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High school students who reported higher levels of gender non-conformity were associated with symptoms of mental distress, according to a cross-sectional study.

Among female students, moderate gender non-conformity was associated with feeling sad and hopeless (adjusted prevalence ratio 1.22, 95% CI 1.05-1.41) compared to students with low gender non-conformity -- with similar risks seen among male students (APR 1.55, 95% CI 1.25- 1.92), reported Richard Lowry, MD, of the CDC, and colleagues.

Moderate gender non-conformity was also significantly associated with seriously attempting suicide (APR 1.41, 95% CI 1.14- 1.74) and making a suicide plan (APR 1.52, 95% CI 1.22-1.89) among female students, the authors wrote in .

"Gender-nonconforming individuals often experience increased social stress resulting from exposure to prejudice, discrimination, harassment, and violence," the authors wrote. "This appears to be especially true for adolescents; gender nonconforming youths experience elevated rates of harassment and violence by peers, as well as increased exposure to childhood abuse."

In previous studies, the authors said that gender non-conformity was associated with depressive symptoms and less life satisfaction in young adulthood. However, more research is needed in order to understand this association independent of sexual orientation, the authors said.

Researchers examined data from the CDC Youth Risk Behavior Survey from two large urban school districts in California and one in Florida. A seven-point gender non-conformity scale was created based on students' answers to "How do you think people at school would describe you?" and "What is your sex?"

In total, 6,082 students completed the optional survey, 2,919 (50%) of which were girls. The majority of students were Hispanic (55.1%), followed by non-Hispanic black (19.1%) and non-Hispanic white (15.9%). Most teens identified as heterosexual (87.6%), with 2.5% identifying as lesbian or gay, 4.6% as bisexual, and 4.3% as "not sure."

One in five students reported either moderate (11.9%) or high (8.4%) levels of gender non-conformity, with a higher prevalence of gender nonconformity found in lesbian or gay (41.7%) and bisexual students (15.7%), the authors report. Additionally, more boys were classified as high gender non-conforming (13%) compared to girls (4%).

The authors found that among male students, attempting suicide (APR 2.78, 95% CI 1.75-4.40), seriously considering attempting suicide (APR 1.79, 95% CI 1.17-2.73), and making a suicide plan (APR 1.72, 95% CI 1.16-2.56) were associated with students with high gender non-conformity compared to those with low gender non-conformity.

Among male students, substance abuse was also more likely among students with high gender non-conformity, including the use of the following drugs:

• Prescription drugs: APR 1.81 (95% CI 1.23-2.67)

• Cocaine: APR 2.84 (95% CI 1.80-4.47)

• Methamphetamine: APR 4.52 (95% CI 2.68-7.61)

• Heroin: APR 4.59 (95% CI 2.48-8.47)

• Injection drugs: APR 8.05 (95% CI 4.41-14.70)

"Additional research is needed to better understand the links between gender norms, social stressors, and substance use behaviors across the spectrum of gender conformity," co-author Michelle Johns, PhD, of the CDC's Division of Adolescent and School Health, told MedPage Today in an email. "Also, given that transgender youth often have risk factors and experiences that overlap heavily with those of cisgender, gender nonconforming youth, it is important to investigate whether associations of mental distress and substance use with self-reported transgender identity are similar to our findings with gender nonconforming youth."

Symptoms of mental distress may arise in gender non-conforming teens due to feelings of shame or from keeping their identities hidden from family members or classmates, according to Ellen Selkie, MD, of the University of Michigan in Ann Arbor, who wrote an to accompany the study. However, Selkie said these symptoms could also be attributed to "vicarious experiences," when students witness negative behaviors regarding gender expression.

"The major implication of the study results is that inclusive mental health interventions are an important consideration for improving well-being in gender-nonconforming youth," she wrote. "In addition, to consider primary prevention of mental health disparities, we must also further research and address the social factors contributing to distress and substance use in this population."

The authors noted several limitations to the study. Because the data was collected from youths attending school, it may not be representative of all sexual minority teens, many of which have dropped out of school, they said. The authors added that since teens who are more willing to report gender non-conformity may also be more willing to report mental health symptoms, estimates could be overinflated. Finally, the extent of adolescents overreporting or underreporting their behaviors cannot be determined, the authors noted.