UC San Diego

Background: Transgender women and transfeminine nonbinary adults may be at disproportionate risk of problematic substance use and the co-occurrence of problematic substance use and psychological distress due to a lack of access to economic/social resources and gender affirmation. This dissertation estimated associations between social determinants of health and substance use and co-occurrence with psychological distress, which can inform prevention efforts.Methods: Data from The LITE Study, a longitudinal cohort of transgender women and transfeminine nonbinary adults in the Southern and Eastern United States, were analyzed. Cohort participants (N~1,300) were adults not living with HIV at baseline. Paper one used the baseline sample to estimate latent classes of substance use behavior and examine cross-sectional associations between social determinants of health and latent class membership and between latent class membership and problematic drug use. Paper two assessed associations between baseline social determinants of health and 6-month co-occurrence of problematic drug use and psychological distress. Paper three assessed associations between baseline medical and legal gender affirmation with 12-month problematic drug use and problematic alcohol use. Results: Paper one: Four classes were identified (“low/moderate alcohol use,” “problematic alcohol and cannabis use,” “poly substance use,” and “opioid and cannabis use”). Legal and medical gender affirmation, food insecurity, homelessness, and arrest predicted class membership. The “problematic alcohol and cannabis use,” “poly substance use,” and “opioid and cannabis use” had greater odds of problematic drug use compared to the “low/moderate alcohol use” class. Paper two: More income, never homelessness, never arrested, more food security, and not experiencing health care discrimination was negatively associated with co-occurrence of problematic substance use and psychological distress. Paper 3: Those who successfully obtained medical gender affirmation had 0.68 times the risk (95% CI 0.47—0.98) of problematic drug use compared to those who unsuccessfully tried to obtain medical gender affirmation. Conclusions: Access to economic/social resources and gender affirmation was negatively associated with problematic substance use and the co-occurrence of problematic substance use and psychological distress. Increasing access to such resources may improve substance use outcomes. Community-based intervention work is needed to develop culturally sensitive interventions for transgender women and transfeminine nonbinary adults.