A qualitative study of alcohol use disorder psychotherapies for transgender and nonbinary individuals: Opportunities for cultural adaptation

Background: Transgender and nonbinary (TGNB) populations experience high rates of hazardous drinking (HD) and alcohol use disorder (AUD) as well as unique treatment barriers. This is due, in-part, to discrimination and stigma within and outside of the healthcare system. Cultural adaptation of clinical interventions can improve outcomes for marginalized populations, but no such adapted interventions exist for AUD among TGNB in-dividuals. This study sought to understand how TGNB individuals perceive currently available AUD psycho-therapies and to generate knowledge about potential areas for cultural adaptation.Methods: As part of a qualitative study of HD among TGNB individuals (N=27), participants were asked to imagine that they were clients in psychotherapy vignettes corresponding to cognitive behavioral therapy, motivational enhancement therapy, and twelve step facilitation. Interviews were audio-recorded and profes-sionally transcribed. A coding team used an iterative codebook to guide coding. Categories emerged from this process that reflected participants' perceptions and allowed for the identification of potential cultural-adaptation targets.Results: Across all three psychotherapies, participants wanted therapists to explicitly discuss gender identity and culturally salient HD risk factors for TGNB individuals (e.g., discrimination, stigma, gender dysphoria). There were also modality-specific recommendations to incorporate principles of trauma-informed care into cognitive behavioral therapy, avoid motivational enhancement therapy exercises that oversimplify decision-making, and recognize that the twelve-step-facilitation concept of "powerlessness" may conflict with how many TGNB people see themselves.Conclusions: These findings highlight areas for cultural adaptation that can be evaluated in future intervention trials in an effort to improve psychotherapy acceptability and efficacy for TGNB individuals.