Project Summary/Abstract Transgender and gender diverse (TGD) adults are at greater risk for alcohol use, alcohol-related problems, and alcohol use disorders relative to cisgender adults. Thus, having culturally-competent alcohol use assessments and interventions that effectively target salient risks within this population is critical from a public health perspective. Yet, despite increased attention on this vulnerable population, extant theory concerning alcohol risk and resilience within TGD populations suffers from numerous theoretical and methodological limitations. This includes (a) a narrow perspective of risk that fails to consider the incremental validity of different stressors facing TGD adults, (b) the operationalization of risk within racially homogeneous, White samples that may not capture risks and strengths relevant in racially, ethnically, and sexually diverse samples, and (c) reliance on quantitative approaches that fail to facilitate the translation of indices of alcohol use within TGD communities into clinical protocols. Addressing these limitations is the answer to laying the foundation for more culturally affirming and clinically useful models for explaining and intervening with alcohol use in TGD populations. Our study is consistent with NOT-MD-19-001, “Notice of Special Interest in Research on the Health of Sexual and Gender Minority (SGM) Populations.” The proposed study seeks to address these aims via a novel, mixed method research approach. In the first phase of the study, we will conduct secondary data analyses on a large, diverse sample of TGD adults (N=27,715; U.S. Transgender Survey) to examine which minority stress experiences in the empirical literature are robust predictors of alcohol use across gender identities (e.g., non-binary, trans men, trans women) and intersecting identities (e.g., race, ethnicity, sexual orientation). Our analytic plan will use a multi-level modeling approach (i.e., MAIHDA models) to better capture the influence of intersecting identities on risk, as well as an evidence-based medicine (EBM) approach to demonstrate the clinical utility and statistical fairness of an alcohol use risk algorithm informed by minority stress theory for TGD adults. In the second phase of the study, qualitative interviews will be conducted with 60 TGD, drinking adults, to gain perspectives on top-down minority stress theories tested in Phase I, as well as other salient risks, needs, and strengths missing from current conceptualizations of alcohol use within the TGD community. The sample will be stratified by gender identity, race, and ethnicity to ensure a representative perspective on the environmental events and dynamic processes most salient to TGD adults’ perspectives on problematic alcohol use. Collective findings from our study will inform an R34 application that focuses on developing a TGD-affirming alcohol intervention.

Project Narrative The proposed mixed method study leverages the unique strengths of secondary data analyses and qualitative interviews to lay the foundation for a more culturally-competent and clinically useful approach to understand risk and resilience for alcohol use in transgender and gender diverse (TGD) adults. Findings from our study will highlight the dynamic risks, strengths, and needs related to alcohol use that comprehensive clinical protocols should target when working with diverse TGD populations.