The Binary Gender Of Addiction Screening Tools: Can Transgender People Benefit From Them?

by Krisoula Kotassidis 

A recent national US study found that transgender people 18-35 years old are more likely than cisgender people to be diagnosed with a substance use disorder¹⁰.Research shows that transgender people face additional stressors due to stigma, compared to the general population¹⁴ which explains their high rates of substance use. As a result, young transgender adults do not feel comfortable accessing medical and mental health care services, including substance use treatment⁷. This is why widespread awareness about transgender stress, and prevention of substance use disorders in these populations is crucial. However, existing prevention tools for substance use screening and treatment may cause more harm than benefit to transgender individuals, as they were designed with exclusively cisgender heterosexual people in mind¹⁰.

Let’s talk labels first

Gender is pretty simple, right? You are born with male genitalia; therefore, you are a boy and your caregiver dresses you in blue. You are born with female genitalia; therefore, you are a girl and your caregiver dresses you in pink. This is a binary cisgender identity which assumes that your sex assigned at birth defaults to only one of two gender options. Individuals who feel happy and comfortable with such an identity and expression usually do not have to think about their gender; they just enjoy being accepted for who they are. Gender identity is your individual experience of being man, woman, both, something in between or something else. Gender expression is the way you communicate your gender identity to others through your clothing, behaviour, preferred pronouns etc.¹

People who do not identify as neither a man nor a woman are non-binary. But, what about transgender people? Transgender is an umbrella term describing individuals whose gender identity or gender expression does not conform to the gender norms associated with the sex (female vs. male) they were assigned at birth⁶. In reality, there are many more ways in which people identify with or express their gender.

From minority stress to substance use to substance use disorders

Although research on transgender populations is extremely limited, the evidence about their poor physical and psychological well being is alarming. Transgender people face more discrimination, receive more threats about their safety, and are more likely to be victims of sexual and physical violence compared to non-transgender people ⁶. In the workplace, transgender people are more likely to get fired and be denied a job because of their gender identity and expression compared to non-trans folks. As a result, trans people are more likely to be homeless.¹⁴

Transgender people learn to expect such stressful events to happen, which makes them hide their gender identity to protect themselves from emotional and physical harm⁶. However, this often exacerbates their distress¹³. At the same time, transgender folks often agree with stigmatising beliefs about the way they identify with and present their gender (aka internalised transphobia) which hinders their ability to cope and accept themselves for who they are¹³.  To make things worse, transgender individuals are less likely to access available health care and report gender-based violence to the police ⁶. This is because transgender prejudice and discrimination is deeply rooted in social institutions, such as our education, healthcare, and law enforcement.¹²

All these experiences are traumatising to the transgender person who lives each day with fear because of the stigma they experience due to their minority status. As a result, trans populations are found with high rates of psychological disorders, substance use disorders, and suicide attempts.⁴⁶

Screening & timely intervention: An example 

The Screening, Brief Intervention, and Referral to Treatment (SBIRT) model is a public health screening process used to identify individuals who use substances⁶. The goal of this process is to:

• identify users who are at risk of developing a substance use disorder
• intervene when the individual is engaged in high-risk substance use, and
• refer individuals with severe use to a specialist. 

The model is usually used in clinical settings by doctors, nurses, social workers and other healthcare professionals⁶; however, there is evidence that the model is also beneficial in non-professional settings used by individuals with little or no clinical training⁶.   Plenty of research supports the effectiveness of this screening tool particularly with vulnerable populations such as racial minorities⁶, prenatal and parenting women, adolescents, and the elderly.⁶

Is SBIRT trans inclusive?

The answer is: no. In fact, this model uses screening tools supported by binary research using gender binary biological standards and language, without taking into account transgender-specific stressors and stigma ⁶. For example, the pre-screening questionnaire only refers to binary risk limits  for alcoholic drinks per day, by expecting individuals to choose only between the risk limits for men (5 or more/day) or women (4 or more/day) when answering the questions.⁷ However, these drinking thresholds are based on biological sex and only refer to biological females or males who also identify as women or men, respectively, in terms of gender. This may be harmful for trans folks because we do not even know how many drinks for them are too much, and also because of the non-affirming language being used.

Gender binary language also includes the use of only she/her and he/him pronouns without considering whether the individual feels comfortable with these pronouns. If you consider the gender-based emotional trauma that transgender folks have to live with, you can understand why language and representation in screening measures are important for them to feel safe in substance use screening and intervention settings. If the person does not feel accepted for who they are, they will be reluctant to receive any advice or treatment no matter how well intended it is.

What if SBIRT (trans)itions?

Just because something doesn’t work the way it’s supposed to doesn’t mean that we should give up on it.  Transgender focused research is almost non-existent, while there are very few transgender-specific substance use disorders healthcare professionals. But, transgender people are still struggling with substance misuse. Transgender people, especially those who are racialized, homeless or involved in sex work are overdosing ¹².Therefore, we need to act fast by changing our already existing tools. Here is how SBIRT and the medical and mental health care field can change:

• By giving priority to transgender healthcare professionals in developing and administering transgender-specific substance use prevention and treatment programs⁶.
• By changing the language of screening questionnaires used in the interviewing process to include gender neutral pronouns ⁶.
• By training healthcare professionals to be sensitive to the lived experiences of trans folks⁶ and aware of their other social identities, such as race and socioeconomic status without making binary assumptions about the individual 
• By making use of effective peer support

How does peer support work?

According to research, peers helping each other is effective for HIV prevention, as well as, depression and substance misuse treatment.¹¹ Therefore, some researchers believe that training transgender individuals to use tools like  SBIRT in transgender spaces could be effective, especially for those at higher risk for substance use¹⁹. Peer support can help with gender-based stressors and build resilience to cope with stigma by creating a non-judgmental environment, while preventing substance use or preparing those with heavy use for treatment⁶.

How you can help 

Be a transgender ally! You do not have to be transgender nor a healthcare professional to support transgender folks at risk of substance use disorders. Although there are available courses for SBIRT training online, you do not have to undergo training in order to help. Instead: 

• Learn more about transgender individuals through social media spaces. My favourite Instagrammer is ALOK. They have helped me so much in understanding gender. The best way to learn about transgender people and be an ally is to listen to them. It is the first big step in removing any  stereotypical thinking you might have adopted.

• Remember the suggestion about SBIRT (trans)itioning? Well, you can do it too! You can change your language by using gender neutral pronouns when you feel ambivalent about one’s gender. Or even better: you can just ask the person what their preferred pronouns are. Trust me, they will very much appreciate it.

• Call out (in a civilised manner) on transphobic jokes or other acts of discrimination against transgender people. If you actively show your allyship, a transgender person will feel more comfortable around you and even trust you in talking to you about their substance use. Take the first step to become an ally here.

• Donate, donate, donate here. Even if you cannot donate, you can volunteer! Don’t have the time to volunteer? No worries! You can make the continuous effort to use the proper pronouns and simply accept transgenders for who they truly are. This is an important first step to allyship.

Dealing with substance use disorders is challenging, especially for transgenders who live with additional stressors because of their gender identity and expression. Be there for them, listen, and give them voice. Provide them with valuable peer support to identify those at risk and point them to trans-affirming treatment environments. Try it! You might save a life.

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References

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 Images & social media 

20. CBC News. (2020). 4 Canadian transgender activists you should know. Retrieved from:https://www.youtube.com/watch?v=zbKXfme1Wkc&ab_channel=CBCNews 
21. Moyano, J. (2019). Retrieved from: https://www.stocksy.com/3251846/covered-by-a-transgender-pride-flag 
22. Keon, J. (2018). Retrieved from: https://www.alokvmenon.com/photo