When gender minority adolescents, including transgender teens, are exposed to transphobia and other gender-related stressors, they are more likely to use alcohol to cope, but family and social support, as well as gender-related pride, can moderate the use of substances, according to trailblazing longitudinal research from Boston Children's Hospital, Harvard Medical School and the Harvard T.H. Chan School of Public Health.

The team surveyed 30 gender minority adolescents in a multiyear study. The results align with a previous study that found gay and bisexual teens were more likely to drink while underage and to binge drink. The team's findings can be especially useful in designing interventions and recommending adaptive coping strategies for gender minority adolescents who abuse alcohol, the co-authors noted in the study, published Wednesday in PLOS ONE.

The paper was released a day after President Joe Biden proclaimed June to be Lesbian, Gay, Bisexual, Transgender, and Queer Pride Month in the U.S. The holiday is celebrated around the world, with millions of people marching in Pride parades from Germany to the Middle East. But the authors of the new study said the fight for equality is far from over.

"The latest attempts to restrict access to [gender-affirming] care are disheartening and make it clear that transphobia is alive and well in this country," lead author and principal investigator Sabra L. Katz-Wise told The Academic Times. 

In just the past six months, 22 states introduced bills that limit medical care for young transgender people. Aside from targeted attacks, self-harm persists at high levels; one recent study found that 85% of transgender adolescents seriously considered suicide.

"Trans and nonbinary youth appear to use substances as a way to cope with gender minority stress," said Katz-Wise. Her motivation to study gender identity is personal: "I'm also a member of the LGBTQ+ community," she said. "Through my research and advocacy efforts, I strive to uplift the experiences of the more marginalized members of our community, including transgender and nonbinary youth."

Katz-Wise and her colleagues designed the study with the aim of helping gender minority adolescents feel accepted and avoid harm. The researchers who conducted the interviews were either LGBTQ+ individuals themselves or identified as allies. If a participant reported an intent to harm themselves or had a high level of psychological distress, the researchers followed a safety plan and connected the adolescent to mental health resources.

Data in the study was collected from the Trans Teen and Family Narratives Project, which is a community-based project seeking to establish how family environments affect the health and well-being of transgender and nonbinary youth in the U.S. The project, led by Katz-Wise and funded by the National Institutes of Health, surveyed families at six-month intervals over a two-year period.

Though the initial results from the project were published in 2018, the current study builds on that analysis by examining risk and protective factors, such as depressive symptoms and resilience, over time.

"This study also highlighted a number of areas that future interventions could focus on," Katz-Wise said.

Qualitative interviews were conducted to assess risk factors and protective factors that gender minority individuals face on a regular basis. Gender-related pride and resilience were two main protective factors, while internalized transphobia and depressive or anxious symptoms were the major stressors. Possible mediators, such as a high level of family functioning and social support, were also addressed through the questions.

Eleven adolescents in the study identified as trans feminine, 15 identified as trans masculine and four identified as nonbinary assigned female. Though gender identities were diverse, the racial makeup of participants was notably homogeneous. The co-authors noted race and ethnicity as two major limitations in the sample: 73% were white and 87% were non-Hispanic.

Substance use significantly increased over the two years of data collection. At the time of the initial survey, 17% of participants reported use of any substance, and 4% reported use of multiple drugs. After two years had passed, 56% of the participants reported substance use, and 32% had used more than one substance.

"For comparison, data from the Youth Risk Behavior Survey collected during 2019 (data for the current study were collected in December 2015 to March 2019) indicated that 37% of high school students reported recent tobacco use, 29% reported recent alcohol use, and 22% reported recent marijuana use," the authors noted in the study, referring to a major national survey of high schoolers in the United States, conducted by the Centers for Disease Control and Prevention. "GM adolescents [in the] current study reported higher rates of alcohol and marijuana use, but not tobacco use."

"Higher exposure to gender minority stressors significantly increased the odds of alcohol use in later waves," the authors wrote in the study. Among the risk factors, increased transphobia stood out, as it was associated with increased odds of anxious and depressive symptoms over time. The authors were surprised that tobacco and marijuana use were not affected by gender-related stressors.

The scope of the gender minority stressors can help mental health providers design effective programs to support gender minority youth, said Katz-Wise. In this area, the Trans Teen and Family Narratives Project can get the pride ball rolling. It proposes a digital intervention based on a storytelling narrative that will help families support their children and all transgender and nonbinary youth.

"My hope for the next 5-10 years is that visibility and acceptance of transgender and nonbinary youth will continue to increase," Katz-Wise said. "Families and parents can best support transgender and nonbinary youth by listening to them and taking their lead in terms of how they identify — and what support and medical care they need to feel completely affirmed in their gender identity."

The study, "Longitudinal effects of gender minority stressors on substance use and related risk and protective factors among gender minority adolescents," published Wednesday in PLOS ONE, was authored by Sabra L. Katz-Wise and S. Bryn Austin, Boston Children's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health; Vishnudas Sarda, Boston Children's Hospital; and Sion Kim Harris, Boston Children's Hospital and Harvard Medical School.