Informed consent was obtained before starting the behavioral survey, which was administered via hand-held tablet computers. All study procedures were approved by the Institutional Review Board at the University of California, San Francisco. Written consent was obtained from all youths aged 18 years or older and written assent was given by younger participants . Psychosocial exposures measured included PTSD, psychological distress, gender-related discrimination and a parental drinking or drug problem . PTSD symptoms were determined by use of the four-item Primary Care PTSD Screen with a cutoff of three out of four symptoms in the last twelve months . Psychological distress was measured with the 18 item version of the Brief Symptom Inventory , converting the BSI-18 Global Severity Index to Tscores and using a validated clinical cutoff of T > 62 for symptomatic psychological distress in the last seven days . Gender-related discrimination was determined by questions that asked whether participants had ever experienced poor treatment from parents/caregivers, faced difficulties obtaining employment, lost a job/career or educational opportunity, changed schools and/or dropped out of school, or moved away from friends or family as a result of gender identity or gender presentation. Experience of any of the above types of discrimination at any time was defined as having gender-related discrimination in a dichotomous variable for this exposure.
PDAP was determined by a single question based on the DSM-IV criteria for substance abuse,ebb flow tray which asked whether parents or immediate caregivers had ever “had a drinking or drug problem that got in the way of their work and/or relationships” . Socioeconomic status was determined using self-reported household annual income while accounting for the number of individuals dependent on that income using the US Department of Housing and Urban Development’s FY2014 Income Limits for the San Francisco, CA HUD Metro Federal Market Rent Area . HIV status was obtained by rapid HIV testing. Rapid finger prick tests were offered by the research assistants to all participants regardless of self-reported HIV status. Participants were asked to stay for their results but were not required. All participants who tested positive were referred to the San Francisco Department of Public Health Linkage Integration Navigation Comprehensive Services program which provides and coordinates comprehensive HIV care for newly tested positives and known positives who are currently out of care. Other measures such as whether or not participants had been sexually active in the last six months, highest level of education completed, immigration status, and length of time in the San Francisco Bay Area were also collected. Primary outcomes of interest were drug use, defined as any use of marijuana, methamphetamine, crack, cocaine, non-prescribed prescription drugs, ecstasy, GHB, ketamine, heroin or poppers; alcohol use; drug use before or during sex, measured by the question, “how often did you use drugs other than alcohol before or during sex in the last 6 months?”, which was converted into a binary variable to assess presence or absence of any drug use before or during sex; use of multiple drugs; use of multiple light substances and no heavy drugs; and use of multiple heavy drugs, regardless of the use of light substances, in the last six months. “Light” substances included marijuana, poppers and alcohol. “Heavy” drugs included methamphetamine, crack, cocaine, ecstasy, GHB, ketamine and heroin.
These definitions, except for the alcohol use and use of multiple light substances , exclude the use of alcohol and are consistent with prior analyses of poly drug use . We use the term “substances” to refer to both drugs and alcohol, whereas we use the term “drugs” to refer to drugs exclusive of alcohol. Although not a primary outcome, binge drinking was defined as 5 or more drinks on one occasion. In this sample of trans*female youth, we observed a high prevalence of substance use; use of multiple substances was also common. The prevalence of substance use among our sample was greater than that of the general U.S. adolescent population. For example, in the Youth Risk Behavior Surveillance System, 41% of high school adolescents used marijuana, 7% used ecstasy, 18% used non-prescribed prescription drugs, 6% used cocaine, and 3% used methamphetamine, whereas among our sample of trans*female youth, 63% used marijuana, 20% used “club drugs” such as ecstasy, 20% used non-prescribed prescription drugs, 16% used cocaine/crack, and 13% used methamphetamine . Although the elevated prevalences in our sample could be partially explained by differences in sampling methods between the compared studies, they are consistent with other studies of trans*female youth . We also note that the prevalence of substance use among trans*female youth approached levels reported by trans*female adults in San Francisco and studies of other adult transwomen populations, indicating very early onset . Additionally, we found that roughly one in three trans*female youth reported using drugs in conjunction with sexual intercourse. Thus, the association between PTSD, gender-related discrimination, PDAP and drug use before or during sex is of particular importance because situational use of drugs or alcohol before or during sex has been associated with an increased risk of HIV infection and may be part of the explanation for the extremely high prevalence of HIV among transwomen .
Given the acute and long-term consequences associated with substance use in adolescence, including substance use later in life and increased risk for HIV infection, developing targeted interventions to reduce substance use and associated harm among trans*female youth is a pressing public health issue . In this study, trans*female youth also reported high prevalence of PTSD, gender-related discrimination, psychological distress, and PDAP, which were in turn independently and positively associated with drug use in general, as well as use before or during sex. The significant relationship between PTSD and substance use is consistent with prior studies among young people, which have found that PTSD was a significant predictor of substance use . Researchers have postulated that substances may be used by youth to cope with symptoms of post traumatic stress—a process described as the “self medicating” hypothesis . This hypothesis may also explain the association between gender-related discrimination, psychological distress and increased likelihood of substance use. Indeed, discrimination has been implicated as a contributing factor in substance use in general . It is plausible that trans*female youth use substances to cope with stress and transphobia they experience due to their gender identity. Research on racial discrimination, for instance, has found that engaging in substance use to cope with racial discrimination moderated the relationship between discrimination and substance use overtime . Psychological distress related to a young person’s gender identity may similarly influence substance use as a method of coping . These relationships could also be explained by the “minority stress” theory,flood and drain tray which describes how chronic stress—including discrimination and trauma—experienced by minority groups can lead to negative health outcomes and increased risk behaviors . Studies exploring the motivations behind the use of various substances can further elucidate the impact of discrimination and trauma on substance use outcomes. Unfortunately, few studies have explored the role of discrimination and trauma on substance use outcomes among trans*female youth . Future studies should endeavor to examine how psychosocial stressors influence substance use and evaluate the long-term impact of these co-morbidities on the health outcomes of trans*female youth. In the interim, interventions that provide and support alternative coping skills may have some success in reducing substance use as a method of dealing with stressors related to genderbased discrimination . Because trans*female youth are particularly susceptible to the assessed psychosocial risk factors, linkages represent important avenues through which to focus interventions to curb substance use and associated risk behaviors in this population. Structural level interventions aimed at reducing stigma and gender-identity discrimination may be needed to prevent substance use in this uniquely vulnerable group. Similarly, interventions that give parents the skills to prepare their children to recognize and cope with gender-based discrimination may reduce the negative reactions to such stigma and reduce the need for coping, as has been shown in programs and research related to racial and cultural socialization practices of parents . Furthermore, our findings highlight the potential harmful effect of PDAP on trans*female youth. Our findings, though cross-sectional, are consistent with the documented influence of familial substance abuse on substance use among youth in general, which has been observed in many studies .
Researchers posit that the familial influence may be due to youth modeling their behaviors after that of their substance-using parents, as explained by social learning theory . Hence, screening for substance abuse and providing referrals to treatment for substance using parents may translate to reductions in substance use among their offspring. This study has several limitations. First, the cross-sectional design of the study limits our ability to make causal inferences related to the psychosocial risk factors and substance use among our sample. As the on-going cohort progresses, our analysis provides the framework and opportunity to assess the causal relationships between the strong correlations described here and subsequent risk. Second, our sample was limited to the San Francisco Bay Area so is not generalizable to trans*female youth in other geographic regions. In addition, the self-reported data from this study may be subject to social desirability and recall bias. Also, due to the exploratory nature of this analysis, we did not formally adjust for multiple tests of association. Thus, findings with marginal p-values, such as the association between PTSD and use of multiple light substances or psychological distress and the use of multiple heavy drugs , should be interpreted with caution. Although the link between alcohol use and increased sexual risk behavior has been well documented in other populations, we did not assess this association in our sample, a limitation which highlights the importance of this link in future research among trans*female youth . Furthermore, this is a non-probability sample which limits our findings from being generalizable to the broader population of trans*female youth in the San Francisco Bay Area. In particular, the over representation of trans*female youth of color may limit the generalizability of our findings. However, we note that the proportion of participants of color is low relative to a recently conducted population-based study of trans*females in San Francisco, where women of color made up 82% of the sample . Moreover, because trans*females of color are disproportionately affected by HIV in San Francisco, it is important to have a high percentage of youth of color represented in these data . Although our analyses controlled for potential confounding by race/ethnicity and socioeconomic status in order to focus on gender-related discrimination, it is important for future studies to explore the intersectional effects of multiple dimensions of inequality, such as gender, race/ethnicity and socioeconomic status. Regardless of these limitations, this study provides important insights into the prevalence and correlates of substance use among an understudied and marginalized population, which has a practical implications for research and public health programming. Future research should explore the societal, institutional and interpersonal bases of PTSD and gender-related discrimination to better understand how they interact with personal coping and substance use among trans*female youth. The illumination of these pathways has the potential to inform the development of policies and programs aiming to mitigate the rampant health disparities facing trans*female adults. Additionally, the potential link between parental drinking or drug problems and substance use among trans*female youth merits further investigation and draws attention to the potential value of inter-generational and familial interventions. Individuals with psychotic disorders were for many decades not considered appropriate candidates for psychotherapy. The first case reports detailing the use of cognitive behavioral techniques to treat psychosis were published in the 1980s , while the first randomized controlled trial of cognitive‐behavioral therapy for psychosis originated in the United Kingdom in the 1990s . Presently, CBT is listed as a preferred treatment for psychosis by the Schizophrenia Patient Outcome Research Team in the United States, a set of strictly evidenced‐based treatment guidelines . A combination of antipsychotics and structured therapy has been shown to improve both positive and negative symptoms and result in global functional improvement . The CBT focus on cognitive restructuring, normalizing, behavioral self‐monitoring, and activity scheduling promotes social engagement . In one community‐based study, CBT improved positive symptoms, general mental health problems, and depression, as well as reduced admission rates following treatment . The PORT guidelines also recommend social skills training , which targets social cognitive processes, psycho‐education,life management skills , and relapse prevention skills .