Purpose: We examined how substance use differed as a function of sex assigned at birth and gender identity (cisgender, transgender, or nonbinary/genderqueer) by type of substance. We sought to test whether current gender identity and sex assigned at birth were key factors in substance use among a large contemporary sample that included transgender and nonbinary/genderqueer adolescents. Methods: We analyzed data from a large national U.S. sample of sexual and gender minority (SGM) adolescents (n = 11,129) collected between April and December 2017. Chi-square tests of independence were used to test whether substance use behaviors varied by sex assigned at birth and gender identity. A series of multivariate logistic regression models tested the odds of substance use by sex assigned at birth and gender identity, as well as the interaction between sex assigned at birth and gender identity. Results: More than half of our sample reported lifetime alcohol use, and one-fourth of the sample reported lifetime marijuana use. Adolescents assigned male at birth had higher prevalence of substance use compared with adolescents assigned female at birth (AFAB). Multivariate models elucidated greater risk for most substance use outcomes for transgender adolescents compared with cisgender adolescents. We found significant interaction effects between gender identity and sex assigned at birth for recent alcohol use and lifetime and recent cigarette use among adolescents AFAB. Conclusions: These findings have implications for stakeholders who develop nationally representative surveys, researchers who examine substance use disparities among SGM adolescents, and mental health professionals who treat underage substance use among vulnerable populations.

Some health care providers work with gender expansive youth; preliminary evidence notes that many of these youth do not disclose their gender identity to all of their health care providers. No previous research focused on youth has explored gender identity disclosure to health care providers, nor linked youth disclosure to negative mental health outcomes (e.g., symptoms of depression). Data were drawn from the LGBTQ National Teen Survey to test the relationship between gender identity disclosure, symptoms of depression, and self-esteem among 13-to 17-year old (n ϭ 5,637, M age ϭ 15.6) participants who identified as transgender boys, transgender girls, and nonbinary youth assigned female at birth (AFAB) or assigned male nonbinary youth assigned male at birth (AMAB). Transgender boys reported the highest symptoms of depression and the lowest levels of self-esteem in comparison with other groups. Among the full sample, 66.8% had not disclosed their gender identity health care providers-nonbinary AMAB youth were least likely to disclose (77.6%). Symptoms of depression were the highest and self-esteem was the lowest for transgender boys with mixed levels of disclosure. Transgender girls reported the lowest symptoms of depression-these youth had also disclosed their identities the most. Findings suggest that mixed disclosure to health care providers is problematic for gender expansive youth, especially transgender boys. Findings suggest a need to better prepare health professionals to understand not all gender expansive youth may feel comfortable disclosing their gender identities in medical contexts. Future research should explore gender affirmative health care as a protective factor for negative mental health outcomes. Public Significance StatementIn our study, most transgender and nonbinary youth had not disclosed their gender identity to health care providers. Mixed levels of disclosure to health care providers was associated with higher depressive symptoms and lower self-esteem. These findings inform clinicians and policymakers of the need to improve gender-based clinical practices for transgender and nonbinary youth.

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