Understanding alcohol use in UK transgender and non-binary communities
Creators: name: Connolly, Dean
Publisher: name: Nature Awards for Inclusive Health Research
Year: 2025
Subjects: classificationCode: 420602
subject: Health equity

description: Abstract Through review and evaluation of the published literature, and novel analyses of international samples, we identified considerable disparities in alcohol dependence and other harm experienced by trans and non-binary (TNB) people. Most published research had been conducted in North America and reported minimal TNB involvement. No original research had been carried out in the UK despite the TNB community facing unprecedented violence and exclusion from society, fuelled by relentless vitriolic media discourse and political scapegoating (that is, transphobia). Since discrimination was associated with particularly harmful patterns of alcohol use in the US, we worked closely with individual and professional community stakeholders to co-produce the UK’s first survey of alcohol use in TNB communities, striving to ensure that living and lived experience informed a body of work with a net gain for the community. Introduction Dean Connolly co-led the study with senior researcher Emma Davies, who is a reader in psychology at Oxford Brookes University which hosted and funded the project. Davies and Connolly contributed to data analysis, report writing, presentations and blogs. Connolly provided administrative support and led community-engagement work. All partner organizations supported a recruitment campaign on social media between UK LGBT+ History Month and the International Transgender Day of Remembrance. Recruitment assets were developed by Drugs and Me. National lesbian, gay, bisexual, transgender and queer or questioning (LGBTQ+) sector leaders at Brighton and Hove LGBT Switchboard, the LGBT Foundation, London Friend, OUTpatients and Stonewall contributed to survey development. The Institute of Alcohol Studies, the National Health System (NHS) Health and Care LGBTQ+ Leaders Network, and Pride in Education disseminated the study widely within private networks. A community advisory group (CAG) contributed to every aspect of the work. The Transgender Professional Association for Transgender Health and international transgender health-professional groups endorsed the work and disseminated recruitment assets. Who should benefit? In the 2021 British Census, 262,000 people (0.5%) reported that their gender identity did not match their sex registered at birth. Since 6% of the population did not respond to this question, this was likely an under-estimate. The 262,000 comprised 48,000 trans men, 48,000 trans women, 30,000 non-binary persons, 18,000 people with different identities, and 118,000 who did not define their gender. Although UK research with this very small population has been limited in scope and scale, evidence from abroad informs us of the stark inequalities in mental and physical health and risk behaviours associated with marginalization. TNB people in the UK and globally are extremely resilient in the face of record levels of violent hate-crime, precarious housing and homelessness, exclusion from healthcare and education, underemployment, and intimate-partner violence. The consequence is a highly morbid population who often manage considerable distress, loneliness, and gender dysphoria — these findings, established by North American and international research, were corroborated in our study. Minority-stress theories, supported by a wealth of cross-sectional and longitudinal evidence, assert that the burden of these inequalities confers heightened risk of alcohol- and other drug-related harm, and mental illness. Although there were no reports on experiences with alcohol-reduction services, trans community organizations (such as TransActual) have published research demonstrating widespread barriers to accessing primary-, secondary- and tertiary-healthcare across the UK. Much of the peer-support available to support alcohol reduction (such as Alcoholics Anonymous) has principles which are inseparable from religion, or display power structures that reflect wider society. TNB people are often excluded or in danger in these settings. Trans people are constantly exposed to antecedents of alcohol dependence, report disproportionate harm following drinking (such as blackout, suicidality and sexual violence), and have limited access to public, clinical or peer intervention. This is an unacceptable health inequality. Earlier work by Connolly and Davies contributed understanding and motivated the pursuit of this study. We hope that the engagement work with community stakeholders has prompted individual and organization-wide reflections on alcohol use leading to reduced drinking or harm-reduction initiatives, respectively. The study findings can encourage discussions among clinicians, public-health professionals (including service commissioners) and researchers who we hope will now acknowledge TNB people as a priority group for alcohol-reduction efforts. Engagement From conception to dissemination, our study was conducted by a team predominantly composed of lived/living experience partners independent of the host institution and funder. This study, co-led by a peer researcher and informed by the ‘Nothing About Us Without Us’ movement, sought to raise the voice of silenced communities and address their underrepresentation in alcohol research.  Community engagement was achieved with a three-stage approach.  First, from study conception onwards, the research was informed by a paid CAG of TNB people, diverse in sex, gender identity, sexual orientation, ethnicity, (dis)ability and neurodivergence. The CAG refined the project aims and contributed to grant applications, survey design and protocol development, ensuring that the study was truly TNB-led.  Second, we collaborated with the CAG to identify, contact and partner with national, regional and local TNB-led support, advocacy or community-building organizations, selected to ensure intersectional diversity and multi-sector representation. These partnerships predominantly centred around recruitment and were instrumental in maximizing the size and diversity of the sample recruited from this ‘hidden’ population. Since limited funds precluded remuneration of each participant, we sought to ensure spending benefited the LGBTQ+ community and raffled vouchers for a historically significant, community-owned bookshop (Gay’s The Word). Partner organizations were invited to contribute to developing the survey, study protocol and all dissemination materials, including academic papers. Third, to support the development of TNB researchers, after removing any potentially identifying information, study data will be made freely available online and partners notified. One planned report was postponed to allow a trans master’s student to use the data to gain research experience under our supervision. Davies also gave freely of her time to enthusiastically support and encourage Connolly to develop as a researcher. Sexual and, in particular, gender minority researchers experience considerable barriers to career development in the UK. The support to conduct nationwide primary research in their own communities has been an invaluable learning experience. This research has value beyond its clinical and public-health insights. It demonstrates meaningful involvement of marginalized communities in minimally funded research. The detailed description of this approach in publications, presentations and teaching output will challenge others to adopt similarly inclusive practices. Research Community engagement shaped every aspect of the project. The CAG advised on measures to be included or omitted from the survey, and informed our adaptation of scales for culturally competent use with TNB communities. They also advised on the most appropriate categorization of participants’ gender identities to facilitate analyses and write-up. The interpretation of findings was discussed with the CAG and partner organizations’ representatives who assisted with editing all dissemination materials. Prior to this study, no UK-based primary alcohol research had specifically sought to understand the experiences of TNB people. General population UK research rarely if ever collects accurate and detailed data to describe gender identity and trans status. This was a true evidence gap that could lead to a potential public-health crisis. While we recruited participants from across the UK, we struggled to involve people in Wales, Northern Ireland and (to a lesser extent) Scotland. We believe this reflects the overrepresentation of our partner organizations in England and the greater density of TNB people found there (particularly in London).  There was breadth of expertise within the research team. Davies is a senior researcher with expertise in survey development and administration as the Alcohol Lead for the Global Drug Survey. Connolly is a medical doctor with experience in psychiatry (under which alcohol-use services are provided in the UK), and a public-health specialist focused on LGBTQ+ health equity and alcohol/other drug policy who currently contributes to national groups such as the Royal College of Physicians (RCP) Faculty of Public Health (FPH) Drugs Special Interest Group (SIG) and the Alcohol SIG. Translating into impact A great success of this project so far has been the development of productive partnerships with organizations, community leaders and individuals within the UK LGBTQ+ sector who are at the centre of the campaign for equality and have a wealth of expertise from which we can learn. We are extremely grateful for their knowledge and will continue to take advice from these organizations and their representatives.