"I Think Providers See Trans People as Unstable Patients": Exploring Substance Use Communication Experiences of Transgender and Gender Diverse Adults During Primary Care Encounters.

Numerous studies have linked minority stress to substance use among transgender and gender diverse (TGD) individuals. Yet there has been limited research on how TGD patients experience alcohol, tobacco, and substance use communication with their providers. We used qualitative interviews to explore the substance use communication experiences of transgender and gender diverse adults with their primary care providers. We interviewed 25 TGD adults from New England in January and February of 2022. Approximately half (n=12) of the participants were healthcare providers themselves, and 14 were non-binary, genderqueer, genderfluid, or similar identity. Using a thematic analytic approach, we identified three broad themes of TGD adults' perceptions of communication with their primary care providers about substance use: 1) facing stereotypes about TGD people and substance use, 2) encountering a gender essentialist approach to substance use risk screening, 3) perceiving that TGD patients who disclose substance use will appear unstable and may not receive gender-affirming care. Second, participants raised implications for policy and clinical practice including understanding links between minority stress and substance use, considering alternatives to sex-based metrics when screening for harmful or hazardous substance use, and establishing clinic policies aimed at protecting access to gender-affirming care. More interventions are needed that address provider awareness and promote TGD patient disclosure for risk and harm reduction purposes while ensuring access to gender-affirming care.