A podcast episode written and produced by Susanna Lee
A friend jokingly uses it as an excuse for why they can’t resist online shopping. A news article blames it as the reason why some celebrity just can’t seem to shake their drug habit. A family member rejects a glass of wine for fear that it will prevent them from being able to stop themselves. We’ve all heard the term before one way or another. In this episode of Mind Myths, we debunk one of the most popular myths about addiction and substance use: the myth of the addictive personality.
MDMA, ecstasy, molly, E (Sharifimonfared & Hammersley, 2020) – no matter what it’s called, this popular club drug has found its way into our collective vocabulary. Ecstasy, which has been a mainstay on the party scene since the early 1990s, is now one of the most commonly used illegal drugs. In fact, over 18 million Americans have reported using MDMA at least once in their lifetime (SAMHSA, 2017). Since this drug has become so widespread, it is important from an individual and public health standpoint to understand both the short- and long-term effects of its use. This article will explore these issues, as well as providing resources for safer ecstasy consumption.
How Does MDMA Affect the Brain and Body?
People mostly use ecstasy because it can produce enjoyable short-term effects. MDMA stimulates the release of neurotransmitters like dopamine and serotonin, which can produce euphoric feelings such as heightening of the five senses and increased empathy (Mustafa et al., 2018). On the flip side, however, it can also cause insomnia, appetite loss, restlessness, jaw clenching, and in rare cases, overdose and death (Curran, 2000).
Ecstasy is generally not considered physically addictive, meaning that although people may crave the high, their bodies will not become dependent on the substance and experience painful withdrawals when they stop using it. For this reason, people rarely require psychological treatment for their use (Sharifimonfared & Hammersley, 2020). But does this mean we don’t have to worry about its long-term effects?
Although researchers have been studying ecstasy toxicity for years, some of the evidence is mixed (Mustafa et al., 2018). This issue is a bit confusing, but it may be more relevant now than ever: not only is MDMA a drug of choice for millions, it is also a potential medicine of the future. While notorious for its recreational use, MDMA was actually first studied as a treatment for psychological disorders (Müller et al., 2019). In recent years, researchers have been taking a second look at this possibility, and are specifically interested in whether it could be an effective treatment for post traumatic stress disorder (PTSD) (Mustafa et al., 2018). This makes it even more important to understand how this drug affects the brain and body. Though MDMA neurotoxicity studies aren’t perfect, they can still provide valuable insight into the possible risks of this drug and how they can be reduced. With that in mind, let’s take a look at what the research says and why these findings are so important.
What is Neurotoxicity?
Neurotoxicity describes a given substance’s harmful effects on the brain and the rest of the nervous system. This can include damage to nerves and neurons, which are responsible for communicating signals (messages) in the brain. Neurotoxins can be found in a variety of substances such as heavy metals, pesticides, and drugs. The severity of neurotoxicity depends on the substance and how it is consumed. There is a significant range in how these neurotoxins affect us, and how much they harm our bodies and functioning (Robertson, 2019).
Is MDMA Neurotoxic?
The short answer is yes, most research suggests that this drug is neurotoxic. MDMA is thought to cause damage to brain cells by disrupting the flow of neurotransmitters, the messengers that allow cells to communicate with one another. It also causes an overflow of free radicals: molecules with an unstable structure that eat away at cells. These molecules can kill brain cells by limiting the cell’s ability to produce energy. Although our bodies are built to flush out free radicals, ecstasy can overload the detoxification process, which puts a strain on the system (Mustafa et al., 2018). Free radicals are possibly linked to the development and/or worsening of a variety of diseases, such as cancer and Alzheimer’s (Halliwell, 2001).
Examining the Evidence
Most of the evidence on MDMA neurotoxicity comes from either animal studies or correlational research, which looks at whether there is an association between two variables. In animal studies, MDMA has consistently shown to be toxic to serotonin structures. This has been observed in every animal tested, and while some animals recover normal serotonin function over time, many suffer lasting effects (Curran, 2000). Additionally, correlational research has found associations between MDMA use and neurotoxicity in humans. This means that MDMA use can predict changes to the brain.
In most correlational studies, researchers use something called SERT (serotonin transporter) density to measure MDMA neurotoxicity. Serotonin is a neurotransmitter that plays a key role in mood regulation, and is often described as producing feelings of wellness and happiness. Studies have shown that ecstasy use can reduce SERT in many parts of the brain, such as the hippocampus and temporal lobe (both of which are associated with memory function) (Müller et al, 2019). There is also evidence that MDMA users have less 5-HT, a receptor that is responsible for binding to serotonin and receiving its signals. This decrease seems to be linked with the amount of MDMA use: in other words, the more MDMA a person has done, the fewer 5-HT receptors they seem to have (Curran, 2000).
What Does this Mean?
If MDMA is technically neurotoxic, does this mean it affects people’s thoughts, behaviour, and daily life? Some research, as described by Mustafa and colleagues (2018), suggests that people who have used ecstasy over long periods of time perform worse on memory tasks (Wunderli et al., 2017). It is also believed that ecstasy can negatively affect the working memory, the system that allows us to pay attention to and manipulate information before we commit it to our long-term memories. In a 2013 study, Potter, Downey, & Stough found that MDMA users performed significantly worse than non-drug users on spatial working memory tasks, which required them to remember visual information. The MDMA group averaged a score of 0.85, while the non-drug group averaged a score of 0.96. The MDMA group also had longer reaction times across tasks, averaging 302.47 milliseconds compared to 286.00 milliseconds in the non-drug group.
Psychological Impact
It is possible that these changes to the brain also have psychological consequences. Even though relatively few people require psychological treatment for their MDMA use, this does not necessarily represent a lack of impact on mental health. In a turn-of-the-millennium study on ecstasy users in the UK, researchers found that 83% reported midweek “low mood”, and 80% reported concentration or memory problems. which are often related to low mood (Curran, 2000). These changes in mood and functioning could be linked to serotonin toxicity, as well as damage to brain regions involved in key tasks such as learning and memory. Interestingly, Potter and colleagues found that the average depression level (as measured by the Beck Depression Inventory) was 13.35 in people who used MDMA, 7 points higher than that of non-drug users (2013). Although this difference was not large enough to be significant, it is still important to note since MDMA users commonly report low mood.
Is the Damage Permanent?
The good news is that the effects of MDMA neurotoxicity might be reversible over time. Researchers have found a link between SERT density and the length of abstinence, a period where the drug is not being used. This means that, without MDMA, serotonin and 5-HT levels may be restored in the brain (Müller et al., 2019), which in turn could possibly lead to improved mood and memory.
What Else Should We Know?
Although these studies share important findings about how MDMA interacts with the brain, there are limits to their design and how well their results can be applied to real life. Let’s explore some of these limitations:
Most researchers study heavy or long-term ecstasy use, but are unable to describe the long-term effects of the drug on people who use it occasionally and moderately. It’s currently believed that the more severe neurotoxic effects are linked to binges, which requires taking lots of ecstasy at once (Müller et al., 2019)
It’s extremely difficult to determine a cause-and-effect relationship between MDMA and neurotoxicity in the human brain, because there could be a variety of other factors that cause these changes. Human participants have unique and complicated lifestyle factors that can be difficult to control for in experiments. For example, many people who use ecstasy also use other recreational drugs that could be responsible for cell damage
The findings from animal studies do not necessarily apply directly to humans, since each animal’s brain functions differently
It is impossible to compare dosage between participants, since it’s unlikely they know the exact amount of ecstasy they have taken in their lifetime (Curran, 2000)
The drugs used in labs are very different from street drugs. Street ecstasy has developed a reputation for its impurity, since it is often cut with drugs like methamphetamine, cocaine, and bath salts (Curran, 2000). Sometimes it doesn’t contain any MDMA at all! This makes it even harder for people using the drug to get a sense of what they’re taking and how it might affect them in the short- and long-term
What Can I Do with This Information?
Like any recreational drug, there are significant risks to using MDMA. Neurotoxicity studies can help us understand how common and severe these risks are in the long run. Since MDMA may soon become legal as a treatment for PTSD, it is also helpful to learn more about how different types of use have different effects. Therapeutic MDMA would be used differently than recreational ecstasy (for example, doses would be small and given by a psychiatrist or doctor), so it is very unlikely that it would have concerning neurotoxic consequences (Müller et al., 2019).
If you do decide to use ecstasy, researchers Sharifimonfared and Hammersley (2020) have outlined some helpful harm reduction tips:
Stay informed about this drug and its effects- it is important that you are making an informed decision, and that you can create harm reduction strategies that best suit you. This can also help you prepare for unwanted side effects
Test your drugs- since ecstasy is often mixed with other substances, it’s important to ensure that you know what you’re putting into your body to prevent a bad trip or accidental overdose
Drink a healthy amount of water while using ecstasy- sweating will cause you to lose fluid, so it’s important to stay hydrated- but make sure not to overcompensate by drinking too much, as this is also dangerous
Don’t mix ecstasy with other drugs- this could increase the risk of a negative outcome
Don’t use too much at once, and don’t use the drug too often
In addition, websites such as www.rollsafe.org provide nonjudgmental advice that helps ecstasy users stay updated and educated. If you are struggling with ecstasy use, strategies such as tapering off the drug, making positive lifestyle changes, or seeking professional help may be useful. Helplines such as ConnexOntario (1-866-531-2600) and therapy providers such as the Centre for Addiction and Mental Health (https://www.camh.ca/) are valuable resources for individuals struggling with their own or a loved one’s drug use.
Center for Behavioral Health Statistics and Quality (2017). 2016 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration. 1-2889.
Curran, H. V. (2000). Is MDMA (‘ecstasy’) neurotoxic in humans? An overview of evidence and of methodological problems in research. Neuropsychobiology, 42(1), 34-41. 10.1159/000026668
Halliwell, B. (2001). Role of free radicals in the neurodegenerative diseases: therapeutic implications for antioxidant treatment. Drugs & Aging, 18(9), 685-716. 10.2165/00002512-200118090-00004
Müller, F., Brändle, R., Liechti, M. E., Borgwardt, S. (2019). Neuroimaging of chronic MDMA (“ecstasy”) effects: A meta-analysis. Neuroscience and Biobehavioral Reviews, 96, 10-20. https://doi.org/10.1016.j.neubiorev.2018.11.004
Mustafa, N. S., Bakar, N. H. A., Mohamad, N., Adnan, L. H. M., Fauzi, N. F. A., Thoarlim, A., Omar, S. H. S., Hamzah, M. S., Yusoff, Z., Jufir, M., Ahmad, R. (2020). MDMA and the brain: A short review of the role of neurotransmitters in neurotoxicity. Basic and Clinical Neuroscience, 11(4), 381-388. http://dx.doi.org/10.32598/bcn.9.10.485
Potter, A., Downey, L., Stough, C. (2013). Cognitive function in ecstasy naïve abstinent drug dependants and MDMA users. Current Drug Abuse Reviews, 6(1), 71-76. 10.2174/1874473711306010008
Robertson, S. (2019, September 16). What is neurotoxicity? News-Medical Life Sciences. https://www.news-medical.net/health/What-is-Neurotoxicity.aspx
Sharifimonfared, G., Hammersley, R. (2020). Harm reduction and quitting techniques used by heavy MDMA (ecstasy) users. Addiction Research & Theory, 28(3), 222-230. https://doi.org/10.1080/16066359.2019.1622684
While having a beer, glass of wine, or cocktail on occasion might be relatively low-risk, university students tend to drink a lot more alcohol than this on average.1 In fact, a 2019 national survey found that 33% of students had engaged in binge drinking in the past month and almost 9% were diagnosed with an alcohol use disorder.1 Since alcohol use is so common among students it’s important for clinicians, universities, and the general public to understand the reasons why they drink, so that the issue can be better addressed.
Figure 1: An anxious emoticon face with a thought bubble coming out of its head, containing the phrases “I feel like such an outcast..”, “They’re judging me..”, and “Everyone’s looking at me..” A group of their peers stands nearby. Graphic by Jenna Vieira, template from CANVA is licensed under a Free Media License Agreement.
One possible reason for university students’ drinking might have to do with social anxiety. At its core, social anxiety is an intense fear of being judged or evaluated when in social situations,2 like public speaking, ordering food at a restaurant, or meeting someone new. A person with this kind of anxiety is worried that they will “mess up” or do something that will cause others to think poorly of them. Although social anxiety is something that everyone experiences from time to time, it can be severe and persistent enough to be diagnosed as a mental disorder.3
Alcohol is known to have anxiety-reducing effects.4 This means that drinking alcohol might allow someone with social anxiety to feel more relaxed, comfortable, and able to socialize in situations that would normally cause them a lot of distress.
Interestingly, much of the university experience takes place in the form of social events, like living and hanging out with roommates, going to big parties, and visiting bars and clubs.5 What do all of these events tend to have in common? The presence of alcohol and the ability to trigger social anxiety. University students often find themselves in situations that present opportunities for both drinking and feeling socially anxious, and as mentioned, alcohol can reduce this anxiety.4 So, could it be that some students drink alcohol as a way of coping with their social anxiety?
What the research says
A number of studies have indeed found support for the idea that university students drink alcohol to cope with social anxiety. In one study, highly socially anxious university students reported greater drinking to cope with negative emotions, like sadness and anxiety, compared to students with lower levels of social anxiety.5 On top of this, highly socially anxious students tended to report drinking for conformity reasons, or in other words, to fit in with their peers. This suggests that these students drink not only to manage unpleasant emotions, but also uncomfortable experiences that might arise from being rejected and ridiculed by others around them.
Another study found that highly socially anxious university students were more likely to drink to cope with and reduce negative emotions, like nervousness and depression, compared to students with lower levels of social anxiety.5 In addition, they reported drinking more to increase positive emotions, like feeling good and having fun. Importantly, highly socially anxious students who reported drinking as a way to manage both negative and positive emotions were more likely to experience problems related to their alcohol use.
Figure 2: A sad face and a happy face next to three alcoholic drinks. Graphic by Jenna Vieira, template from CANVA is licensed under a Free Media License Agreement.
Some studies have even found evidence that university students drink alcohol as a way of coping with anticipatory social anxiety; in other words, anxiety about an upcoming social situation or event rather than one a person is already in. One such study found that highly socially anxious students were more likely to experience anxiety about an upcoming social event, which made them more likely to drink alcohol before that event in order to prepare for and manage their anxiety about it.7 It was also found that anticipatory anxiety, social anxiety, and pre-drinking were related to more drinking and feelings of intoxication during that social event.
To sum up, university students with social anxiety tend to drink alcohol, and sometimes greater amounts of alcohol, compared to their non-anxious peers. They appear to do this not only to cope with negative emotions (including anxiety), but also to feel more positive emotions and to prepare for situations in which they are afraid of being judged or rejected.
Why does this matter?
These findings show that a desire to cope with social anxiety is one reason behind university students’ alcohol use. They also suggest that drinking to cope with social anxiety might put university students at higher risk for alcohol-related problems, like developing an addiction.
Using alcohol as a strategy to manage and cope with emotions, whether positive or negative, is generally unhealthy.6 For socially anxious university students, it’s associated with drinking more in social situations7, which can make a person more likely to become very intoxicated, make impulsive and unsafe decisions, and be unable to remember what happened while they were drinking.
It’s well-known that alcohol use can be unhelpful and dangerous in the long run. However, a socially anxious student might still continue to drink because it makes them feel better in the moment.8 If this drinking becomes severe enough that it’s difficult to control and gets in the way of the student’s ability to fulfill their everyday personal, social, and academic obligations, they might end up qualifying for a diagnosis of alcohol use disorder.3 Given that about 20% of people with social anxiety have an alcohol use disorder, this isn’t an unlikely possibility.9
So, the question is: how can socially anxious university students who drink alcohol be helped?
What clinicians and universities can do
It goes without saying that it’s unrealistic to ask students to simply stop drinking or going to social events, since these tend to be common and even meaningful parts of the university experience. However, there are a few different ways in which clinicians – such as psychologists, counsellors, and therapists – can approach supporting students who might be at risk.
Figure 3: A university student seeks support from a counsellor. A person sits and talks with a therapist. There are two thought bubbles with ellipses in them. Graphic by Jenna Vieira, template from CANVA is licensed under a Free Media License Agreement.
For socially anxious students who have not yet shown signs of problematic drinking or drinking to cope, preventing these behaviours from developing might be the most important thing clinicians can help with. To do this, they can consider providing evidence-based treatments to students for their social anxiety, such as cognitive behavioural therapy (CBT). This type of therapy involves working with a client to help them change unhelpful thought patterns, beliefs, and behaviours about the situations that provoke their social anxiety.10 CBT has been found to be useful for reducing anxiety when delivered in both individual and group formats.7
For socially anxious students who already use alcohol to cope, clinicians can attempt to treat aspects of both their social anxiety and alcohol use together. One way in which they can do this is by helping a client to identify healthier ways of coping with their emotions in social situations.6 Given that drinking to cope is linked to drinking in larger quantities,6 they can also work with a client to plan safety behaviours that they can engage in when they are drinking in social situations; for example, switching between alcoholic and non-alcoholic drinks to avoid becoming too intoxicated.6
Universities also have a role to play in helping their students overcome problems with social anxiety and alcohol use. Ways in which they can support this initiative include using funding to provide therapy and counselling services to students; making these services accessible by offering them at a range of costs or allowing them to be covered under university health insurance; and spreading awareness about these services through posters, social media, and other avenues to reduce stigma and encourage students to seek help.
What you and I can do
As members of the general public, we can also do a few small but important things to support university students who are drinking to cope with their social anxiety, or facing mental health difficulties generally.
One way to do this is by spreading awareness about mental health resources using platforms that university students are likely to use, such as Instagram and Twitter. If you know someone who is struggling personally, you might even consider letting them know about these resources. Some example resources include free mental health- and therapy-focused apps, like MindBeacon (Ontario) and AbilitiCBT (Ontario, Manitoba), and even the counselling centre at the university you attend (for example, Ryerson University).
Another option is to share resources about alcohol use, again on social media and/or within your personal circles, so that students can become better educated about drinking and its potential harms. For example, this website provides a set of short, easy-to-read of free fact sheets about the effects that alcohol can have on a person’s body, how to calculate alcohol calories and blood alcohol content, and myths about alcohol.
Finally, if you’re a university student yourself, you might think about getting involved in a club or association at your school that is dedicated to mental health advocacy. If this doesn’t exist, consider taking the initiative and start one yourself!
In sum, the research findings discussed in this blog post are only as meaningful as we make them. In other words, uncovering even just one of the factors that encourage university students to drink – in this case, social anxiety – is the very first step in helping them to overcome their mental health struggles. It’s up to us as members of the public, clinicians, and policymakers to put this knowledge into practice and help university students who drink alcohol to cope with social anxiety to live healthier lives.
4. Goodman, F. R., Stiksma, M. C., & Kashdan, T. B. (2018). Social anxiety and the quality of everyday social interactions: The moderating influence of alcohol consumption. Behavior Therapy, 49(3), 373-387. https://doi.org/10.1016/j.beth.2017.10.002
5. Terlecki, M. A., & Buckner, J. D. (2015). Social anxiety and heavy situational drinking: Coping and conformity motives as multiple mediators. Addictive Behaviors, 40, 77-83. https://doi.org/10.1016/j.addbeh.2014.09.008
6. Buckner, J. D., Lewis, E. M., & Walukevich-Dienst, K. (2019). Drinking problems and social anxiety among young adults: The roles of drinking to manage negative and positive affect in social situations. Substance Use & Misuse, 54(13), 2117-2126. https://doi.org/10.1080/10826084.2019.1637892
7. Buckner, J. D., Lewis, E. M., Terlecki, M. A., Albery, I. P., & Moss, A. C. (2020). Context-specific drinking and social anxiety: The roles of anticipatory anxiety and post-event processing. Addictive Behaviors, 102, 106184-106184. https://doi.org/10.1016/j.addbeh.2019.106184
8. Kim, S., & Kwon, J. (2019). The impact of negative emotions on drinking among individuals with social anxiety disorder in daily life: The moderating effect of maladaptive emotion regulation strategies. Cognitive Therapy and Research, 44(2), 345-359. https://doi.org/10.1007/s10608-019-10045-8
10. Heimberg, R. G. (2002). Cognitive-behavioral therapy for social anxiety: Current status and future directions. Biological Psychiatry, 51(1), 101-108. https://doi.org/10.1016/S0006-3223(01)01183-0
Images
1. Canva (March 2021). [An anxious emoticon face with a thought bubble coming out of its head, containing the phrases “I feel like such an outcast..”, “They’re judging me..”, and “Everyone’s looking at me..”. A group of their peers stands nearby].
2. Canva (March 2021). [A sad face and a happy face next to three alcoholic drinks].
3. Canva (March 2021). [A university students seeks support from a counsellor. A person sits and talks with a therapist. There are two thought bubbles with ellipses in them].
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.
Photo credit: Juan Moyano, 2019 [Photo description: Person standing in the middle of a beach, shown from the chest and up. The transgender flag including the colours of blue, pink and white covers their head. At the background the sky is clear with only a few clouds].
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
Image by: NCTE [Photo description: Activists on the street protesting for transgender rights. They are standing in front of a historical building and only their heads are depicted in the picture. One person, closest to the camera, holds a sign reading “We want to live free”. The rest of people are holding primarily transgender flags, and one person is holding the US flag].
Infographic made on Canvas by: Krisoula Kotassidis
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.
Image by: SAMHSA [Image description: Four smaller pictures places next to each other creating a square and showing images of family, friends, and a hospital setting with a doctor standing in front of the camera having their hands crossed. On the right side the background of the image is in blue reading “SBIRT: Screening, Brief Intervention and Referral to Treatment”].
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-screeningquestionnaire 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.
Image by: Shutterstock [Image description: Six people standing next to each other, all of different ethnicities wearing a pink, orange, yellow, green, violet, and purple clothing. They each have their preferred pronouns written on their tops].
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:
Photo credit: John Keon, 2018 [Photo description: Portrait of writer and performance artist, ALOK. They are wearing a pink, blue, and light brown hair extension. Their make-up is in pink, white, and purple tone. They are also wearing long purple and white earrings and a navy blue and white striped, long sleeved top with gold buttons].
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.
Bavinton, B., Gray, J., & Prestage, G. (2013). Assessing the effectiveness of HIV prevention peer education workshops for gay men in community settings. Australian and New Zealand Journal of Public Health, 37(4), 305–310. doi: 10.1111/1753-6405.12076
Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality, 51, 53–69. doi: 10.1300/J082v51n03_04
Dentato, M. P., Ortiz, R., Orwat, J., Kelly, B. L., Gates, T. G. & Propper, E. (2019) Peer-based education and use of the SBIRT model in unique settings with transgender young adults, Journal of Social Work Practice in the Addictions, 19:1-2, 139-157, doi: 10.1080/1533256X.2019.1589884.
Gilbert, P. A., Pass, L. E., Keuroghlian, A. S., Greenfield, T. K., & Reisner, S. L. (2018). Alcohol research with transgender populations: A systematic review and recommendations to strengthen future studies. Drug and alcohol dependence, 186, 138–146. https://doi.org/10.1016/j.drugalcdep.2018.01.016
Glynn, T. R., & van Den Berg, J. J. (2017). A systematic review of interventions to reduce problematic substance use among transgender individuals: A call to action. Transgender Health, 2(1), 45–59. doi:10.1089/trgh.2016.0037
Gonzalez, C.A., Gallego, J.D., Bockting, W.O. (2017). 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. J. Prim, 38, 419–445. doi:
Hughto, J. W., Quinn, E. K., Dunbar, M. S., Rose, A. J., Shireman, T. I. & Jasuja, G. K. (2021). Prevalence and co-occurrence of alcohol, nicotine, and other substance use disorder diagnoses among US transgender and cisgender adults. JAMA Network Open, 4(2), e2036512–. doi: 10.1001/jamanetworkopen.2020.36512
Kelly, J. F., & Yeterian, J. D. (2015). Outcome research on twelve-step programs. In M. Galanter & H. D. Kleber (Eds.), Textbook of substance abuse treatment (5th ed., pp. 579–595). Washington, DC: American Psychiatric Press.
Martino, W., Kassen, K. & Omercajic, K. (2020) Supporting transgender students in schools: Beyond an individualist approach to trans inclusion in the education system, Educational Review, doi: 10.1080/00131911.2020.1829559
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“You can’t do it for us, you can only do it with us” Understanding substance use in Indigenous communities and how to help
Samantha Johnstone, Yasmine Noureddine, Elena Kastoras, and Jenna Vieira
Indigenous peoples are much more likely than others to experience mental health issues, including substance use disorders.1 In fact, 16% of Indigenous peoples reported drinking heavily on a weekly basis, compared to only 7.9% of other Canadians.1 On top of that, over 50% of Indigenous survey respondents reported using at least one illegal drug in the past year, compared to less than 1% of the general Canadian population.1
Figure 1: Cartoon therapist and patient, thought bubble coming from patient contains words such as “Indigenous” and “Oppression”. Graphic by Yasmine Noureddine, template from CANVA is licensed under a Free Media License Agreement.
A substance use disorder can be understood as when a person experiences a loss of control over their use of drugs or alcohol, misses important social and work-related events, and experiences cravings for the substance that can’t be ignored.2 Not only can facing a substance use disorder make it really hard for a person to cope with the demands of everyday life, but it can also worsen their mental health. This is particularly likely to be the case for Indigenous peoples.
A long history of colonization, racism, and other forms of discrimination have led Indigenous peoples to experience difficulty in accessing the same quality of healthcare, social services, and opportunities that other Canadians receive.3 Because the voices of this community have been silenced by discrimination for so long, it is important to listen to their personal challenges, opinions, and needs rather than imposing Western ideas of assistance on them.
Taking a look at Indigenous substance use and mental health
Focusing in on a subgroup of Indigenous peoples – university students – reveals that they are indeed at an increased risk of experiencing substance use disorders and other mental health issues.4 Researchers conducted a survey of 34 thousand Canadian students in hopes of determining if universities are meeting the needs of Indigenous students.4 As it turns out, they are not. Indigenous students were overwhelmingly more likely to be diagnosed with depression and anxiety.4 They also reported more self-harming behaviours and a longer history of suicide attempts.4 This is likely due to the lack of access to healthcare and poverty4 caused by years of colonization, oppression, and loss of cultural connections.5
So how does this relate to substance use? Well, the increased psychological distress faced by Indigenous students means that those who do engage in binge drinking or smoking are more likely than their non-Indigenous peers to have comorbid mental illnesses.5Comorbidity simply means that two disorders are occurring at the same time in one person. Researchers have identified a few ways in which comorbidities can develop:
Substance use can increase the risk of developing a mental illness, like depression, due to changes in the brain.6
Some people may try to self-medicate to deal with symptoms of their mental illnesses. This can increase the risk of becoming dependent.6
Common genetic risk factors can increase the risk of both substance use and mental health problems.6
Having to cope with a mental disorder and a substance use disorder at the same time can make it really hard to recover from either illness. This is concerning, as Indigenous students in the 2019 study also reported greater levels of binge drinking and drug use than their non-Indigenous peers.4 Along with the reports of overwhelming psychological distress, it is clear that Indigenous students are suffering to a great extent. Specifically, we see that Indigenous students who use substances have more negative outcomes and greater levels of psychological and social hardships compared to non-Indigenous students.5
Figure 2: Head of women each have a speech bubble emerging from them; the first head has a sad icon, the second alcohol and weed. Graphic by Yasmine Noureddine, template from CANVA is licensed under a Free Media License Agreement.
How can clinicians use this information?
It is important for clinicians to recognize the inequalities faced by Indigenous students and ensure that comprehensive assessments are conducted. This means that instead of just diagnosing the substance use disorder, clinicians also have to ask about psychological distress and assess the risk of suicide, to get to the full picture. But once we have the full picture, what do we do with it?
Offering culturally appropriate services:
We emphasize that culturally appropriate services need to be available for Indigenous students. When healthcare is culturally appropriate it integrates the patients culture into delivery of the service while maintaining dignity and recognizing social and economic hardships.7One way this can be achieved is by having Indigenous counsellors onsite that can help students maintain their cultural identity even when they are away from home.4
When to step in:
Indigenous counsellors can also help to maneuver decisions about when to provide treatment. Cultural differences play a role in deciding what does (or does not) constitute a substance use disorder. Western definitions of disordered substance use may not translate to what Indigenous communities see as problematic. For example, traditional ceremonies in Indigenous cultures often use tobacco2, and it would be inappropriate to characterize this practice as disordered. We also know that Indigenous communities have not yet established a definition for binge drinking.4
Proper diagnosis means better treatment:
Interventions, like sweat lodge ceremonies, address Indigenous mental health while promoting a holistic model.8 Holistic interventions heal the mind, body, emotion, and spirit in an integrated manner8, which is essential when treating comorbidities. These interventions are beneficial in improving mental health and reducing substance use. More importantly, Indigenous students have reported that they prefer these types of services over standard ones.4
Not only for students:
Although this study specifically focused on university students, comorbid substance use and mental illness are common in Indigenous communities.2 We can use this research to push for changes in government policies and practices. When Indigenous leaders have control over their health services, are able to use their traditional languages, and maintain cultural identity, there are notably lower rates of substance use and suicide.4 Supporting Indigenous self-governance is an important step in addressing the inequalities and hardships that Indigenous peoples face.
How can you and I help?
While researchers and clinicians may be the frontline responders to understanding and accurately assessing substance use in the Indigenous peoples and their youth, this doesn’t mean that you can’t contribute in your own way to provide help and support. Some tips on how to do this include9:
Taking the time to learn about the history of Indigenous people in Canada.
Knowledge of the historical factors that contributed to today’s issues surrounding Indigenous mental health and substance use can provide a better understanding of how and why they are so prevalent. It also allows for a look at how circumstances have changed over the decades, and what still needs to be done to ensure equity and proper care. Checking out recommended books at your local library, as well as sources like podcasts, is a great way to start!
Reaching out and building strong connections with the Indigenous peoples, organizations, and communities near your own.
In supporting the communities, you are supporting everyone who is a part of it, including the older generation, as well as students. These relationships allow non-Indigenous peoples a chance to understand how substance use and mental health are viewed and best approached by Indigenous communities. Checking out your local Indigenous cultural centre and community organizations can be a launching pad for fostering good relations.
Knowing what support services and programs are available for Indigenous peoples and their youth.
Familiarizing yourself with the services and programs available helps you to know exactly where to direct your support and allows for more access/reach to what is needed, by promoting the programs and making it known to the wider public that they exist, are available, and would benefit from support from outside of the Indigenous community (as a way of highlighting their importance). Some programs and services include:
Figure 3: Map of Canada with the population of Indigenous peoples by province/territory. Information from Statistics Canada10. Graphic by Yasmine Noureddine, template from CANVA is licensed under a Free Media License Agreement.
The mental health and well-being of marginalized groups is the responsibility of all to ensure a well-supported, equal-opportunity community that is free from stigma and risk factors. Given that Indigenous peoples reside all across Canada and broadly experience higher levels of disordered substance use compared to the general Canadian population2, supporting your local community is a way to help out Indigenous communities as a whole. Canadians can’t address and fix inequalities for Indigenous peoples; we can only do it with Indigenous peoples.11
References
Firestone, M., Tyndall, M., & Fischer, B. (2015). Substance use and related harms among Aboriginal people in Canada: A comprehensive review. Journal of Health Care for the Poor and Underserved, 26(4), 1110-1131. https://doi.org/10.1353/hpu.2015.0108
Urbanoski, K. A. (2017). Need for equity in treatment of substance use among Indigenous people in Canada. Canadian Medical Association Journal, 189(44), 1350-1351. https://doi.org/10.1503/cmaj.171002
Hop Wo, N. K., Anderson, K. K., Wylie, L., & MacDougall, A. (2019). The prevalence of distress, depression, anxiety, and substance use issues among Indigenous post-secondary students in Canada. Transcultural Psychiatry, 57(2), 263–274. https://doi.org/10.1177/1363461519861824
Sittner, K. J. (2015). Trajectories of Substance Use: Onset and Adverse Outcomes Among North American Indigenous Adolescents. Journal of Research on Adolescence, 26(4), 830–844. https://doi.org/10.1111/jora.12233
Teesson, M., Degenhardt, L., Proudfoot, H., Hall, W., & Lynskey, M. (2005). How common is comorbidity and why does it occur? Australian Psychologist, 40(2), 81–87. https://doi.org/10.1080/00050060500094605
Caffery, L. J., Bradford, N. K., Smith, A. C., & Langbecker, D. (2018). How telehealth facilitates the provision of culturally appropriate healthcare for Indigenous Australians. Journal of Telemedicine and Telecare, 24(10), 676–682. https://doi.org/10.1177/1357633×18795764
Rowan, M., Poole, N., Shea, B., Gone, J. P., Mykota, D., Farag, M., Hopkins, C., Hall, L., Mushquash, C., & Dell, C. (2014). Cultural interventions to treat addictions in Indigenous populations: findings from a scoping study. Substance Abuse Treatment, Prevention, and Policy, 9(1), 34. https://doi.org/10.1186/1747-597x-9-34
Caron, N. R. (2005). Getting to the root of trauma in Canada’s Aboriginal population. Canadian Medical Association Journal (CMAJ), 172(8), 1023-1024. https://doi.org/10.1503/cmaj.050304
Images
Canva (February 2021). [Image of cartoon therapist with patient, patient has a thought bubble with words such as ‘Indigenous’ and ‘Oppression’ in a word cloud].
Canva (February 2021). [Head of women each have a speech bubble emerging from them; the first head has a sad icon, the second alcohol and weed].
Canva (February 2021). [Map of Canada with the populations of Indigenous peoples by province/territory. Information from Statistics Canada].
