Violence Victimization, Substance Use Disparities, and Gender-Nonconforming Youth.

INTRODUCTION: Exposure to violence victimization may help explain disparities of substance use among gender-nonconforming youth (i.e., those whose gender expression differs from societal expectations). METHODS: In 2015, three large urban school districts (2 in California and 1 in Florida) conducted a Youth Risk Behavior Survey that included the assessment of gender expression among a racially/ethnically diverse population-based sample of 6,082 high school students. Five categories of violence victimization were assessed (felt unsafe at school, threatened or injured with a weapon at school, bullied at school, electronically bullied, and forced sexual intercourse). In 2019, the effect of violence victimization on substance use disparities was examined by calculating sex-stratified prevalence ratios by gender nonconformity, adjusted for sexual identity, race/ethnicity, and grade (adjusted prevalence ratio 1 [APR1]), and comparing these with prevalence ratios adjusted for those variables plus violence victimization (adjusted prevalence ratio 2 [APR2]). RESULTS: Among female students, only being threatened or injured with a weapon was significantly (p<0.05) associated with gender nonconformity and there were no substance use disparities by gender nonconformity. Among male students, every category of violence victimization was more prevalent among gender-nonconforming than among gender-conforming students and most substance use categories demonstrated significant gender nonconformity disparities. After controlling for violence victimization, these disparities decreased but remained statistically significant for the use of cocaine (APR1=2.84 vs APR2=1.99), methamphetamine (APR1=4.47 vs APR2=2.86), heroin (APR1=4.55 vs APR2=2.96), and injection drug use (APR1=7.90 vs APR2=4.72). CONCLUSIONS: School-based substance use prevention programs may benefit from strategies that support gender diversity and reduce violence victimizations experienced by gender-nonconforming students, by providing a safe and supportive school environment.

Nonconforming Gender Expression and Associated Mental Distress and Substance Use Among High School Students.

Importance: The cultural roles and expectations attributed to individuals based on their sex often shape health behaviors and outcomes. Gender nonconformity (GNC) (ie, gender expression that differs from societal expectations for feminine or masculine appearance and behavior) is an underresearched area of adolescent health that is often linked to negative health outcomes. Objective: To examine the associations of GNC with mental distress and substance use among high school students. Design, Setting, and Participants: Cross-sectional study based on data from the Youth Risk Behavior Survey (YRBS) conducted in 2015. The setting was 3 large urban US school districts (2 in California and 1 in Florida). Participants were a racially/ethnically diverse population-based sample of 6082 high school students representative of all public school students in grades 9 through 12 attending these 3 school districts. Main Outcomes and Measures: Sex-stratified adjusted prevalence ratios (APRs) (adjusted for race/ethnicity, grade, and sexual identity) for high gender-nonconforming students (very/mostly/somewhat feminine male students or very/mostly/somewhat masculine female students) and moderate gender-nonconforming students (equally feminine and masculine students) relative to a referent group of low gender-nonconforming students (very/mostly/somewhat masculine male students or very/mostly/somewhat feminine female students). Results: Among 6082 high school students, 881 (15.9%) were white, 891 (19.1%) black, 3163 (55.1%) Hispanic, and 1008 (9.9%) other race/ethnicity. Among female students (2919 [50.0% of the study population]), moderate GNC was significantly associated with feeling sad and hopeless (APR, 1.22; 95% CI, 1.05-1.41), seriously considering 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); however, substance use was not associated with GNC. Among male students (3139 [50.0% of the study population]), moderate GNC was associated with feeling sad and hopeless (APR, 1.55; 95% CI, 1.25-1.92); high GNC was associated with seriously considering attempting 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), as well as nonmedical use of prescription drugs (APR, 1.81; 95% CI, 1.23-2.67), cocaine use (APR, 2.84; 95% CI, 1.80-4.47), methamphetamine use (APR, 4.52; 95% CI, 2.68-7.61), heroin use (APR, 4.59; 95% CI, 2.48-8.47), and injection drug use (APR, 8.05; 95% CI, 4.41-14.70). Conclusions and Relevance: This study suggests mental distress is associated with GNC among female and male students. Substance use also appeared to be strongly associated with GNC among male students. These findings underscore and suggest the importance of implementing school-based programs to prevent substance use and promote student mental health that are inclusive of gender diversity in students.

Social Stress and Substance Use Disparities by Sexual Orientation Among High School Students.

INTRODUCTION: Sexual minority youth often experience increased social stress due to prejudice, discrimination, harassment, and victimization. Increased stress may help explain the disproportionate use of substances like tobacco, alcohol, marijuana, and other illicit drug use by sexual minority youth. This study examined the effect of social stress on substance use disparities by sexual orientation among U.S. high school students. METHODS: In 2016, data from the national 2015 Youth Risk Behavior Survey, conducted among a nationally representative sample of 15,624 U.S. high school students, were analyzed to examine the effect of school-related (threatened/injured at school, bullied at school, bullied electronically, felt unsafe at school) and non-school-related (forced sexual intercourse, early sexual debut) social stress on substance use disparities by sexual orientation, by comparing unadjusted prevalence ratios (PRs) and adjusted (for social stressors, age, sex, and race/ethnicity) prevalence ratios (APRs). RESULTS: Unadjusted PRs reflected significantly (p<0.05 or 95% CI did not include 1.0) greater substance use among students who identified as lesbian/gay or bisexual than students who identified as heterosexual. APRs for injection drug use decreased substantially among lesbian/gay (PR=12.02 vs APR=2.14) and bisexual (PR=2.62 vs APR=1.18) students; the APR for bisexual students became nonsignificant. In addition, APRs among both lesbian/gay and bisexual students decreased substantially and were no longer statistically significant for cocaine, methamphetamine, and heroin use. CONCLUSIONS: School-based substance use prevention programs might appropriately include strategies to reduce social stress, including policies and practices designed to provide a safe school environment and improved access to social and mental health services.

Distributing free fresh fruit and vegetables at school: results of a pilot outcome evaluation.

OBJECTIVES: Consumption of fruit and vegetables among children is generally below recommended levels. This evaluation addressed two questions: (1) To what extent did children's attitudes toward, familiarity with, and preferences for fruit and vegetables change during the school year? and (2) To what extent did children's consumption of fruit and vegetables change during the school year? METHODS: During the 2004-2005 school year, the Mississippi Department of Education, Child Nutrition Programs initiated a pilot program to distribute free fruit and vegetables to students (kindergarten through 12th grade) during the school day. Data were collected in 2004-2005 within a one-group pretest/posttest design using a self-report questionnaire (n=725) and 24-hour dietary recalls (n=207) with a sample of students from five schools in Mississippi. Data were analyzed in 2006-2007. RESULTS: Results showed greater familiarity with fruit and vegetables at all grade levels (p<0.05) and increased preferences for fruit among eighth- and 10th-grade students (p<0.01). Eighth-grade students also reported more positive attitudes toward eating fruit and vegetables (p<0.01), increased perceived self-efficacy to eat more fruit (p<0.01), and increased willingness to try new fruit. Finally, results showed increased consumption of fruit, but not vegetables, among eighth- and 10th-grade students (p<0.001). CONCLUSIONS: Distributing free fruit and vegetables at school may be a viable component of a more comprehensive approach for improving students' nutrition attitudes and behaviors. More program emphasis is needed on ways to promote vegetable consumption.

Dimensions of sexual orientation and HIV-related risk among adolescent females: evidence from a statewide survey.

OBJECTIVES: We examined the relationship of 2 dimensions of sexual orientation--sexual identity and sex of partners--with self-reported behaviors and experiences to identify factors that may place adolescent females at risk of HIV/AIDS. METHODS: We gathered data on sexually experienced female high school students from 4 waves of a population-based survey. We used logistic regression analyses to investigate the association between their sexual identity (3666 heterosexual; 184 lesbian, gay, or bisexual; 113 not sure) and sex of partners (3714 male only, 79 female only, and 180 both males and females) with HIV-related risk behaviors. RESULTS: Self-defined sexual identity was often inconsistent with sex of sexual partners. Sexual identities other than heterosexual and having same-sex partners (either exclusively or in addition to male partners) were associated with high rates of several HIV-related risk behaviors. Coerced sexual contact was significantly associated with every risk outcome. AIDS education in school predicted lower HIV risk on 4 of 6 indicators. CONCLUSIONS: Programs to prevent HIV infection among adolescent females should take into account the complexity of sexual orientation and should address the needs and behaviors of sexual-minority youths.

All4You! A randomized trial of an HIV, other STDs, and pregnancy prevention intervention for alternative school students.

This study evaluated All4You!, a theoretically based curriculum designed to reduce sexual risk behaviors associated with HIV, other STDs, and unintended pregnancy among students in alternative schools. The study featured a randomized controlled trial involving 24 community day schools in northern California. A cohort of 988 students was assessed four times during an 18-month period using a self report questionnaire. At the 6-month follow-up, the intervention reduced the frequency of intercourse without a condom during the previous 3 months, the frequency of intercourse without a condom with steady partners, and the number of times students reported having intercourse in the previous 3 months. It also increased condom use at last intercourse. These behavioral effects were no longer statistically significant at the 12- and 18-month follow-ups. The All4You! intervention was effective in reducing selected sexual risk behaviors among students in alternative school settings; however, the effects were modest and short term.