By Lisa Rapaport

(Reuters Health) – Compared to teens whose gender expression matches societal expectations, gender nonconforming adolescents may be more likely to experience mental health problems, a U.S. study suggests.

Four in five high school students in the study described themselves in terms that conformed with traditional gender expectations; they were either female students who said they were mostly feminine or male students who said they were mostly masculine.

About one in five students, however, described themselves as being either “moderately” gender nonconforming because they were either equally masculine and feminine, or “highly” gender nonconforming, because their gender self-expression didn’t match the gender they were assigned at birth.

“Our study found that gender nonconformity was associated with feeling sad and hopeless, as well as suicidal thoughts and/or behaviors,” said study co-author Michelle Johns, a scientist at the Division of Adolescent and School Health at the Centers for Disease Control and Prevention in Atlanta, in email to Reuters Health.

Gender – the cultural roles and expectations assigned to women and men based on their physical attributes at birth – has long been shown to help shape health behaviors and outcomes, researchers note in JAMA Pediatrics.

Masculinity in men, for example, predicts heavy alcohol use and violence perpetration, and femininity in women is linked to less condom use and increased depression, researchers note.

Gender nonconformity is increasingly also being tied to negative health outcomes, which may be related to stress from exposure to prejudice, discrimination, harassment and violence, researchers note. Less is known, however, about the ways that gender nonconformity may shape health in adolescence.

For the current study, researchers examined survey data collected from 6,082 high school students in three large urban districts — two in California and one in Florida. Overall, about one in five students described themselves as either equally masculine and feminine, as females who were more masculine, or as males who were more feminine.

Moderate gender nonconformity was associated with a higher likelihood of mental health problems. Compared to gender-conforming youngsters, the risk of feeling sad and hopeless was 22 percent higher for females who described themselves as masculine and 55 percent greater for males who described themselves as feminine, the study found.


Moderate gender nonconformity was also tied to a bigger chance of planning suicide: 52 percent higher for females who described themselves as masculine and 79 percent higher for males who described themselves as feminine.

Male students were also more than twice as likely to have attempted suicide when they identified as at least moderately feminine.

In nonconforming teens born as males, but not females, substance use was also linked to gender nonconformity, with more than four times the likelihood of using cocaine or methamphetamine and eight times greater likelihood of injection drug use.

Even though the chance of substance use or mental health issues might be higher for gender nonconforming teens, overall rates of these problems were still relatively low.

The study also wasn’t a controlled experiment designed to prove whether or how gender expression might directly impact teens physical or mental health. And, the three school districts in the study might not be representative of experiences for all teens nationwide.

Still, the results suggest that parents should be on the lookout for potential problems, said Dr. Ellen Selkie, author of an accompanying editorial and an adolescent medicine expert at the University of Michigan’s CS Mott Children’s Hospital in Ann Arbor.

“There are a lot of social factors that could make life difficult for gender nonconforming youth, such as harassment or exclusion on the part of families, schools, and/or peers,” Selkie said by email. “Kids at this age are very affected by the ways they fit in (or don’t) with peers, and feeling left out of a social community can certainly lead to distress.”

When teens use a different style of dress or makeup than might be expected based on traditional definitions of gender roles, parents should check in to see how their child is doing and how things are going with peers, Selkie advised.

“It can also be important to keep up with the school’s policies on discrimination and pay attention to school climate,” Selkie added. “Parents may need to advocate for their child if a bullying incident does occur.”

SOURCE: JAMA Pediatrics, online September 24, 2018.