Transgender Youth Substance Use Disparities: Results From a Population-Based Sample

Published:September 21, 2017DOI:



      The purpose of this study was to examine rates of substance use between transgender and nontransgender youth using a representative population-based sample and to examine mediating risk factors.


      A statewide cross-sectional sample of California middle and high schools collected between 2013 and 2015. This representative sample of students in California included 335 transgender and 31,737 nontransgender youth. Using multivariate linear and logistic regression, we assessed differences between transgender and nontransgender youth in substance use behaviors related to alcohol, cigarette, marijuana, other illicit drugs, polysubstance use, and heavy episodic drinking. Substance use was assessed with lifetime use, age of onset, and past 30-day use for alcohol, cigarettes, and marijuana. Past 30-day use was also assessed for other illicit drugs and polysubstance use. Models were adjusted for demographics and risk factors including victimization, depressive symptoms, and perceived risk of substance use.


      The prevalence of substance use was 2.5–4 times higher for transgender youth compared with their nontransgender peers (depending on the substance). Transgender youth were also at greater risk for early age of onset and recent substance use than nontransgender youth. In addition, psychosocial risk factors related to victimization, depressive symptoms, and perceived risk of substance use partially mediated the relationship between gender identity and substance use.


      Using data from the first representative study of youth to include a measure of gender identity, we show that transgender youth are at heightened risk for substance use compared with nontransgender peers. Future research is needed to identify the structural and psychosocial mechanisms that drive these disparities.


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        • Faden V.B.
        • Goldman M.
        The effects of alcohol on physiological processes and biological development.
        Alcohol Res Health. 2005; 28: 125-132
        • Kann L.
        • Kinchen S.
        • Shanklin S.L.
        • et al.
        Youth risk behavior Surveillance — United States, 2013.
        MMWR Surveill Summ. 2014; 63: 1-170
        • Schulenberg J.E.
        • Maggs J.L.
        Destiny matters: Distal developmental influences on adult alcohol use and abuse.
        Addiction. 2008; 103: 1-6
        • Sloan F.
        • Grossman D.
        • Platt A.
        Heavy episodic drinking in early Adulthood and outcomes in Midlife*.
        J Stud Alcohol Drugs. 2011; 72: 459-470
        • Behrendt S.
        • Wittchen H.-U.
        • Höfler M.
        • et al.
        Transitions from first substance use to substance use disorders in adolescence: Is early onset associated with a rapid escalation?.
        Drug Alcohol Depend. 2009; 99: 68-78
        • Dawson D.A.
        • Goldstein R.B.
        • Patricia Chou S.
        • et al.
        Age at first drink and the first incidence of adult-onset DSM-IV alcohol use disorders.
        Alcohol Clin Exp Res. 2008; 32: 2149-2160
        • Tharp-Taylor S.
        • Haviland A.
        • D’Amico E.J.
        Victimization from mental and physical bullying and substance use in early adolescence.
        Addict Behav. 2009; 34: 561-567
        • Conner K.R.
        • Pinquart M.
        • Gamble S.A.
        Meta-analysis of depression and substance use among individuals with alcohol use disorders.
        J Subst Abuse Treat. 2009; 37: 127-137
        • Fisher L.B.
        • Miles I.W.
        • Austin S.B.
        • et al.
        Predictors of initiation of alcohol use among US adolescents: Findings from a prospective cohort study.
        Arch Pediatr Adolesc Med. 2007; 161: 959-966
        • IOM (Institute of Medicine)
        The health of lesbian, gay, bisexual, and transgender People: Building a Foundation for Better understanding.
        National Academies Press, Washington, D.C.2011
        • Talley A.E.
        • Hughes T.L.
        • Aranda F.
        • et al.
        Exploring alcohol-use behaviors among heterosexual and sexual minority adolescents: Intersections with sex, age, and race/ethnicity.
        Am J Public Health. 2014; 104: 295-303
        • Garofalo R.
        • Deleon J.
        • Osmer E.
        • et al.
        Overlooked, misunderstood and at-risk: Exploring the lives and HIV risk of ethnic minority male-to-female transgender youth.
        J Adolesc Health. 2006; 38: 230-236
        • Hotton A.L.
        • Garofalo R.
        • Kuhns L.M.
        • et al.
        Substance use as a mediator of the relationship between life stress and sexual risk among young transgender women.
        AIDS Educ Prev. 2013; 25: 62-71
        • Reisner S.L.
        • Greytak E.A.
        • Parsons J.T.
        • et al.
        Gender minority social stress in adolescence: Disparities in adolescent bullying and substance use by gender identity.
        J Sex Res. 2015; 52: 243-256
        • De Pedro K.T.
        • Gilreath T.D.
        • Jackson C.
        • et al.
        Substance use among transgender students in California public middle and high schools.
        J Sch Health. 2017; 87: 303-309
        • Meyer I.H.
        • Wilson P.A.
        Sampling lesbian, gay, and bisexual populations.
        J Couns Psychol. 2009; 56: 23-31
        • McGuire J.K.
        • Anderson C.R.
        • Toomey R.B.
        • et al.
        School climate for transgender youth: A mixed method investigation of student experiences and school responses.
        J Youth Adolesc. 2010; 39: 1175-1188
        • Mustanski B.S.
        • Garofalo R.
        • Emerson E.M.
        Mental health disorders, psychological distress, and suicidality in a diverse sample of lesbian, gay, bisexual, and transgender youths.
        Am J Public Health. 2010; 100: 2426-2432
        • Kosciw J.G.
        • Greytak E.A.
        • Diaz E.M.
        Who, what, where, when, and why: Demographic and ecological factors contributing to hostile school climate for lesbian, gay, bisexual, and transgender youth.
        J Youth Adolesc. 2009; 38: 976-988
        • Almeida J.
        • Johnson R.M.
        • Corliss H.L.
        • et al.
        Emotional distress among LGBT youth: The influence of perceived discrimination based on sexual orientation.
        J Youth Adolesc. 2009; 38: 1001-1014
        • Russell S.T.
        • Ryan C.
        • Diaz R.M.
        • et al.
        Lesbian, gay, bisexual, and transgender adoloscent school victimization: Implications for young adult health and adjustment.
        J Sch Health. 2011; 81: 223-230
        • Goodman E.
        • Huang B.
        Socioeconomic status, depressive symptoms, and adolescent substance use.
        Arch Pediatr Adolesc Med. 2002; 156: 448-453
        • Birkett M.
        • Espelage D.L.
        • Koenig B.
        LGB and questioning students in schools: The moderating effects of homophobic bullying and school climate on negative outcomes.
        J Youth Adolesc. 2009; 38: 989-1000
        • Cochran S.D.
        • Grella C.E.
        • Mays V.M.
        Do substance use norms and perceived drug availability mediate sexual orientation differences in patterns of substance use? Results from the California Quality of Life Survey II.
        J Stud Alcohol Drugs. 2012; 73: 675-685
        • Substance Abuse and Mental Health Services Administration (SAMHSA)
        Results from the 2012 national survey on drug Use and Health: Summary of national findings.
        Substance Abuse and Mental Health Services Administration, Rockville, MD2013
        • Luk J.W.
        • Wang J.
        • Simons-Morton B.G.
        Bullying victimization and substance use among U.S. adolescents: Mediation by depression.
        Prev Sci. 2010; 11: 355-359
        • Johnston L.D.
        • O’Malley P.M.
        • Miech R.A.
        • et al.
        Monitoring the future: National results on adolescent drug use: Overview of key findings.
        Institute for Social Research, The University of Michigan, Ann Arbor2015
        • Austin G.
        • Bates S.
        • Duerr M.
        Guidebook for the California Healthy Kids survey part II: Data use and dissemination (2013-14 edition).
        WestEd, San Francisco, CA2015
        • Austin G.
        • Polik J.
        • Hanson T.
        • et al.
        School climate, substance use, and student well-being in California, 2013-2015. Results of the fifteenth Biennial Statewide Student Survey, Grades 7, 9, and 11.
        WestEd Health & Human Development Program, San Francisco, CA2016
        • Austin G.
        • Bates S.
        • Duerr M.
        Guidebook to the California Healthy Kids Survey part II: Survey content core module (2013-14 edition).
        WestEd, San Francisco, CA2015
        • StataCorp
        Stata statistical software: Release 14.
        StataCorp LP, College Station, TX2015
        • Enders C.K.
        Applied missing data analysis.
        The Guilford Press, New York, NY2010
        • Shrout P.E.
        • Bolger N.
        Mediation in experimental and nonexperimental studies: New procedures and recommendations.
        Psychol Methods. 2002; 7: 422-445
        • Durso L.E.
        • Gates G.J.
        Serving our youth: Findings from a national survey of services providers working with lesbian, gay, bisexual and transgender youth who are homeless or at risk of becoming homeless.
        The Williams Institute with True Colors Fund and The Palette Fund, Los Angeles2012
        • Rosario M.
        • Schrimshaw E.W.
        • Hunter J.
        Risk factors for homelessness among lesbian, gay, and bisexual youths: A developmental milestone approach.
        Child Youth Serv Rev. 2012; 34: 186-193
        • Snapp S.D.
        • Hoenig J.M.
        • Fields A.
        • et al.
        Messy, Butch, and queer LGBTQ youth and the school-to-Prison Pipeline.
        J Adolesc Res. 2015; 30: 57-82
        • Reisner S.L.
        • Conron K.J.
        • Tardiff L.A.
        • et al.
        Monitoring the health of transgender and other gender minority populations: Validity of natal sex and gender identity survey items in a US national cohort of young adults.
        BMC Public Health. 2014; 14: 1