(151) Interactions of Gender Identity and Social Factors in Unhealthy Alcohol Use

Background & Introduction: Unhealthy alcohol use is a risk factor for morbidity and mortality, linked to 2.6 million deaths worldwide (4.7% of all deaths) in 2019. In the United States, it is the eighth leading cause of death and the third leading preventable cause. Acute harms include impaired functioning in employment, relationships, and increased risk of violence, motor vehicle accidents, and self-injuries. Long-term consequences include chronic anxiety, depression, polysubstance use, liver cirrhosis, cardiovascular disease, and cancer. Individuals experiencing minority stress including transphobic discrimination and gender dysphoria have elevated risk. Despite higher rates of alcohol use disorder, the specific factors contributing to this risk in transgender populations remains poorly understood and necessitates further research. This study aims to identify patient characteristics, such as age, psychiatric comorbidities, and race/ethnicity, associated with higher risk of unhealthy alcohol use among transgender adults compared to cisgender adults.

Methods: This retrospective cohort study examined electronic health records-based data of a cohort of adult (≥ 18 years) cisgender and transgender Kaiser Permanente Northern California members from 2013 through 2021, with a 2-year follow-up through 2023. Individuals with Unknown race were excluded from the regression analyses. A Poisson regression model assessed the effect modification of gender identity on the relationship between sociodemographic characteristics and unhealthy alcohol use (defined as exceeding the daily or weekly drinking limits recommended by the National Institute on Alcohol Abuse and Alcoholism). The model for each interaction term controlled for other sociodemographic variables of interest (age group, race and ethnicity, Neighborhood Deprivation Index (NDI) quartile, insurance type, Charlson Comorbidity Index ((CCI), any mental health diagnosis, any drug use disorder).

Results: The cohort included 79,050 adults (93% cisgender; 7% transgender; 13% vs 11.9% Asian, 5.4% vs 6.7% Black, 15.5% vs 15.9% Hispanic, 63.3% vs 63.1% White, 2.9% vs 3.5% other/unknown; p < 0.01). More transgender adults were ages 18-34 (40.7% vs 33.4%) and 65+ (3.6% vs 2.4%), while cisgender adults had a higher proportion aged 35-49 (30.4% vs 25.8%) and 50-64 (33.8% vs 30.0%). The proportion with any drug use disorder was higher for transgender adults compared to cisgender adults (4.2% vs 1.5%, p< 0.01). Gender identity significantly modified the relationship between race and unhealthy alcohol use (X2 (4) = 40.47, p< 0.001). Among race and ethnicity-specific subgroups, Asian and White transgender adults showed significantly lower prevalence of unhealthy alcohol use (PR, 0.65; 95% CI, 0.50-0.85; p=0.001; PR, 0.67; 95% CI, 0.59-0.75; p< 0.001, respectively) compared with White cisgender adults. However, this association was not observed when Asian transgender adults were compared to White transgender adults (PR 0.97; 95% CI, (0.73-1.29; p=0.86). Compared to White cisgender adults, Black (PR, 0.63; 95% CI, 0.56-0.70; p< 0.001), Hispanic (PR, 0.66; 95% CI, 0.61-0.70; p< 0.001), and other race/ethnicity (PR, 0.65; 95% CI, 0.54-0.78; p< 0.001) cisgender individuals had significantly lower prevalence of unhealthy alcohol use. Their transgender counterparts also had lower prevalence of unhealthy alcohol use compared to White cisgender individuals, however, the effect sizes were smaller and not statistically significant (Black: PR, 0.7; 95% CI, 0.49-1.00; p=0.05; Hispanic: PR, 0.84; 95% CI, 0.68-1.03; p=0.09; Other: PR, 0.65; 95% CI, 0.30-1.39; p=0.26). Among transgender individuals, Black, Hispanic, and other race/ethnicity did not record higher unhealthy alcohol use compared to White adults. Furthermore, gender identity interacted with mental health diagnoses (X2 (1) = 6.16, p=0.01), as transgender adults with any mental health diagnosis had a lower unhealthy alcohol use prevalence than cisgender adults without such diagnoses (PR, 0.72; 95% CI, 0.63-0.83; p< 0.001). However, this association was not observed among cisgender adults with vs. those without any mental health diagnosis (PR, 0.98; 95% CI, 0.93-1.04; p=0.49). Among transgender individuals, those with mental health diagnoses had lower prevalence compared to those without (PR, 0.77; 95% CI, 0.64-0.92; p=0.005).

Conclusion & Discussion: Transgender identity impacts the relationships between certain sociodemographic factors (race/ethnicity, mental health comorbidity) and unhealthy alcohol use. Prior research indicates transgender communities of color may be at higher risk of unhealthy alcohol use, but subgroup analysis is limited. Additionally, the relationship between mental health diagnoses and alcohol use in transgender versus cisgender populations is understudied. In this study, transgender identity and mental health comorbidity may be associated with less unhealthy alcohol use. Further research is needed to examine potential factors, such as attitudes and receptiveness to alcohol-related care and engagement with specialty care. Conclusions from this study are limited in that other social determinants and subgroups were not examined, including transphobic discrimination and veteran status, which have been associated with unhealthy alcohol use in prior studies. We were unable to classify by specific mental health diagnoses or stratify by severity, which may influence generalizability. Moreover, protective factors supporting resiliency including activism, family, and social support were not examined. Despite these limitations, our results suggest varying associations between race/ethnicity, mental health comorbidity, and alcohol use for transgender versus cisgender individuals. Overall, incorporating gender-sensitive and holistic approaches in alcohol use screening and treatment plans may improve disease detection and health outcomes.

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