(152) Socioeconomic Status and Unhealthy Alcohol Use Among Transgender Adults

Background & Introduction: Alcohol-related health outcomes are shown to be associated with different levels of alcohol consumption in men and women (1). However, there is limited research specifically addressing alcohol use and outcomes in gender-diverse and transgender people; major limitations include imprecise categorization of participants’ sex and gender, lack of comparator cisgender participants, and limited demographics information (2). The literature indicates that unhealthy alcohol use among transgender people is associated with gender identity-based minority stress (3), but complex interactions exist with other sociodemographic risk factors (4). One such risk factor is socioeconomic status (SES). Current research shows that alcohol use increases with SES and is moderated by other demographic factors including gender (5). Thus, this project aimed to compare how SES impacts alcohol use in transgender patients from a large, integrated healthcare system, informing both an intersectional and biopsychosocial approach to clinical care.

Methods: This retrospective cohort study utilized electronic health record (EHR) data from Kaiser Permanente Northern California (KPNC). The sample included transgender (N = 5,593) and cisgender (N = 73,089) adults (≥18 years) from the Study of Transition, Outcomes and Gender who received alcohol screening through the Alcohol as a Vital Sign program between 2013-2021.

Patients were identified as transgender (transmasculine or transfeminine) or cisgender through EHR data. SES was measured through neighborhood deprivation index (NDI) and insurance type. NDI is a neighborhood-level measure of SES based on American Community Survey data that was geocoded to patient residences, serving as a proxy for individual-level SES; higher NDI is associated with lower SES. NDI was categorized into quartiles based on the KPNC member distribution. The primary outcome, as defined by National Institute on Alcohol Abuse and Alcoholism guidelines, was unhealthy alcohol use.

Logistic models were fit to examine associations between SES and gender identity with unhealthy alcohol use. Models adjusted for age, race/ethnicity, mental health diagnosis, drug use disorder, and Charlson comorbidity score. Interaction terms were used to assess whether associations between SES and outcomes differed between cis- and transgender patients. Analyses used R version 4.3.1.

Results: Transgender patients were less likely to have unhealthy alcohol use than cisgender patients when controlling for other demographic factors (adjusted OR [95% CI] = 0.715 [0.633, 0.807]). Patients in the second and third NDI quartile were both less likely to have unhealthy alcohol use as compared to the first quartile (adjusted OR [95% CI] = 0.896 [0.862, 0.931] and 0.862 [0.801, 0.927] respectively). Patients in the fourth quartile did not have statistically different unhealthy alcohol use when compared to the first quartile. Patients with Medicaid and Medicare were significantly less likely to have unhealthy alcohol use than patients with commercial insurance (adjusted OR [95% CI] = 0.501 [0.425, 0.591] and 0.645 [0.504, 0.827] respectively). There were no statistically significant differences in the association of NDI or insurance type with unhealthy alcohol use in transgender patients as compared with cisgender patients.

Conclusion & Discussion: Transgender patients had lower incidence of unhealthy alcohol use than cisgender patients. Of note, alcohol screening employs gendered language, which may complicate interpretation. Socioeconomic status was positively correlated with unhealthy alcohol use by insurance measures, as supported by the literature. However, the lowest and highest NDI quartiles did not have significantly different levels of unhealthy alcohol use. The middle quartiles had lower levels of unhealthy alcohol use. It should be noted that patients in this study, as members of an integrated care system, may receive more social and clinical support and may represent narrower socioeconomic categories than the general public. There was no indication that socioeconomic status impacts unhealthy alcohol use in transgender patients differently than it does in cisgender patients. Regardless, understanding demographic factors that impact alcohol use among transgender adults should inform patient-centered clinical decisions for screening and intervention. Further investigation of SES’s impact on alcohol use in gender subcategories (e.g., transfeminine vs transmasculine) is warranted.

References: 1. Wechsler H, Dowdall GW, Davenport A, Rimm EB. A gender-specific measure of binge drinking among college students. American journal of public health. 1995;85(7):982-985.
2. Gilbert PA, Pass LE, Keuroghlian AS, Greenfield TK, Reisner SL. Alcohol research with transgender populations: A systematic review and recommendations to strengthen future studies. Drug and alcohol dependence. 2018;186:138-146.
3. Gonzalez CA, Gallego JD, Bockting WO. 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. The Journal of Primary Prevention. 2017;38:419-445.
4. Simpson MD, Klibert JJ, Pritulsky CL, Weiss BJ. The Conditional Effects of Savoring on the Relationship between Minority Stress and Alcohol Misuse in an LGBTQIA + Sample. Substance Use and Misuse. 2023;58(11):1367-1376.
5. Collins SE. Associations Between Socioeconomic Factors and Alcohol Outcomes. Alcohol Research. 2016;38(1):83-94.