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 Table of Contents  
BRIEF COMMUNICATION
Year : 2022  |  Volume : 38  |  Issue : 4  |  Page : 369-372

Factors influencing substance use among transgender individuals in India: Knowledge gap and way forward


Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth (Deemed-to-be University), Puducherry, India

Date of Submission16-May-2021
Date of Decision10-Jun-2021
Date of Acceptance27-Jun-2021
Date of Web Publication28-Jul-2022

Correspondence Address:
Dr. Karthick Subramanian
Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth (Deemed-to-be University), Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_126_21

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  Abstract 


Background: Due to various psychological and psychosocial factors, transgender (TG) individuals suffer from psychiatric disorders including substance use disorders (SUDs). Although factors influencing mental illness and stigma in TG persons have been identified, the literature is scarce regarding the factors influencing substance abuse among the TG population. The present review identifies the burden and risk factors for substance use among TG individuals in India. Methods: An electronic search of databases such as MEDLINE, ProQuest, and Google Scholar yielded 11 relevant Indian research articles. The factors moderating substance abuse among TG persons were reviewed. Results: Studies reveal that alcohol and tobacco use disorders are the most common SUDs among TG persons in India, apart from illicit drug use. Depressive symptoms, anxiety, unemployment, and discrimination in various spheres of life were associated with elevated substance use among TG individuals. Not being married, higher income, often out with family and friends, having more sexual partners, and interpersonal violence with partner predicted harmful and illicit patterns of substance use. Conclusion: Various demographics, sexual relationship characteristics, and psychosocial factors tend to influence substance abuse patterns. Future studies are needed to explore the influence of various physical, psychosexual, psychological, and psychosocial factors on the substance use patterns among TG persons in India.

Keywords: Addiction, India, risk factors, transgender


How to cite this article:
Subramanian K, Kavya M. Factors influencing substance use among transgender individuals in India: Knowledge gap and way forward. Indian J Soc Psychiatry 2022;38:369-72

How to cite this URL:
Subramanian K, Kavya M. Factors influencing substance use among transgender individuals in India: Knowledge gap and way forward. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Dec 9];38:369-72. Available from: https://www.indjsp.org/text.asp?2022/38/4/369/352512




  Introduction Top


Transgender (TG) individuals have gender identities or gender roles, which differ from gender constructs of their birth-assigned sex.[1] It is estimated that 4.88 million of the adult population in India identify themselves as TG.[2] In India, TG people are recognized by various names such as Aravanis, Jananas, Kinnars, Hijra, Kothi, and Dhurani discriminating based on their gender and sexual minority (GSM) status.[3] Gender-based discrimination, widespread stigma, and gender-based violence against TG individuals adversely affect their physical and mental health conditions. Due to various psychological and psychosocial factors, TG individuals suffer from psychiatric disorders, notably depression, anxiety neuroses, and substance use disorders (SUDs). In the Indian context, studies have delineated crucial factors influencing the burden of mental health issues, stigma, and social support in TG individuals. However, the literature is scarce regarding the factors influencing substance abuse among the TG population.

The present brief narrative review aimed at identifying Indian literature on the burden and risk factors for substance use among TG individuals.


  Methods Top


An electronic search of databases such as MEDLINE through PubMed, ProQuest, and Google Scholar was performed to retrieve appropriate reference literature. The period was set from inception till May 2021 to identify relevant English language peer-reviewed articles on substance abuse among TG people. We used the following combinations of free-text terms such as “substance*,” “alcohol*,” “drug*,” “transgender*,” “Gender Sexual Minor*,” “prevalence,” “epidemiology,” “risk factors,” and “India.” The two independent authors performed a liberal search of the literature, and the final list of articles was selected based on mutual consensus. A total of 127 original research articles were initially shortlisted, and based on a reading of the abstracts and full-texts, 11 articles were selected for the review. For the present narrative review, we neither attempted computation of effect sizes nor performed a risk of bias assessment for included papers.


  Results Top


Burden of psychiatric morbidity and substance use disorders among transgender individuals

TG individuals were found to be suffering from higher psychiatric morbidity compared to the cisgender people.[4]

A comprehensive review of mental health issues among TG people in India revealed that depression (20%–70%) is the most common psychiatric illness, followed by dysthymia and anxiety disorders (6%–40%) including social phobia, generalized anxiety disorder, posttraumatic stress disorder, and panic disorder. Studies also revealed that the suicidal risk among TG people was greater than cisgender population estimates.[4],[5]

Regarding the burden of substance abuse among the TG people, studies have reported varying but significant rates across various gender identities. Among the substances, alcohol abuse (23%–62.5%) and dependence (31.2%) were the most common SUDs.[5],[6] However, few other studies reveal that tobacco use was the most common followed by alcohol use.[7],[8] In addition, illicit drug use disorders and polysubstance use were also frequently reported among TG individuals.[5],[7]

Identified risk factors for substance use disorders among transgender individuals

Although relatively fewer studies have studied the burden of psychiatric morbidity among TG people in India, epidemiological studies in India dedicated to substance abuse and the associated factors among TG individuals are rarer. As such, exclusive Indian studies exploring the risk factors for substance are rarer. However, few studies have attempted to map risk factors for substance use among TG people, who also experienced other psychiatric comorbidities.

Factors having association with substance use among transgender people

The most common observation is that the substance use risk was increasingly common in TG people who reported depressive symptoms, followed by anxiety symptoms.[5],[7] A recent Indian study reported a high exposure to physical, sexual, and psychological violence in many of the participants.[7] The same study found that high rates of alcohol use were associated with poor quality of life in the social domain of TG individuals.

Factors predicting substance use patterns among transgender people

One study, conducted among men having sex with men in Maharashtra, revealed different patterns of substance use: hazardous drinking (23%), illicit substance (12%), and polysubstance use (9%). The authors went ahead and found predictors for alcohol use among TGs: having more sexual partners (odds ratio [OR] = 1.05, 95% confidence interval [CI] [1.02, 1.08]), not married to women (OR = 0.33, 95% CI [0.11, 0.97]), and having higher income (OR = 2.62, 95% CI [1.50, 4.58]) predicted hazardous drinking. Similarly, staying and working outside with friends and family (OR = 2.45, 95% CI [1.26, 4.77]), having more sexual partners (OR = 1.03, 95% CI [1.00, 1.06]), not married to women (OR = 0.18, 95% CI [0.02, 1.45]), having experienced interpersonal violence in the past 1 year (OR = 2.21, 95% CI [1.12, 4.38]), and having engaged in condomless anal sex (CAS) with a male partner (OR = 2.43, 95% CI [1.22, 4.82]) predicted illicit or polysubstance use among TG individuals.[9]


  Discussion Top


TG individuals in India belong to the fringes of societal clusters, making them vulnerable to various psychological and psychosocial hardships.[2],[5],[8] Consequently, they suffer from various mental health issues, especially depression and substance abuse.[5] The rates of substance use among the TG population are higher than those reported among the general population due to various factors.[1],[10] However, literature is limited regarding the factors that might predispose or promote substance abuse among such persons. An overview of global research evidence and the existing Indian literature on risk factors for substance use in TG people becomes necessary to identify and address crucial gaps in knowledge regarding this burgeoning problem among TG individuals. Furthermore, awareness about the factors leading to common mental health issues among TG people in India might serve as possible research avenues since many psychosocial factors are common for the induction of mental illnesses and substance abuse.

What do we know from global literature?

Global studies have identified risk factors in discrete domains: demographic, gender identity/sexual orientation, psychological, and psychosocial. Sociodemographic factors such as age, gender, and ethnicity tend to influence the substance abuse in TG individuals: early adolescence, Black ethnic origins, men > women.[11],[12] Studies also found that sexual orientation (bisexuals/gay/lesbian vs. heterosexuals) influences the rate, pattern, and choice of substance use.[12] In terms of psychological and psychosocial risk factors, global studies have highlighted the minority stress model, given by Meyer, to explain the dynamics between substance use in TG and numerous psychological and psychosocial risk factors. The model discusses persistent and socially constructed stressors, which can be either proximal or distal, which tend to initiate and perpetuate substance abuse among the TG population. Proximal stressors are internal stressors (e.g., fear of rejection, shame, low self-esteem, and internalized transphobia) and distal stressors arise from the environment (e.g., lack of social support).[13]

Identified risk factors for substance use patterns among transgender people in India

Although the Indian literature on risk factors for substance abuse among TG people is relatively sparse, a considerable number of Indian studies provide an overview of the burden and risk factors for substance abuse among TG people. Although most studies revealed that depression, poor socioeconomic status, and discrimination were associated with substance abuse,[5],[7] one study identified strong predictors for harmful substance abuse patterns among TG people: marital status, living conditions, employment, income, number of sexual partners, partner relationship, and partner violence.[9]

Possible risk factors for substance use disorders among transgender people in India

Research into the factors leading to common mental health problems among TG individuals in India reveals that:

  • TG people are subjected to abuse and violence both within the family and in society. Lack of acceptance from family, violence from peers and partners, and discrimination at school and workplaces exert adverse effects on their physical and mental health, leading to various psychiatric disorders[5],[6],[8]
  • Discrimination in family, schools, workplace, or the community significantly affects access to education and employment. The consequent social insecurity leads to self-isolation and internalized stigma[7],[8],[14]
  • Another form of violence TG people experience is the physical and mental harassment secondary to forced employment in commercial sex work. Studies have noted that commercial sex work was associated with both hazardous and heavy episodic alcohol use[15]
  • Due to chronic, recurrent exposure to trauma and discrimination, TG people develop psychological barriers in the form of internalized stigma. They characteristically develop an internal stigma, namely the fear of disclosure of identity, also referred to as the “stigma of gender nonconformity.” Studies have shown that stigma of gender nonconformity has been associated with an increased risk of substance use.[5]


Possible protective factors

Studies have revealed that TG individuals demonstrating better resilience and greater perceived social support reported less stigma and mental health burden.[16] The TG persons with higher education, mainstream occupation, and residing in the family of origin and mainstream society displayed a better level of resilience than their counterparts.[6]


  Conclusion Top


Substance abuse is on the rise among transgender individuals in India. Various demographics, sexual relationship characteristics, and psychosocial factors tend to influence substance abuse patterns. Nevertheless, the existing Indian research evidence on risk factors for substance abuse among TG people needs to be expanded and built upon the observed knowledge gaps.

Future studies should attempt to meet the following research needs to enhance our understanding of the SUD pathology among TG individuals in India:

  • A larger sample size involving multiple TG identities
  • The effects of demographic indicators such as age, age at onset, socioeconomic status, occupation, and domicile
  • The influence of gender identity and sexual orientation on substance preference and patterns
  • The association of clinical factors such as physical and mental health correlates, sexual health and functioning, and hormonal therapies
  • The relationship between substance use and psychological factors such as personality styles, coping strategies, and help-seeking behaviors
  • The relationship between substance use and psychosocial factors such as peer influence, stigma, social support, unemployment, and forced employment.


The knowledge, thus acquired, would help in early identification, intervention, and perhaps, prevention of substance abuse in this vulnerable population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Connolly D, Gilchrist G. Prevalence and correlates of substance use among transgender adults: A systematic review. Addict Behav 2020;111:106544.  Back to cited text no. 1
    
2.
Sawant N. Transgender: Status in India. Ann Indian Psychiatry 2017;1:59.  Back to cited text no. 2
  [Full text]  
3.
Bhattacharya S, Ghosh D. Studying physical and mental health status among Hijra, Kothi and transgender community in Kolkata, India. Soc Sci Med 2020;265:113412.  Back to cited text no. 3
    
4.
Niranjan Hebbar Y, Singh B. Psychiatric morbidity in a selective sample of transgenders in Imphal, Manipur: A descriptive study. Ann Indian Psychiatry 2017;1:114.  Back to cited text no. 4
    
5.
Wandrekar JR, Nigudkar AS. What do we know about LGBTQIA+mental health in India? A review of research from 2009-2019. J Psychosexual Health 2020;2:26-36.  Back to cited text no. 5
    
6.
Virupaksha HG, Muralidhar D. Resilience among transgender persons: Indian perspective. Indian J Soc Psychiatry 2018;34:111-5.  Back to cited text no. 6
  [Full text]  
7.
Sartaj D, Krishnan V, Rao R, Ambekar A, Dhingra N, Sharan P. Mental illnesses and related vulnerabilities in the Hijra community: A cross-sectional study from India. Int J Soc Psychiatry 2021;67:290-7.  Back to cited text no. 7
    
8.
Poguri M, Sarkar S, Nambi S. A pilot study to assess emotional distress and quality of life among transgenders in South India. Neuropsychiatry 2016;6:22-7.  Back to cited text no. 8
    
9.
Wilkerson JM, Di Paola A, Rawat S, Patankar P, Rosser BR, Ekstrand ML. Substance use, mental health, HIV testing, and sexual risk behavior among men who have sex with men in the state of Maharashtra, India. AIDS Educ Prev 2018;30:96-107.  Back to cited text no. 9
    
10.
Day JK, Fish JN, Perez-Brumer A, Hatzenbuehler ML, Russell ST. Transgender youth substance use disparities: Results from a population-based sample. J Adolesc Health 2017;61:729-35.  Back to cited text no. 10
    
11.
Mereish EH. Substance use and misuse among sexual and gender minority youth. Curr Opin Psychol 2019;30:123-7.  Back to cited text no. 11
    
12.
Schuler MS, Rice CE, Evans-Polce RJ, Collins RL. Disparities in substance use behaviors and disorders among adult sexual minorities by age, gender, and sexual identity. Drug Alcohol Depend 2018;189:139-46.  Back to cited text no. 12
    
13.
Parent MC, Arriaga AS, Gobble T, Wille L. Stress and substance use among sexual and gender minority individuals across the lifespan. Neurobiol Stress 2019;10:100146.  Back to cited text no. 13
    
14.
Pandya A kumar, Redcay A. Access to health services: Barriers faced by the transgender population in India. J Gay Lesbian Ment Health 2020;14:1-26.  Back to cited text no. 14
    
15.
Chakrapani V, Vijin PP, Logie CH, Newman PA, Shunmugam M, Sivasubramanian M, et al. Understanding how sexual and gender minority stigmas influence depression among trans women and men who have sex with men in India. LGBT Health 2017;4:217-26.  Back to cited text no. 15
    
16.
Chakrapani V, Kaur M, Newman PA, Mittal S, Kumar R. Syndemics and HIV-related sexual risk among men who have sex with men in India: Influences of stigma and resilience. Cult Health Sex 2019;21:416-31.  Back to cited text no. 16
    




 

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