We examined differences in substance use patterns and changes in the frequency of substance use during the COVID-19 pandemic by gender identity among a global TNB sample. Our cross-sectional study found the majority of TNB participants used tobacco and alcohol, and a notable minority used cannabis. Compared to transfeminine participants, alcohol use among transmasculine participants, and cannabis use among non-binary participants increased during the COVID-19 pandemic. We also presented the cross-sectional prevalence of reported changes, providing important estimates for clinical providers and health researchers working with TNB populations. Our study importantly reports differences in substance use patterns and the pandemic’s impact on substance use between TNB sub-groups, which has implications for designing substance interventions for these populations.

Our study is novel in reporting on a large sample of TNB participants, the majority of whom identified as non-binary. A recent synthesis of the prevalence and correlated factors for substance use among TNB participants noted that no study to date has drawn such distinctions, particularly around non-binary, transfeminine, and transmasculine participants [22]. Non-binary participants are often underrepresented in research, especially in substance use studies [22, 30, 52, 53]. Additionally, many substance use studies, including those conducted during the pandemic, have aggregated transgender participants with men who have sex with men, despite evidence that these populations have different needs [29, 30, 54]. Drawing distinctions between TNB subgroups is imperative in identifying the issues facing these individual subcommunities within the broader gender non-conforming community, to help tailor future research and interventions around substance use disorders and behavioral health for this population. The necessity of disaggregation also extends to understanding the impact of minority stress on TNB communities [33, 40, 55]. Experiences of both explicit and implicit discrimination and prejudice [55], as well as more ambient stress would likely lead to intra-group differences among TNB communities for how they may use substances to cope or socially engage with peers.

During the COVID-19 pandemic, compared to before the pandemic, transmasculine people reported the highest proportion of increased alcohol use in descriptive statistics, though we lacked power to determine statistical significance. Additionally, transmasculine participants were more likely to self-report lower income and educational attainment, factors often correlated with increased alcohol consumption and alcohol-related deaths among a general population [56–58]. Other studies have indicated that transmasculine individuals have higher rates of alcohol use compared to transfeminine individuals [38, 55]. Therefore, while our finding was not significant after adjustment, this line of research deserves future investigation to disentangle these effects and what factors contribute to alcohol use in this group. Health programs should also consider tailoring alcohol services to the unique needs of transmasculine communities to address external risk factors and internal beliefs related to alcohol use.

Transfeminine participants were less likely to use cannabis compared to non-binary participants, but those reporting cannabis use were more likely to report an increase during the pandemic compared to non-binary and transmasculine participants. We lacked power to discern the role of additional covariates, but potentially, it could be related to enacted stigma, such as violence and discrimination. Nuttbrock et al. (2014) found that changes in experiencing gender-based violence were associated with increased cannabis use, as well as other recreational substances, among transgender women [59]. Based on a recent proposed framework of minority stress among TNB groups [60], this would be related to the differential stressors they face as a marginalized group specific to their positionality as transgender women, compared to cisgender women or transgender men. Prior evidence similarly supports a differential effect of discrimination and anticipated stigma among TNB groups [61], and it is worth noting that transfeminine participants endorsed higher proportions of discrimination compared to non-binary and transmasculine participants in our sample. Our study did not examine specific experiences of transgender-related discrimination, and more research is needed to determine the role it may play on cannabis use.

Participants across all gender identities who used cannabis used the same amount or more since the start of the COVID-19 crisis. This is in contrast to a recent community-based study in Argentina, which found that substance use generally declined among TNB people during COVID-19 [62]. Given our study drew upon a global sample of participants, substance availability and pandemic-related factors that impact substance use likely differed from this Argentinian population, impacted by a wider range of socioenvironmental factors compared to a country-specific sample. Additionally, recruitment via a social networking and dating app, where individuals may be more connected to social scenes where substance use is common, may not mirror a community-based sample. Rather, the pandemic may have exacerbated existing stressors and created new ones, resulting in stress-coping through increased cannabis use. For example, LGBTQ + populations may have sheltered in place within households that were not gender affirming or faced disconnection from affirming communities and social networks [63]. Given cannabis use has been previously associated with anxiety disorders [64], and TNB people have higher prevalence of anxiety disorders compared to cisgender people [65, 66], the pandemic may have exacerbated prior stress-related disorders and substance use. Further research should directly investigate this.