Nonconforming gender expression can be a major source of mental distress and, in some cases, is strongly associated with substance abuse, according to a study published in JAMA Pediatrics.

Researchers set out to measure how societal expectations regarding gender can adversely affect health and found that gender nonconformity is associated with mental distress and substance abuse in both male and female students. Researchers examined data from the Centers for Disease Control and Prevention’s Youth Risk Behavior Survey of high school students in grades 9 through 12 in 3 large school districts in California and Florida. Feelings of sadness and hopelessness increased with gender nonconformity but were nonlinear, with the greatest prevalence occurring among the middle of the gender-nonconformity scale. The findings also indicate that “while there were some similarities in the associations between gender nonconformity and mental distress among male and female students, there were differences as well.”

Among female students, feelings of sadness and hopelessness (adjusted prevalence ratios [APR], 1.22; 95% CI, 1.05-1.41), seriously considering suicide (APR, 1.41; 95% CI, 1.14-1.74), and making a suicide plan (APR, 1.52; 95% CI, 1.22-1.89) were more likely among students with moderate gender nonconformity than among those with low gender nonconformity. Among male students, feelings of sadness and hopelessness were similarly more likely for students with moderate as opposed to low levels of gender nonconformity (APR, 1.55; 95% CI, 1.25-1.92). However, seriously considering suicide (APR, 1.72; 95% CI, 1.16-2.56), making a suicide plan (APR, 1.79; 95% CI, 1.17-2.73), and attempting suicide (APR, 2.78; 95% CI, 1.75-4.40) were more likely among students with high gender nonconformity than among those with low gender nonconformity.

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The researchers noted that the study includes only data on adolescents who attend school and may disproportionately represent sexual minority and gender minority students who dropped out or were not present. They also noted that the stigmatization of the questions involved may affect the data and there may be overreporting or underreporting. Additionally, they noted that the small sample size of the most gender-nonconforming students weakened the study’s ability to examine associations across the spectrum for females.

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The researchers concluded that the findings demonstrate the importance of developing support systems within schools for gender-nonconforming students as an important means to improve mental health and reduce substance abuse among high school students.


Lowry R, Johns MM, Gordon AR, Austin SB, Robin LE, Kann LK. Nonconforming gender expression and associated mental distress and substance use among high school students [published online September 24, 2018]. JAMA Pediatr. doi:10.1001/jamapediatrics.2018.2140