Transgender and gender diverse (TGD) individuals (i.e., people whose gender differs from their sex assigned at birth) experience excess levels of stressors and sizable health disparities. Minority stress theory suggests that having a minoritized sexual or gender identity is associated with higher levels of stressors due to marginalization and stigma (Meyer, 1995, Brooks, 1981, Meyer, 2003). Minority stressors, like enacted stigma such as violence, rejection, and discrimination (including daily, repeated, and acute incidents), overburden coping resources and impair emotion regulation (Hatzenbuehler, 2009). This increases the risk of psychological distress (e.g., depression and anxiety; Drabish and Theeke, 2022; Pellicane and Ciesla, 2022) and “health harming” coping behaviors, such as alcohol use, drug use, and suicide attempts (Miller and Grollman, 2015, Pellicane and Ciesla, 2022, Testa et al., 2012, Bockting et al., 2013, Drabish and Theeke, 2022, Hatzenbuehler and Pachankis, 2016, Hendricks and Testa, 2012). Given these effects of stigma, the current study examined associations between enacted stigma, psychological distress, and alcohol and substance use. In addition, we explored the potential mediating effects of expectations of stigma given that enacted stigma may come to shape one’s anticipation of their future exposure to adverse events.

The concept of minority stress was first created to understand the unique stressors lesbian women face (Brooks, 1981). Meyer, 1995, Meyer, 2003 later extended minority stress to be inclusive of sexual minority cisgender men, and the model was later expanded to TGD populations (Hendricks and Testa, 2012). This model continues to be elaborated on to reflect the unique lived experiences of TGD people (Puckett et al., 2021, DuBois and Juster, 2022). According to the Minority Stress Model (Meyer, 1995, Meyer, 2013, Brooks, 1981, Hendricks and Testa, 2012), chronic exposure to minority stressors has appreciable effects on mental and physical health. Minority stressors may be external and distal from the self (e.g., discrimination). Minority stressors may also be proximal and dependent on appraisals, perceptions, and internalizations of distal stressors (e.g., victimization may result in higher expectations of future encounters of stigma).

Minority stressors are theorized to impact health and wellbeing by leading to dysregulations in emotions, social/interpersonal interactions, and cognitive processes, which heighten risks (Hatzenbuehler, 2009). Minority stressors can also span many levels, including structural (e.g., policies), interpersonal (e.g., family rejection), and individual levels (e.g., internalized stigma; Herek, 2016; White Hughto et al., 2015). Many studies have focused on distal sources of stigma like structural and interpersonal factors, and less research has concomitantly evaluated linkages between distal forms of minority stress, subsequent proximal stressors, and health outcomes like psychological distress or substance use.

Key health concerns among TGD individuals include hazardous drinking (Klein and Golub, 2016) and other drug use. Hazardous drinking is defined as heavy alcohol consumption that puts individuals at risk of adverse consequences (Reid et al., 1999). Rates of hazardous drinking among TGD populations are difficult to estimate given the heterogeneity of samples, methods, and measurements (Gilbert et al., 2018). Some studies suggest that almost half of all TGD individuals report hazardous drinking (Kerr-Corrêa et al., 2017, Herrera et al., 2016) and that the rates are higher among TGD individuals than among their cisgender counterparts (Reisner and Hughto, 2019). Other studies show no differences in other alcohol-related outcomes between TGD and cisgender participants (Blosnich et al., 2017). Indeed, a recent meta-analysis suggests no differences between cisgender and transgender people in current alcohol use or alcohol use disorder (Cotaina et al., 2022). However, hazardous drinking is associated with increased risks for secondary harms that disproportionately affect TGD individuals such as suicidal ideation, intimate partner violence, sexual violence, and the exacerbation of mental and physical health concerns (Coulter et al., 2015, Gilbert et al., 2018), highlighting the importance of a deeper understanding of hazardous drinking risks among TGD individuals.

A meta-analysis of substance use suggests that TGD people have higher lifetime substance use and higher current use of specific substances (apart from tobacco and alcohol), but not higher likelihood of a substance use disorder compared to cisgender people (Cotaina et al., 2022). Similarly, a recent review of drug use research among TGD populations more broadly defined suggests higher cannabis use, higher risk for cannabis use disorder, and higher prevalence of use of other substances among TGD compared to cisgender people (Ruppert et al., 2021). Research suggests associations between distal minority stressors and hazardous drinking (Lindley and Bauerband, 2022b, Lindley et al., 2021) and use of other substances (Wolford-Clevenger et al., 2021, Connolly and Gilchrist, 2020) but more mixed findings for proximal minority stressors like internalized stigma (Wolford-Clevenger et al., 2021, Gonzalez et al., 2017).

TGD individuals also experience high rates of psychological distress such as depression (McDowell et al., 2019, Borgogna et al., 2019, Reisner and Hughto, 2019), anxiety (Borgogna et al., 2019, Puckett et al., 2019), and other mental health concerns in response to stigma. These higher risks for distress have been linked to distal minority stressors such as discrimination (McDowell et al., 2019, Puckett et al., 2020), violence (Reisner and Hughto, 2019), and microaggressions (Timmins et al., 2017). Research also shows that proximal minority stressors like internalized stigma and expectations of rejection are similarly associated with mental health concerns (Pellicane and Ciesla, 2022, Helsen et al., 2021). In a study that included both distal (a latent factor that included microaggressions and victimization) and proximal (e.g., self-stigma and expectations of rejection) minority stressors, there were direct effects of both distal factors and self-stigma on psychological distress (Timmins et al., 2017). In addition, higher levels of distal minority stressors were associated with higher levels of self-stigma and expectations of rejection. Understudied is the potential impact of expected or anticipated minority stressors (King et al., 2020, Rendina et al., 2020) and their potential mediating effects that could explain how enacted stigma comes to get “under the skin” as elaborated in Hatzenbuehler’s psychological mediation framework (Hatzenbuehler, 2009).

In the current study, we applied the minority stress model to a TGD sample to examine the effects of enacted stigma on psychological distress, alcohol use, and drug use. Furthermore, we explored a potential mediating pathway of expectations of stigma as this proximal stressor may constitute a mechanism by which enacted stigma comes to influence these outcomes.