: A culturally-sensitive curriculum was developed in consultation and partnership with a community advisory board comprising people from the San Francisco Department of Public Health, community-based organisations serving the transgender community, and transgender community members. The objectives were to reduce substance use, reduce sexual risk, develop supportive social networks and healthier/prosocial community activities, and increase self-esteem and pride in being transgender women.
• Brief intervention (up to two, two-hour counselling sessions) to deliver individualised health information: The objectives were to provide brief information and guidance about substance use and HIV risk reduction, provide information about hazardous substance use and HIV risk behaviour patterns without confrontation and convey positive intentions or ideas for substance use and HIV prevention, present a menu of options for prevention and/or behavioural change methods and plan achievable short-term goals.
• Control group: Providing the data against which the active interventions were benchmarked, these participants were just supplied information on substance use and HIV prevention.
All 114 participants completed assessments at baseline, 93 completed follow-up assessments at three months and 78 at six months.
From baseline to the six-month follow-up, drinking, cannabis, and amphetamine use decreased among both intervention groups. The reduction was significant in the motivational enhancement group compared with the brief intervention and control groups. Decreases in frequency of use of alcohol, cannabis, and amphetamine were greater among participants in the motivational enhancement group between baseline and the six-month follow-up.
A further two studies were identified but had not been completed/published at the time the review was conducted – the first, a pilot with 20 transgender women and subsequent trial with 240 participants randomised to an intervention (motivational interviewing plus cognitive-behavioural skills training) versus a control group of transgender women on a waiting list; and the second, testing the feasibility, acceptability, and efficacy of electronic screening and brief interventions on drinking, as well as a ‘seek, test, treat, and retain’ model of care for people who use drugs and are at risk of HIV.
There are numerous barriers to treatment for transgender people that should be addressed in the design of substance use programmes, including: staff who don’t have any knowledge about the realities and experiences of transgender people; little formal education for staff regarding the needs of transgender people; treatment providers holding negative attitudes; verbal, physical, and sexual abuse by other clients and staff; and discrimination such as being required to wear only clothes judged to be appropriate for their birth sex.
Consistent themes from the wider literature indicate that, within general substance use programmes, integrated care should be developed and amended to be culturally sensitive. Programmes that do not cater to transgender people specifically should make every effort to foster an environment and treatment experience of affirmation and inclusivity to allow for a transgender people to focus on their substance use problems. Examples include not restricting access to restrooms that are appropriate for their gender identity, and using appropriate names and pronouns.
Within specialised transgender substance use programmes services should:
• Identify specific issues that affect transgender people and consider how to target these issues when developing interventions.
• Encourage participation of transgender people and transgender advocates in the design of interventions, enabling them to confirm the needs of the transgender community and elicit new needs that have not been identified in the research.
• Address co-occurring issues.
• Support interventions being delivered by transgender peers and interventions which promote a positive identification with the transgender community.
Perhaps the most important conclusion of the featured review was that well-designed and theoretically-informed research into substance use interventions for people who are transgender is alarmingly scarce.
Evidence-based practice tends to be developed from and tested among majority populations, disregarding important differences, especially for those at higher risk of substance use problems. Specialised care remains difficult to find, and therefore cultural-sensitivity training for providers and staff in general care is important.
commentary The major limitation of the featured review was the lack of studies involving and reporting the outcomes of transgender people in substance use interventions – so lacking in fact that only two studies could be identified, both of which were conducted by the same research team, and only one of which had been published in a peer-reviewed journal. Such a dearth of research would typically cast doubt on the relevance of highlighting the review. However, there is an argument to be made that not discussing the findings would be reinforcing the problem that transgender people continue to be neglected in substance use intervention research.
The authors described the review as part ‘call to action’. In their own words:
“The research regarding predictors, associations, barriers, and needs for transgender substance use treatment has been well documented; it is now time to design, implement, and disseminate interventions using this information to provide needed services to the transgender community.”
The pair of studies described in the review (as well as two studies that were yet to be completed at the time of publication) featured samples of transgender women only. Therefore, within the under-represented and marginalised population of transgender people it is important to note that there are subgroups even less well represented in research including transgender men and people who are non-binary.
The two studies were conducted by the same research team, but targeted different groups of transgender women – the Transgender Empowerment and Motivational Interviewing (TEAM-I) intervention designed to reach transgender African American and Latina women who reported drinking alcohol almost every day or using drugs more than three days a week in the past six months, compared with the Transgender Resources and Neighborhood Space (TRANS) intervention which was open to all transgender women regardless of cultural background or substance use.
As the TRANS intervention did not screen on the basis of problem substance use, the study may have been limited in its ability to evaluate the effects of treatment, or in other words ‘underpowered’ to detect significant changes because the sample was diluted with participants who may have been drinking and using drugs, but who did not have substance use problems as such to overcome. This was likely compounded for detecting changes in illicit drug use, because the final sample of participants who completed a minimum of 10 workshops reported significantly less illicit drug use at baseline than those who did not. More broadly, the failure to report findings for the whole sample means that rather than an effect of the intervention, any findings may have been wholly or partly due to the whittling out of the types of participants who were unable or unwilling to attended 10 of the 18 planned sessions. Another limitation, as the authors noted, was the lack of a control group, preventing the authors from attributing changes in participants’ behaviour to the intervention as opposed to other factors.
Researchers working on the TRANS programme acknowledged that San Francisco offered a relatively progressive setting in which to deliver the intervention. However, outside of this setting the TRANS curriculum could be implemented by general health service providers interested in developing culturally-sensitive practices.
While the review could not meet its main aim, it did provide value in formulating recommendations for both specialised and general substance use treatment programmes based on the known barriers to treatment. One of the most important messages was that to help transgender people focus on their substance use problems, treatment programmes need to be culturally sensitive and support their clients’ gender identities. A report published in 2017 by the Scottish Trans Alliance, in partnership with North Ayrshire Alcohol and Drug Partnership and North Aryshire Health and Social Care Partnership, uncovered concerns that the opposite was true of drug and alcohol services. A survey sampling 202 transgender people living in Scotland found that respondents feared harassment, hurtful, demeaning and insulting language, feared that trans-specific healthcare would be stopped or refused due to their ‘addiction status’, and that services would not know enough about transgender people to help. Some had also experienced being ‘misgendered’ – both intentionally and unintentionally – and a lack of understanding that they might not be able to ‘prove their identity’ where current documentation does not reflect their gender identity. Over half of a sub-sample of 137 participants had at some point felt unable to approach specialist services for help with their drug and alcohol problems – 62% refrained from approaching their GP, 57% one-to-one addiction services, 56% peer support, and 50% charities and voluntary organisations. The figure may have been higher for GPs if participants saw them as ‘gatekeepers’ to trans-specific healthcare, such as referring them to gender identity clinics, monitoring their bloodwork, and prescribing hormones.
Instead of (or as well as) drawing theoretical foundations from the general substance use treatment literature, interventions for transgender people could be enriched if informed by specific theories of substance use problems among transgender people, for example the ‘minority stress theory’. This posits that particular social groups can experience additional stressors related to their marginalised status in society. Prolonged exposure to prejudice and discrimination (eg, transphobia) is associated with adverse psychological outcomes and health risk behaviours such as substance use. The TEAM-I intervention demonstrated how using community-based participatory research methods can enable members and advocates of the transgender community to identify or confirm the needs of this population.
The World Health Organization identifies transgender people as one of five key populationsFive key populations at risk of HIV are men who have sex with men, people who inject drugs, people in prisons and other closed settings, sex workers, and transgender people. disproportionately affected by HIV in all countries and settings. Its 2014 consolidated guidelines cover targeted HIV prevention, diagnosis, treatment and care for these at-risk groups.
The National Institute for Health and Care Excellence (NICE), the UK’s health and social care advisory body, acknowledges that transgender people are at risk of developing problems with illicit drugs, new psychoactive substances (previously known as ‘legal highs’) and prescription-only medicines, and provides evidence-based guidance on how to improve delivery of substance use prevention to these and other at-risk groups of children, young people, and adults.
Last revised 16 January 2019. First uploaded 06 December 2018