Substance Use in Transgender Population

Epidemiology of substance use in transgender people

In the transgender-specific literature, only a small amount of data related to smoking, alcohol use, and illegal substance use (including marijuana, methamphetamine, ketamine, ecstasy, poppers, and inhalants) is available compared to that of LGB (Gay, Lesbian, and Bisexual) individuals. However, there is an observation that the transgender population may exhibit a higher rate of substance use than the heterosexual population. This was reported in meta- analysis research, which collected data from LGB individuals. The study found that compared to heterosexual individuals, LGB individuals have 1.5-2 times greater risk of having alcohol and illegal substance use problems.1 A survey in the United States reported that 26.7% of male-to-female transgender individuals used illicit substances, 20.2% used marijuana, and 13.7% used alcohol and other substances. This rate was higher than that of the heterosexual population.

In Thailand, surveys were conducted on transgender individuals living in different locations. Guadamuz et al.4 observed the behavior of a group of 474 transgender people in Bangkok, Chiang Mai, and Phuket in 2005. The study revealed that the sample group’s average age was 24. In the past three months, 81% consumed alcohol, and 42.6% misused hypnotics. Another study conducted by Suwat et al.5 observed the behavior of 140 transgender people in Chiang Mai province from 2008 to 2009. It was found that 85.3% consumed alcohol, 13.9% were heavy alcohol users (drinking more than seven times per week), 10% used methamphetamine, 0.7% used marijuana, and 0.7% used heroin. Additionally, Nemoto et al.6 conducted a study in 112 male- to-female transgender individuals who lived in Bangkok and engaged in sex work (average age of 25). The study found that 99.1% of the sample group used alcohol within the past year, 32.1% used marijuana, 35.7% used ecstasy, 19.6% used ketamine, and 9.8% used amphetamine. Furthermore, the study found that in the past six months, 97.3% of the sample group had sex with their clients under the influence of alcohol, 98.3% had sex with their non-client partners under the influence of alcohol, 43.2% had sex with their clients under the influence of an illegal substance, and 23.3% had sex with their partners under the influence of an illegal substance. These factors could contribute to a higher risk of HIV, hepatitis, and other sexually transmitted diseases. The details related to substance use in transgender people are shown in table.

Substance use in transgender people in Thailand

Substance	Mechanism of action, symptoms, and possible abnormalities that may result from usage	Addiction treatment
Nicotine (Cigarette)	Stimulates the brain's nicotinic acetylcholine receptors, resulting in alertness and better concentration, memory, and mood. It can easily lead to addiction. Many toxins in cigarettes can contribute to various cancers, cardiovascular diseases, and stroke.	Medication for treatment include varenicline, bupropion, and nicotine replacement therapy, along with psychosocial therapy.
Alcohol (Whiskey, beer, wine)	Acts as a sedative and increases GABA function, thereby decreasing neural input. Additionally, alcohol produces a sense of relaxation, decreases self-restraint, and causes irregular movement and drowsiness. If used in a high dose, it could lead to respiratory suppression and death. Regular alcohol consumption could contribute to addiction, withdrawal symptoms, various cancers, and other hepatic diseases, such as hepatitis and cirrhosis.	Benzodiazepine drugs are used to reduce alcohol withdrawal symptoms. Topiramate baclofen and disulfiram are used to reduce alcohol craving (under physician supervision) together with psychosocial therapy.
Heroin	Acts as a sedative and interacts with opioid receptors, causing a sense of dizziness, pleasure, and addiction. It also reduces pain and increases drowsiness. If used in high doses, it could suppress respiration and result in death. If used as an injection, it can contribute to a higher risk of HIV, hepatitis B, and hepatitis C.	Medication used for withdrawal symptoms and prevention of relapse include methadone and psychosocial therapy.
Amphetamine/ Methamphetamine	Acts as a stimulant and increases dopamine levels in the brain, causing alertness, a sense of happiness, and eventually addiction. Psychologically, it may cause anxiety, paranoia, or hallucinations. For some users, this substance may be used for sexual arousal. If administered as an injection, it could contribute to a higher risk of HIV, hepatitis B, and hepatitis C.	Currently, there is no medication for addiction treatment. Management may include psychosocial therapy, such as motivational interviewing, cognitive and behavioral psychotherapy (CBT), contingency management, environment change, or therapeutic community.
Ecstasy	Acts as a stimulant and hallucinogen that increases the function of dopamine and serotonin, resulting in alertness, a sense of pleasure, and abnormal sensations. It may also result in anxiety, paranoia, and visual or auditory hallucinations.
Ketamine	Interacts with NMDA receptors, resulting in a dissociative state, a sense of happiness, double vision, change of internal feelings, change in visual perception, and addiction. Possible side effects include hepatitis and cystitis.
Popper	A nitrite inhalant that acts as a vasodilator, resulting in a warm sensation and flushed face. It may increase sexual arousal. If used for a long time, it can cause cardiovascular problems.
Marijuana	A cannabinoid substance that interacts with cannabinoid receptors in the brain, causing a sense of pleasure and decreasing anxiety, results in slower actions and addiction. It may also contribute to cognitive abnormalities or psychological disorders, such as hallucination.
Hypnotics	Acts as a sedative like alcohol, causing drowsiness and possibly dizziness and impaired decision-making. If used with other sedatives, it may contribute to a higher risk of respiratory suppression and death.	Gradual dosage reduction until treatment dosage. Sedatives may be given when treatment is initiated.

Several factors could account for the higher prevalence of alcohol and illegal substance use in transgender individuals. For example, they may have used these substances to self-medicate, such as to alleviate stress, anxiety, or depression that may occur in their daily lives or by gender discrimination. These substances may also be used to help socialize with others in the transgender community. On the other hand, risks of substance use may not be completely understood by the user at the time, such as addiction (losing the ability to control substance usage), drug resistance (a higher dose is needed to elicit the same action), and withdrawal symptoms after quitting. Furthermore, these substances may cause work, study, and relationship problems, including legal issues.

Effects of substance use on gender reassignment surgery

Substance use is one factor that can hinder gender reassignment surgery. That is because, before gender reassignment surgery, the patient must undergo a psychological evaluation, which includes the evaluation of alcohol and substance use. If the patient uses substances, surgery plans could be put on hold because the patient may have withdrawal symptoms or substance craving during hospitalization.

Physician generally recommends that patients should be treated and control their substance addiction before undergoing surgery.7 Moreover, some substances, such as toxins in cigarette, may delay postoperative recovery.8 The use of stimulants, such as methamphetamines, could contribute to vascular problems and affect wound healing. Additionally, a history of substance use could become a stigma that acts as a barrier to medical treatment because patients may be worried about legal ramifications or being discriminated against by medical professionals.

Initial Screening

Two methods can be used for substance use screening. The first method is used when healthcare providers would like to screen for substances frequently detected in individuals using only a few substances. They may use separate evaluation forms for each type of substance, such as the Fagerstrom Test for Nicotine Dependence (FTND) for nicotine addiction or the Alcohol Use Disorder Identification Test (AUDIT) for evaluating the risk of alcohol use. The second method is used when healthcare providers would like to globally screen for substance use. Epidemiological studies have shown that transgender individuals have a higher chance of being on multiple substances at once. Therefore, the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) is the most appropriate for multiple substance screening. Thus, it is more suitable for the transgender population.

ASSIST was developed by the WHO (World Health Organization) with committee members from many different countries. It aims to serve as a screening tool that is easy to use, is not time intensive (requires only 5- to 10-minutes to complete) and can be readily used in primary healthcare facilities to evaluate risk of substance and effect. Moreover, ASSIST was developed for use in various cultural contexts. It can screen for many types of substances, such as tobacco (cigarettes, cigar, pipes), alcoholic beverages, marijuana, cocaine, amphetamine stimulants (methamphetamine and amphetamine), sedatives or hypnotics, hallucinators, inhalants (such as glue, volatile solvents, and poppers), opioids (heroin, opium, tramadol) and other substances. Its screening results can be used as a risk indicator for substance use and as a counseling tool for patients. After risk assessment, healthcare providers can then decide on course of treatment, which my span from short-term therapy to referral to specialist for further evaluation and treatment.

ASSIST allows healthcare facilities to learn about the patient’s history of substance use and substance use behaviors in the past three months. Additionally, this form can also highlight problems arising from substance use during different periods, such as toxicity, intoxication, addiction, problems in relationships and life, and behaviors related to intravenous substances. ASSIST, translated into Thai and checked for consistency for use in the field, consists of eight questions, as shown in table.

Examples of questions in ASSIST

No.	Objective	Sample Question
1	To ask the patient about the types of substances used in the past	In your life, have you ever used the following substances? (non-medical use only)
2	To ask the patient about the frequency of recent substance use	In the past three months, how often have you used ......?
3	To ask the patient about the frequency of recent cravings or intense cravings for the substance	In the past three months, how often have you had a strong urge or desire to use .........?
4	To ask the patient about the frequency of recent problems in different aspects of life caused by substance use	In the past three months, how often has ....... use led to health, family, social, legal, and financial problems?
5	To ask about the most recent impact of substance use on the patient’s job or responsibilities	In the past three months, how often were you not able to do what was expected of you, because of your use of ....?
6	To ask the patient about other people who may have noticed that the patient’s substance use may cause problems and if those people have expressed concern.	Has a friend, relative, or anyone else ever expressed concern (or worry) or warned you about your use of ......?
7	To ask the patient about their failed attempts to reduce or quit using the substance	Have you ever tried and failed to stop or cut down the use of ....?
8	To ask the patient about their recent or historical use of injectable substances, which could impose harm	Have you ever used any drug by injection? (non- medical use only)

The scores from all questions are added up and categorized into three levels: low, medium, and high risk of substance use. The score range of alcohol use differs from that of other substances. If the patients are low risk, healthcare providers can give information on substances without providing therapy. If the patients have medium risk, healthcare providers will choose a brief intervention. If patients are high risk or have recently used injectable drugs, they will be referred to a specialist for further evaluation and intense therapy. The place patients are referred to must have a psychiatrist or psychologist who can treat substance abuse patients. The scores and guidelines for patient care can be found in the table.

Substance use in transgender people in Thailand

Substance Type	Score
Substance Type	Low Risk	Medium Risk	High Risk*
Tobacco	0-3	4-26	27+
Alcoholic Beverages	0-10	11-26	27+
Marijuana	0-3	4-26	27+
Cocaine	0-3	4-26	27+
Amphetamine Stimulants	0-3	4-26	27+
Inhalants	0-3	4-26	27+
Sedatives or Narcotics	0-3	4-26	27+
Hallucinogens	0-3	4-26	27+
Opioids	0-3	4-26	27+
Others ............................ (Please specify)	0-3	4-26	27+
Post-Evaluation Patient Care	Provide Knowledge	Brief Intervention	Transfer of Specialist

*Patients who use an intravenous substance are categorized as high risk. They should also be referred to a specialist and tested for blood-borne viruses, such as HIV, Hepatitis B and Hepatitis C.

Brief intervention

Brief intervention (BI) is counseling aimed at risk reduction in smoking, alcohol use, and substance use. BI typically takes 3-15 minutes after patients complete ASSIST. It is performed only in those with medium or high risk. BI has been proven to reduce the frequency of alcohol drinking11 and the use of marijuana, opioids and amphetamine stimulants. The concept of BI is shown in the table.

The Procedure, objective, and sample sentences used in brief intervention

Procedure	Objective	Sample Sentence
1. Asking	To ask the patient about their willingness to receive their scores to increase their sense of control and decrease resistance	“Would you like to know your ASSIST score?”
2. Feedback	To provide a specific score for each substance by using ASSIST report to counsel the patient on possible risks of substance use	“This is your risk score for each substance. Your .... use is at .... risk level, which may cause symptoms such as ...... now and in the future.”
3. Advice	To provide impartial suggestions on harm reduction or risks of substance use	“The best way to reduce harm/risk is to reduce or quit ...... use.”
4. Responsibility	To let the patient take full responsibility for their decisions.	“It depends on your decision. I am only providing you with information.”
5. Concerned I	To ask about their concerns after receiving feedback	“How do you feel now? Are you worried?”
6. Good things	To ask about the perceived benefits of substance use	“What are the benefits of ...... use?”
7. Less good things	To ask the patient about their willingness to receive their scores to increase their sense of control and decrease resistance	“Would you like to know your ASSIST score?”
8. Summarize and reflect	To provide a specific score for each substance by using ASSIST report to counsel the patient on possible risks of substance use	“This is your risk score for each substance. Your .... use is at .... risk level, which may cause symptoms such as ...... now and in the future.”
9. Concerned II	To provide impartial suggestions on harm reduction or risks of substance use	“The best way to reduce harm/risk is to reduce or quit ...... use.”
10. Take-home materials	To let the patient take full responsibility for their decisions.	“It depends on your decision. I am only providing you with information.”

While using ASSIST and conducting BI with the interviewees, the interviewers should be as unbiased as possible. They should ask further questions to better understand the patient’s history of substance use and their problems and concerns. They should not express bias towards any end, such as repeatedly convincing the interviewee to quit their substance use or criticizing the interviewees who still use, cannot quit, or reduce their substance use. They should not judge what is right or wrong. Instead, the interviewers should demonstrate empathy with the interviewees for the problems they are facing. Keeping strict confidentiality, they should inform the interviewees that the information obtained from this evaluation will be kept confidential so that the interviewees would feel more comfortable answering questions truthfully.

Based on the information given above, the guidelines on initial screening and evaluation of substance use in transgender people for public health facilities could be summarized as follows:

Conduct substance use screening and provide information on smoking, drinking, and illegal substance use for the high-risk transgender individuals receiving medical services, such as those living with human immunodeficiency virus (HIV) or those being tested for sexually transmitted infections (STIs).
Conduct substance use screening and provide information on smoking, drinking, and illegal substance use for high-risk transgender people in communities, such as those engaging in sex work or work night jobs.
Use the Thai version of ASSIST9 to screen for those smoking, drinking, and using illegal substances. Provide brief intervention in cases where the individual presents with medium-level risk or higher. Referral to a specialist should be completed for high risk patients or for those who use intravenous substances.

Harm Reduction

Harm reduction measures refers to policies, programs, or treatments that aim to reduce harmful health, economic, or social impact on the individual, community, or society caused by substance use.16 This was first implemented between 1960 and 1970 to reduce the spread of hepatitis and HIV among intravenous heroin users. During the initial stage, measures included the Needle- Syringe Program (NSP) and Methadone Maintenance Therapy (MMT). Studies have shown that harm reduction measures could reduce the rate of HIV and hepatitis B transmission, prevent overdose, improve access to care, and increase treatment adherence.

The objective of harm reduction is to reduce harm from substance use rather than aim for abstinence. This measure focuses on respecting the user’s individuality, respecting their values as a human, emphasizing the harm of substance use, and having concrete goals.

The harm-reduction measure should be integrated as a component of substance use treatment programs, although some measures are used as alternatives for users who are not ready to quit. This is to provide treatment flexibility by placing primary emphasis on the user’s readiness.

The significance of substance use problems and harm reduction measures for transgender people

The Substance Abuse and Mental Health Services Administration (SAMHSA)17 reported in 2014 that Substance Use Disorder (SUD) was present in 8.4% of the heterosexual population, compared to 25-28% in the transgender population. SAMHSA reported that substance use increases HIV transmission through the sharing of needles and risky sexual behaviors.

Another U.S. study found that male-to-female transgender individuals had a higher prevalence of HIV than female-to-male transgender individuals.18 This finding may demonstrate a difference between male-to-female and female-to-male transgender individuals. Therefore, policies to prevent or reduce harm from substance use should consider this factor.

This chapter aims to demonstrate how harm reduction measures could be implemented in the transgender population. These measures are divided into suggestions for service providers, general harm reduction measures, and harm reduction measures for intravenous substance users. This chapter also examines the current status of harm reduction in Thailand.

Suggestions for service providers

In designing specific harm reduction measures, various factors, including the type of substance used, route of administration, and pattern of use should be taken into consideration. The process could be conducted as follows:

Realize and understand the harm of all substances used by the patient.
Evaluate harm and risks that may occur to substance users. Analyze the drug use pattern with the concept of 6Ws, consisting of When, Where, Why, With/From, Whom, and What happened, because the amount of substance use and different administration routes pose different impacts on health. For example, intravenous drug administration could cause an open wound, blood vessels injury, and sexually transmitted diseases, especially when needles are shared.
Evaluate and counsel users regarding how substance use behaviors may harm them. Healthcare providers should provide information on negative impacts of substance use while motivating patients to change their behavior.
Health care provider and substance user should collaborate in figuring out ways to reduce harm and identify problems and obstacles that may happen.
Encourage substance users to set their own goals related to substance use, identify associated harmful behaviors, and plan methods to achieve their goals.
Track the substance user’s behavior, promote positive change, and provide guidance in dealing with difficulties in behavioral change.

General harm reduction strategies

Education strategies

The first step in harm reduction strategies is to provide information on the effects of the substance, discuss potential risks of substance use, and promote risk reduction behaviors. The education given should consist of information about the health and psychosocial risks secondary to substance use, overdose, infectious diseases, and psychological disorders. Education should be provided together with other treatment methods, such as brief intervention, either privately or in groups. It may be conducted in healthcare facilities or other locations.

A study found that 43.2% of transgender sex workers in Thailand had sex under the influence of substances.6 Therefore, the education should emphasize safe sexual behaviors, methods to reduce the risk of STIs, and possible risks of substance intoxication. Those able to access treatment may be educated in healthcare facilities, while those without access may receive outreach services in their communities or workplaces.

Brief interventions and counselling

Brief interventions focus on changing risky behaviors and may incorporate cognitive- behavioral therapy (CBT) and motivational interviews to motivate patients’ behavioral change.

Intervention to reduce injury and violence

The use of certain substances, such as alcohol, is correlated with injury, violence, and social problems. Research revealed that policy measures, such as controlling alcohol sales and strictly enforcing drunk driving laws, can effectively reduce harm of alcohol consumption.

Availability of measures to prevent acute consequences of stimulant use

There are much fewer studies related to stimulant harm reduction measures than those of opioids. Stimulant harm reduction measures usually focus on providing physical and mental care in emergency conditions (violence, self-injury and non-self-injury, suicide, and homicide). For example, Indonesia had developed an amphetamine harm reduction program that operated proactively to provide substance users with safe equipment and prevent health-related harm

Currently, there is no specific stimulant harm reduction program for transgender people. However, a US study has investigated the feasibility of a mobile harm reduction service in men who have sex with men (MSM) who cannot access services during regular operating hours. The mobile nighttime services included the needle and syringe programs (NSP), education and consultation, oral HIV testing, and urine testing to screen for STIs.

Harm reduction measures for intravenous substance users

Harm reduction measures for intravenous substance users can be divided into eight components as follows:

Needle and Syringe Program (NSP)

The NSP measure could effectively reduce the incidence of HIV and other blood-borne infections23 by reducing sharing needle behavior between substance users. A good NSP should also provide information and better access to services, including addiction treatment, physical health services, and legal and social services. Besides needles and syringes, the NSP offers the following services:

Educating people about the infectious risks of intravenous substance use
Providing information and recommendations on safe substance injection
Providing sterile needles and syringes
Educating people about the safe disposal of used needles and syringes

The NSP service is usually provided for opioids users. However, transgender people are more likely to use methamphetamine. Intravenous methamphetamine use differs from intravenous opioids because users inject methamphetamines more often, leading to a higher risk of disease transmission. As a result, more needles are needed. Additionally, NSP should include services for those who also concomitantly use gender-affirming hormones, which could be administered intramuscularly. Therefore, the NSP must cover both substance and hormonal injections.

Opioid Substitution Therapy (OST)

A study found that Opioid Substitution Therapy (OST), including methadone or buprenorphine maintenance therapy, could reduce heroin use. Furthermore, OST could reduce risks of HIV and hepatitis C, increase adherence to antiretroviral therapy, and reduce risks of opioid overdose in intravenous substance users.
In Thailand, methadone maintenance therapy is available for opioid users who cannot quit completely. However, opioids are less popular in the transgender population than other substances. Therefore, no study has been conducted on the efficiency of harm reduction in this sub-group. Healthcare providers should recommend OST for transgender opioid users who cannot quit and have indications for OST. However, both patient and provider should come to a decision together regarding OST use.

Overdose treatment

Naloxone is a drug used for opioid overdose treatment. Currently, the World Health Organization (WHO) suggests that those at risk for opioid overdose should have access to naloxone and be trained to administer naloxone. Nevertheless, in Thailand, naloxone could only be prescribed by medical professionals. This practice differs from the regulations of countries in Europe and North America, which have already implemented the take-home naloxone program.

Since the take-home naloxone program is still unavailable in Thailand, measures that can be implemented instead at this time is peer-to-peer education on basic first-aid and resuscitation. If overdose is suspected, friends and relatives are encouraged to immediately call emergency medical service.

HIV testing and counselling

HIV testing and counseling are considered the first steps in HIV treatment. Thus, in some cases, outreach screening needs to be implemented in communities because not all substance users can access healthcare facilities. Additionally, the HIV screening services should be linked with treatment programs for those found to be HIV positive. Healthcare providers should also counsel such patients on the prevention of HIV transmission.

Emphasizing non-injection routes of administration over injection routes

This strategy aims to reduce the adoption of the intravenous route in substance users who have never injected and to reduce intravenous substance use among users who are currently practicing this way. Healthcare providers should recommend other, safer routes of administration.

Prevention and treatment of sexually transmitted diseases

STIs can increase the risk of HIV transmission. Related harm reduction measures include using condoms, providing education about safe sex, screening for STIs, and providing treatment for afflicted patients. To ensure treatment adherence, healthcare facilities providing STI treatment should be the same place where substance users receive substance-related services.

Wound care and vein maintenance

Recommendations regarding the importance of sterility, care, and selection of safe injection sites should be part of patient education. Intra-arterial injections should be avoided. The frequency of injections should be minimized, and selection of types of substances with a safer profile emphasized. In addition to substance use, patients may simultaneously be on injectable hormones. Healthcare providers should be aware of this fact and include this in their history-taking, along with recommendations for usage of drugs or substances that meet medical standards.

Prevention, vaccination, diagnosis and treatment for viral hepatitis

The WHO recommends that intravenous drug users receive hepatitis B vaccination and encouraged the vaccinated users to complete the full dose series.

Status of harm reduction policies in Thailand

According to a report of the Joint United Nations Program on HIV/AIDS (UNAIDS)25 on the statistics of harm reduction service access in 2014, Thailand had 71,000 intravenous substance users, 21% of whom had HIV. A total of 5,956 users received opioid substitution therapy. An average of 14 sterile needles per person per year was provided. 95% of substance users used sterile needles in their most recent injection. 51% of all substance users used a condom during their most recent sexual activity. When these numbers are compared to those obtained from developed countries, such as France, France had a higher number of intravenous substance users than Thailand (145,000 people). Its people also had higher access to harm reduction measures than those in Thailand. There were more proactive measures to increase access to health services and a take-home naloxone program to prevent the consequences of substance overdose in France. This information indicates that Thailand's harm reduction measures should be further improved to allow patient-access at a level approaching that in developed countries. However, there is currently no Thai-based study evaluating access to harm reduction measures among the transgender population.

Based on the information above, recommendations for public healthcare service organizations related to harm reduction measures in transgender people could be summarized as follows:

Harm reduction measures should be provided for transgender people unable to achieve abstinence.
The pattern of substance use and possible harms of substance use should be evaluated for all patients to provide specific strategies to reduce specific harms.
Service providers should not neglect substance users who are not committed to achieving abstinence. Instead, they should provide flexibility in treatment by motivating users to quit their substance use in conjunction with harm reduction measures.

Refer: Substance Use in Transgender Population, The Thai Handbook of Transgender Healthcare Services, Center of Excellence in Transgender Health, Chulalongkorn University

REFERENCES

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