LAUSR

TO THE EDITOR: Safer and Tangpricha (1) provide a comprehensive summary of the unique clinical considerations relevant to the care of transgender and gender-nonconforming persons. Those who are gender minorities are at higher risk for hazardous substance use and substance use disorders because of stress related to their minority status, stigma, discrimination, trauma, and isolation (2). Screening, brief intervention, and referral to culturally competent treatment for hazardous substance use (including psychiatric treatment, if indicated) are essential in this population. Of note, current screening methods for hazardous drinking may be insufficient for transgender patient populations. Current U.S. alcohol use guidelines define hazardous use as consumption of greater than 4 standard drinks per day or greater than 14 drinks per week for men younger than 65 years and greater than 3 standard drinks per day or greater than 7 standard drinks per week for women of any age and men older than 65 years, with 1 standard drink equaling 14 g of pure alcohol. These guidelines are based on epidemiologic data for cisgender men and women (3). However, no hazardous alcohol use cutoffs have been established for transgender persons, who may be vulnerable to the adverse effects of alcohol at lower levels than established U.S. cutoffs. Heavy alcohol use is associated with interpersonal violence, sexual and physical assault, depression, sexually transmitted infections, and suicide, and these risks may be increased in transgender patients relative to their cisgender counterparts (2). Whether osteoporosis, cancer, and other adverse health outcomes associated with alcohol use may occur at lower drinking levels among transgender and gender-nonconforming patients who are receiving hormonal therapies because of hypogonadism and hormonal shifts is also unknown. Using the lower screening cutoffs for hazardous drinking that have been established for cisgender women and persons older than 65 years may therefore be prudent in transgender patients until more data are available. Tobacco use should also be proactively screened for and treated in transgender populations. Some studies report that use of tobacco products is higher in transgender youth than cisgender youth (4), although recent data suggest that the prevalence of tobacco use in adult transgender and cisgender populations is similar (5). The high risk for thromboembolic events with concurrent cigarette use and long-term estrogen administration warrants a proactive approach to screening and treatment. In summary, screening and referral to trauma-informed substance use and psychiatric treatment, surveillance for hazardous substance use at low levels, and awareness of potential medical complications associated with hormonal therapies in the setting of problematic substance use are best practices in the care of transgender patients.