People who identify as lesbian, gay, bisexual, or transgendered have benefitted from unparalleled social and legal progress in a remarkably short time span – TIME magazine called 2014 “The Transgender Tipping Point” – but people on the sexual orientation and gender identity spectrum still face many challenges. For transgendered individuals, rates and risk factors of addiction are considerably higher than those of their LGBT and straight peers, shedding light on the problems that still confront them.
There are as many as 25 million transgender people across the world, but even in high-income countries that have recognized transgender rights and protections like the United States (where there are about 1.5 million transgender people), these individuals are “routinely denied” in areas of marriage, employment, housing, and healthcare. As a result, the transgender population sees rates of depression and mental health disorders that are much higher than the general population. Indeed, the National Alliance on Mental Illness suggests that trans people are much more prone to depression and anxiety than the general population, primarily due to minority stress.
The American Journal of Public Health surveyed 1,093 male-to-female and female-to-male transgender persons, 44.1 percent of whom reported clinical depression as a result of their stigma, and 33.2 percent who reported anxiety caused by their stigma. The researchers in the journal were confident that trans people “clearly fit the minority stress model.”
A study released in December 2016 by the National Center for Transgender Equality showed “devastating levels of discrimination in every aspect of life” for transgender people. Researchers noted that deep patterns of mistreatment exist between trans people and the general American population, some of which non-trans and/or non-LGBT people may not even be aware they are exhibiting. Up to 10 percent of transgender individuals reported being violently treated when they came out to their family, and 8 percent said they were turned out of their home. Others noted similar experiences in schools, workplaces, and public bathrooms and services.
One of the lead researchers writing in The Lancet notes that “in no other community is the link between rights and [mental] health so clearly visible as in the transgender community.” Even as their lesbian, gay, and bisexual peers enjoy widespread recognition and rights, trans people are still exposed to deep-seated stigma, discrimination, and abuse, whether in their homes, their offices, or the hospitals where they go for help. Mental illness and gender nonconformity remain heavily stigmatized among the general public, leaving transgender people with the position of bearing two burdens. Those who identify as transgender and internalize the negative views cast on them tend to not seek out help. Many are driven to unsafe sexual practices and addiction, further jeopardizing their wellbeing.
It was only as recently as 2013 that the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association’s classification and diagnostic bible, discontinued using the term gender identity disorder, which implied the existence of a mental health problem for a person who felt that their birth gender and gender identity were misaligned.
Instead, APA now uses the term gender dysphoria to indicate that the distress between the birth gender and the gender identity is “not necessarily pathological,” and that treatment should focus more on resolving the distress and not fixing a disorder.
The Huffington Post compared discontinuation of “gender identity disorder” to APA’s 1973 removal of homosexuality as a mental health disorder. When that happened, APA acknowledged that being homosexual and psychologically healthy were not mutually exclusive. The same intention is signaled with APA’s removal of “gender identity disorder” to describe gender nonconforming individuals, but the reality of trans lives continues to be so mired in psychological distress that NPR asked, “Is it inevitable that being transgender affects mental health?”
In fact, rates of addiction among transgendered people are “disproportionately higher” than rates of substance abuse in the general community, writes the Center for American Progress. As many as 30 percent of LGBT people report abuse of drugs and alcohol, while the general rate of abuse is only 9 percent.The cycle of prejudice, stress, and substance abuse is a vicious one. Millions of transgendered people are often ignored or willfully misunderstood, causing them personal distress and suffering. Many LGBT people have to fight daily (and private) battles against discrimination and prejudice for their gender identity and/or their sexual orientation, which takes the form of poverty, violence and abuse, higher incarceration rates, and double standards in housing, employment, and healthcare. Unsurprisingly, these realities often lead to deep-seated feelings of stress, depression, and anxiety; this, in turn, drives some of those people to use alcohol and drugs to self-medicate and cope with their problems. Deficiencies in LGBT-targeted healthcare also contribute to dangerously high rates of addiction within LGBT communities.
The high rate of addiction among transgendered people means that they are also more likely to die than members of the general population. Figures published by the National LGBT Tobacco Control Network reveal that smoking kills 30,000 gay and/or transgendered people every year. While only 29 percent of straight adolescents smoke, as many as 45 percent of LGBT women and 35 percent of LGBT men consumed tobacco products. LGBT individuals have the highest smoking rates out of every vulnerable population, largely as a reaction to the stress they are subjected to as part of their gender identity and/or sexual orientation.
Rates of abuse are higher when other substances are taken into account; 25 percent of the LGBT population drinks dangerously, for example, but only as much as 10 percent of the overall population does the same. Similarly, LGBT individuals use marijuana, methamphetamines, and heroin to higher degrees than people who identify as heterosexual. As a result of substance abuse, discrimination, and other factors, as many as 40 percent of LGBT teenagers have attempted suicide or have seriously thought of suicide. On the topic of being bullied for their gender identity, 78 percent of transgender students reported suicide attempts as a consequence.
The overlap between religion and family can be especially daunting for an LGBT person who is struggling with questions of identity and belonging. The Human Rights Campaign notes that family relationships are the cornerstone of many Latino communities, and an LGBT person coming out in such an environment risks losing that very important support system. Conservative and traditional families often cast gender nonconformity as a rejection of nature and of God; Biblical teachings “don’t necessarily speak to the complexity of transgender identity,” explains The Atlantic. In 2014, a 17-year-old transgender girl in Ohio killed herself, her suicide note explaining how her conservative Christian mother’s “extremely negative” reaction (that her gender nonconformity was a phase and that her desire to transition to a female identity was false and wrong) led her to hating herself to the point of death.
The CUNY researchers, who published their findings in the LGBT Health journal, looked at the responses of 6,456 adults who participated in the 2008 and 2009 National Transgender Discrimination Survey. The adults were asked if they had ever attempted suicide or took drugs and/or alcohol to feel better about discrimination they had experienced as a result of their transgendered identities. The survey further asked how the adults’ families (where applicable) reacted upon learning that they were transgendered (or gender nonconforming). Examples of reactions included the termination of the relationship with a spouse or partner and whether family members refused to speak or spend time with them.
Around 54 percent of participants said that the amount of family rejection they experienced was “low”; as many as 14 percent of the adults said that the rejection they received from their family could be considered “high.” Approximately 42 percent of the adults said that they had tried to commit suicide at least once, and 26 percent said they abused drugs or alcohol.
The higher the levels of family rejection, the greater the likelihood of drug or alcohol abuse.
For many transgender people, their struggles with addiction don’t end with treatment. Most facilities separate their clients by gender, to better address gender-specific issues of mental health and substance abuse. Transgender clients, however, are left feeling out of place, especially those who are still in the process of transitioning to their desired gender. Such individuals require regular hormone treatments, which could take years; some treatment centers may not be in a position to continue the facilitation of estrogen or testosterone infusions, and some healthcare providers may be uneducated as to the importance of keeping up with the procedure, mistakenly believing such treatments to be “elective.”
Such is the state of healthcare serving transgender people that many transgender individuals face discrimination in the healthcare services they need. A Reuters report from March 2015 found that 42 percent of transgender people said they received verbal or even physical abuse at their doctor’s office or were denied equal treatment because of their gender identity. Most of the people who reported discrimination were “young, white, college-educated people with jobs and private health insurance,” suggesting that transgender individuals who did not fit into those categories (those who are older, not white, uneducated, unemployed, and without adequate health insurance) could be subject to even greater levels of discrimination within treatment.
For example, “nearly all research into transgender individuals’ mental health shows poorer outcomes,” says NPR, especially for transgender people who are low-income, female, and of color. While nearly one-third of trans Americans are HIV-positive, transgender women of color have an even greater risk of being diagnosed with HIV; a 2009 study by the National Institute of Health found that over 56 percent of black transgender women have HIV-AIDS. Most research on transgender health has used white Americans; more is known now about black transgender individuals than before, but “there is almost nothing” known about Hispanic transgender people.
A study published in the JAMA Pediatrics journal examined 300 young transgender women in Chicago and Boston, of whom only 25 percent were white, and researchers discovered that the rate of mental health disorders and substance abuse was as much as 3.6 times greater than that of the general population. Most of the women were unemployed and without health insurance, and a majority of them “lived in extreme poverty,” all of which are factors for mental health stress and the potential effects of discrimination.
On the other hand, when the journal of Pediatrics looked at the “mental health of  transgender children who are supported in their identities,” this study population did not experience greater amounts of depression and had only marginally higher levels of anxiety than their siblings and non-transgender peers. This population received far more emotional support than the women in the JAMA Pediatrics study; they were “affirmed in their gender identities in all aspects of their lives,” getting comfort and reassurance from their parents, teachers, and other important contacts.
One notable difference between the two groups is that the majority of the transgender children came from homes that averaged household incomes of more than $75,000. The transgender women in the JAMA Pediatrics study had annual incomes of less than $10,000; 40 percent of those women had a mental health or substance use disorder; 20 percent of them had at least two diagnosed psychiatric conditions; over 33 percent of them had experienced clinical depression; and 20 percent of them had thought about committing suicide in the past month. Anxiety, post-traumatic stress disorder, and substance dependence were much higher than average.
Even in addiction treatment, transgender people are either excluded entirely from programs and services or grouped with sexual minority groups instead of being put into a dedicated category. Researchers writing in the journal of Substance Abuse Treatment, Prevention and Policy interviewed 34 transgendered individuals from 2012 to 2013 and found that those who were subject to stigma and transphobia in the form of social rejection and violence “left treatment prematurely after isolation and conflicts.” Treatment provider attitudes have been noted as one of the barriers to addiction treatment that transgender people face; the attitudes “are often rooted in stigma” toward transgender individuals for their apparent refusal to conform to society’s gender standards and expectations.
Healthcare providers in rural settings tend to have less experience treating transgender clients, and this unfamiliarity may also translate into an inability for the providers to offer information pertaining to legal issues, such as domestic partnerships, powers of attorney, homophobia, and transphobia, as well as other areas of difficulty that cause stress for transgender people, couples, and families.
An assistant professor at the University of Buffalo School of Nursing points out that “there is evidence that healthcare providers do tend to be judgmental,” and for many transgender people, that extra layer of stigma (combined with other factors) is enough to dissuade them from seeking medical help.
An example of this occurred in 2010 with a transgender woman in Indiana who went to a hospital after coughing up blood. Hospital staff disregarded the gender on her identification card (female) and instead wrote her in as a male, mocking her objections and asked, “So is it a he or a she? Or a he-she?” Two hours after she was admitted, she was told that doctors did not know how to treat someone “with [her] condition,” and she was discharged without receiving any help.
After the story broke, the Human Rights Campaign contacted the hospital and discussed the adoption of an “LGBT-inclusive patient nondiscriminatory policy,” with training for all hospital staff on compliance after “a recent incident experienced by a transgender woman who faced degrading treatment at the hospital.” However, Indiana’s status as a battleground state for LGBT rights shows the extent to which the policies and culture that create discriminatory stress toward transgender people still exist. In February 2016, Republican leaders in the state senate voted against legislation that would have protected Indiana LGBT residents from discrimination in housing, employment, and private services. The status quo exists in 31 other states, where a transgender person could be legally fired for no other reason than their gender identity and/or sexual orientation.
Even when they are not being fired, LGBT people “face high rates of workplace discrimination and harassment,” according to the Center for American Progress, which further contributes to low self-esteem and shame that fuel a substance abuse problem. While 43 percent of gay people reported physical or verbal abuse in their workplaces directly related to their sexual orientation, as many as 90 percent of transgender people said they received comparable treatment; 44 percent felt they were unfairly turned down for jobs, 23 percent said they had promotions taken away from them, and 26 outright lost their jobs because of their gender identity.
This has made the alcohol and tobacco industries (as well as the illegal drug market) very interested in marketing their products to LGBT people, who are already at-risk for developing substance abuse and/or mental health issues as a result of the prejudice and social stress they experience at home and at work. According to the American Cancer Society, tobacco companies directly advertise in local and national LGBT-themed publications, using themes and keywords like “liberation, individualism and acceptance,” that have been commercially tied in to the message that LGBT communities have been advocating for generations.
Even as more and more progress is made by transgender people and advocates for transgender communities, there is still a great deal of stigma (and even hostility) directed toward gender nonconforming individuals, wherever they are on the spectrum of gender identity and sexual orientation. Unfortunately, this means that the risk factors for addiction among transgender people are still very present, and much education and outreach are required to lift the oppression that trans people face every day of their lives.