Psychological distress and substance use among transgender and gender diverse adults in the United States: an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy.

Background: Transgender and gender diverse (TGD) populations have high mental and behavioral health morbidity, yet few studies have explored inequities in TGD people at the intersection of multiple identities.

Purpose: This study sought to describe inequities in severe psychological distress and substance use by gender/sex, race, and socioeconomic status (SES) in TGD adults.

Methods: We conducted an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) with 25 443 TGD people in the 2015 US Transgender Survey, nested within 48 intersectional social strata defined by gender/sex, race/ethnicity, and SES. For each outcome, a multilevel intersectional logistic model was fit with the additive effects of gender/sex, race/ethnicity, and SES and adjusting for age, gender expression, and US region.

Results: Mean age was 31 years (SD = 13); 35% were transgender women, 30% transgender men, 7% nonbinary assigned-male-at-birth, 29% nonbinary assigned-female-at-birth; 18% BIPOC; and 34% SES below poverty. Stratum-specific predicted outcome probabilities ranged from: 26%-64% severe psychological distress, 21%-36% binge drinking, 19%-37% cannabis use, 7%-12% illicit drug use, and 16%-34% cigarette smoking. Highest probabilities of cannabis and illicit drug use were among transgender women below the poverty line identifying as Biracial/Multiracial (37% and 12%) and Black/African American (34% and 12%), respectively.

Conclusion: Findings highlight the nuance of privilege and oppression, heterogeneity in groups that may share one identity, and need for public health and equity efforts.