Interest in over-the-counter progestin-only pills among transgender, nonbinary, and gender-expansive individuals in the United States.

BACKGROUND: In July 2023, the US Food and Drug Administration approved the first nonprescription oral contraceptive, a progestin-only pill, in the United States. Transgender, nonbinary, and gender-expansive people assigned female or intersex at birth face substantial contraceptive access barriers and may benefit from over-the-counter oral contraceptive access. However, no previous research has explored their perspectives on this topic. OBJECTIVE: This study aimed to measure interest in over-the-counter progestin-only pill use among transgender, nonbinary, and gender-expansive individuals assigned female or intersex at birth. STUDY DESIGN: We conducted an online, cross-sectional survey from May to September 2019 (before the US Food and Drug Administration approval of a progestin-only pill) among a convenience sample of transgender, nonbinary, and gender-expansive people assigned female or intersex at birth who were aged 18 to 49 years from across the United States. Using descriptive statistics and logistic regression analyses, we estimated interest in over-the-counter progestin-only pill use (our outcome) overall and by sociodemographic and reproductive health characteristics (our exposures). We evaluated separate logistic regression models for each exposure. In each model, we included the minimally sufficient adjustment set to control for confounding pathways between the exposure and outcome. For the model for age, we ran a univariable logistic regression model; for all other exposures, we ran multivariable logistic regression models. RESULTS: Among 1415 participants in our sample (median age, 26 years), 45.0% (636/1415; 95% confidence interval, 42.3-47.6) were interested in over-the-counter progestin-only pill use. In separate logistic regression models for each exposure, there were higher odds of interest among participants who were aged 18 to 24 years (odds ratio, 1.67; 95% confidence interval, 1.33-2.10; vs those aged 25-34 years), those who were uninsured (adjusted odds ratio, 1.91; 95% confidence interval, 1.24-2.93; vs insured), those who currently used oral contraceptives (adjusted odds ratio, 1.69; 95% confidence interval, 1.17-2.44; vs non-users), had ≤high school degree (adjusted odds ratio, 3.02; 95% confidence interval, 1.94-4.71; vs college degree), had ever used progestin-only pills (adjusted odds ratio, 2.32; 95% confidence interval, 1.70-3.17; vs never users), and who wanted to avoid estrogen generally (adjusted odds ratio, 1.32; 95% confidence interval, 1.04-1.67; vs those who did not want to avoid estrogen generally) or specifically because they viewed it as a feminizing hormone (adjusted odds ratio, 1.72; 95% confidence interval, 1.36-2.19; vs those who did not want to avoid estrogen because they viewed it as a feminizing hormone). There were lower odds of interest among participants with a graduate or professional degree (adjusted odds ratio, 0.70; 95% confidence interval, 0.51-0.96; vs college degree), those who were sterilized (adjusted odds ratio, 0.31; 95% confidence interval, 0.12-0.79; vs not sterilized), and those who had ever used testosterone for gender affirmation (adjusted odds ratio, 0.72; 95% confidence interval, 0.57-0.90; vs never users). CONCLUSION: Transgender, nonbinary, and gender-expansive individuals were interested in over-the-counter progestin-only pill use, and its availability has the potential to improve contraceptive access for this population.

Differential Evaluation of Straight and Gay Men for Nonverbal Effeminate Behavior.

The purpose of this study was to determine how violation of gender-based expectancies might influence straight men's attitudes toward men who differ by sexual orientation (i.e., straight or gay). This study was specifically designed to avoid methodological issues that may have been present in similar research. Hypotheses were informed by Expectancy-Violation Theory (EVT) and the Black Sheep Effect (BSE), which together suggest that an effeminate straight man should be evaluated by other straight men more negatively than an effeminate gay man because the former target negatively violated expectations. Additionally, EVT suggests that a masculine gay man should be evaluated more positively than a masculine straight man because the former positively violates expectations, while the BSE instead suggests the latter should be evaluated more positively than the former due to ingroup bias. Self-identified straight men evaluated a male target whose sexual orientation and gender conformity were manipulated through a photo and vignette. A moderated mediation analysis was performed to determine if perceived expectancy violation mediated the relationship between sexual orientation and evaluations for both effeminate and masculine men. Straight effeminate targets were evaluated more negatively than gay effeminate targets; however, straight masculine targets were evaluated more favorably than gay masculine targets, a finding more consistent with the BSE. In addition, perceived expectancy violation did not mediate the relationship between sexual orientation and evaluations regardless of gender expression. More research should be conducted to identify the mechanisms through which evaluations of straight and gay targets differ based on gender expression.

HIV and gender identity expression among transfeminine people in the Western Cape, South Africa - a thematic analysis of data from the HPTN 071 (PopART) trial.

INTRODUCTION: Transfeminine people in South Africa have a high HIV risk due to structural, behavioural, and psychosocial factors. Transfeminine people and feminine identifying men who have sex with men (MSM) are often conflated or grouped with transgender or MSM categories in HIV service programming, although they don't necessarily identify as either. We aimed to investigate gender expression among feminine identifying people who were assigned male at birth. We examined how local conceptualizations of sexuality and gender intersect with the key population label of 'transgender' imported into local HIV programming. METHODS: A qualitative cohort nested within the HPTN 071 (PopART) trial included longitudinal, in-depth interviews with eight transfeminine people (four who disclosed as living with HIV). Data were collected approximately every six weeks between January 2016 and October 2017. We used a combination of thematic analysis and case study descriptions to explore gender identification among participants. RESULTS: Of the eight participants, only one accepted 'transgender' as a label, and even she used varying terms at different times to describe her identity. For participants, a feminine identity included dressing in normatively feminine clothes; using feminine terms, pronouns and names; and adopting stereotypically feminine mannerisms. Participants would switch between typically feminine and masculine norms in response to contextual cues and audience. For example, some participants accepted identification as masculine gay men amongst their family members. Among peers, they expressed their identity through typically more effeminate gender characteristics, for example self-identifying as "femgay". With partners they often also took on a feminine identity role, for example identifying as women in sexual and romantic relationships (meaning they viewed and expressed themselves as the feminine partner in the relationship). CONCLUSIONS: Our findings are amongst the first exploratory and descriptive data of transfeminine people in South Africa. We show how transfeminine people navigate fluid gender identities that could pose a challenge for accessing and utilizing HIV services that are currently set up for transgender individuals or MSM. More work needs to be done to understand and respond to the diverse and shifting ways people experience their gender identities in this high HIV burden context.

Understanding the relationship between gender and mental health in adolescence: the Gender Adherence Index (GAI).

Half of all mental health disorders appear during adolescence, although it is still far from clear how they relate to gender (not sex) criteria. This study aims both to analyse the relationship between gender and adolescent mental health and to propose an index: the Gender Adherence Index (GAI). We used cross-sectional, secondary data from 3888 adolescents (aged 13-19) from the FRESC Health Survey on Adolescence in Barcelona. We analysed the interaction among sex, age and socio-economic status with several mental health indices. Additionally, we computed a Gender Adherence Index (GAI) to transcend the information-poor binary sex label, and thus assess to what extent mental health can be predicted by the gender expression of adolescents irrespective of their biological sex. We found that older age and lower economic status have a greater impact on the emotional distress of girls, who reported lower self-perceived mental health than boys. Nevertheless, girls obtained higher scores regarding their prosocial behaviour, which is protective against mental health problems. The GAI was retained in all statistical models stressing it as a relevant metric to explain the variability of adolescent emotional distress. Young people who showed adherence to normative femininity in their lifestyles showed higher prosocial behaviour but did not tend to present more emotional distress. Despite its limitations, this is a novel attempt to explore the relationship between gender expression and mental health. Better defined indices of gender adherence could help us to improve our predictive capacity of mental health disorders during adolescence.

Gender identity differences in the experiences of family stressors and violence among transgender and non-binary individuals in China.

Emerging research has demonstrated that transgender and non-binary (TNB) individuals face an elevated risk of experiencing family rejection and violence. However, there remains a significant knowledge gap regarding how TNB individuals manage stressors and their gender identity within the family context, particularly in regions where TNB individuals are highly stigmatized and where legal protections against family violence are lacking. The present study represents one of the first pioneering efforts to provide large-scale quantitative data examining the experiences of family stressors, the management of gender identity and expression, and family violence among TNB individuals in China. A national sample of 1063 TNB individuals in China was involved in the study. They completed questionnaires about their experiences of family stressors and violence. The results indicated that 76.0% of TNB individuals reported having encountered at least one form of violence perpetrated by their family members. Transfeminine individuals were more likely to report experiencing emotional and physical abuse, whereas transmasculine individuals were more likely to be subjected to gender identity and/or expression change efforts. Family stressors, including family non-acceptance and the pressure to marry and reproduce, were positively associated with non-disclosure of gender identity, the suppression of gender expression, and family violence. The findings underscore the substantial burden of family violence borne by TNB individuals in China, which warrants immediate legal, institutional, and social responses. Trans-inclusive family violence prevention and intervention are urgently needed, with a focus on Chinese cultural factors and gender identity differences in violence screening and risk assessment.

Carving the Biodevelopment of Same-Sex Sexual Orientation at Its Joints.

Sexual orientation is a core aspect of human experience and understanding its development is fundamental to psychology as a scientific discipline. Biological perspectives have played an important role in uncovering the processes that contribute to sexual orientation development. Research in this field has relied on a variety of populations, including community, clinical, and cross-cultural samples, and has commonly focused on female gynephilia (i.e., female sexual attraction to adult females) and male androphilia (i.e., male sexual attraction to adult males). Genetic, hormonal, and immunological processes all appear to influence sexual orientation. Consistent with biological perspectives, there are sexual orientation differences in brain development and evidence indicates that similar biological influences apply across cultures. An outstanding question in the field is whether the hypothesized biological influences are all part of the same process or represent different developmental pathways leading to same-sex sexual orientation. Some studies indicate that same-sex sexually oriented people can be divided into subgroups who likely experienced different biological influences. Consideration of gender expression in addition to sexual orientation might help delineate such subgroups. Thus, future research on the possible existence of such subgroups could prove to be valuable for uncovering the biological development of sexual orientation. Recommendations for such future research are discussed.

The measurement of gender expression in survey research.

Previous research on the survey measurement of sexual orientation, gender identity, and gender expression (SOGIE) often focuses on the measurement of identity, with comparably little research focused on gender expression as a key feature of how gender is lived and experienced. This study examines the reliability and validity of survey questions about gender expression in a 2-by-5-by-2 factorial experiment that varies the question order, type of response scale, and the order of gender presentation in the response scale. The results indicate that the effect of which (side of the) scale is presented first on gender expression varies by gender for each of the unipolar items and one of the bipolar items (behavior). In addition, the unipolar items also show distinctions among the gender minority population in ratings of gender expression as well as more nuance with respect to concurrent validity in predicting health outcomes among cisgender respondents. The results of this study have implications for researchers who are interested in accounting for gender holistically in survey and health disparities research.

Gender Identity and Non-Binary Presentations in Adolescents Attending Two Specialized Services in Italy.

BACKGROUND: Recently, the variability and heterogeneity of gender presentations in transgender youths have gained significant attention worldwide. Alongside this, specialized gender services have reported an increase in referrals of youths reporting non-binary identities. In Italy, studies investigating gender identity and expression in gender non-conforming youths are lacking, as are data regarding the non-binary population. AIM: The present study aimed at dimensionally exploring how transgender and non-binary Italian adolescents identify and express their gender. OUTCOMES: Gender expression in trans binary youths and non-binary youths. METHODS: The Gender Diversity Questionnaire (GDQ; Twist & de Graaf, 2019) was used to investigate gender identity, gender fluidity, and gender expression in a sample of 125 adolescent patients from the Gender Identity Development Service (SAIFIP) in Rome and the Gender Incongruence Unit of the Careggi Hospital in Florence, between April 2019-June 2021. RESULTS: The majority of participants (74.4%) identified as trans* binary and the remaining (25.6%) participants identified as non-binary. Trans binary participants reported a stable gender identity, whereas non-binary participants reported a more fluid gender identity across time and contexts. Almost all participants rated external appearance as important to their gender expression, yet trans binary participants attributed more importance to the body in this respect. Body discomfort and pubertal stage emerged as the most influential factors in participants' experiences of gender. Participants who were assigned male at birth expressed significantly more desire for puberty blockers, whereas those who were assigned female at birth had a stronger desire to engage in breast/chest surgery. Non-binary participants sought different medical interventions relative to trans binary participants. CLINICAL IMPLICATIONS: These results may be useful for clinicians working with transgender youths as they provide awareness regarding the features of young people who identify within and outside of binary constructions of gender. STRENGTHS & LIMITATIONS: This study provides useful data in gaining insight into understanding the variety of experiences and challenges of gender non-conforming youths. However as the sample was recruited from specialized services, it may not represent the entire gender non-conforming population in Italy. CONCLUSION: The results describe the range of gender identities and expressions among gender non-conforming youths attending gender specialized services in Italy, thereby improving our understanding of the variety of identities experienced and the specific medical needs of both trans binary and non-binary adolescents. Mirabella M, Piras I, Fortunato A, et al. Gender Identity and Non-Binary Presentations in Adolescents Attending Two Specialized Services in Italy. J Sex Med 2022;19:1035-1048.

Early adolescent gender diversity and mental health in the Adolescent Brain Cognitive Development study.

BACKGROUND: There are known associations between mental health symptoms and transgender identity among adults. Whether this relationship extends to early adolescents and to gender domains other than identity is unclear. This study measured dimensions of gender in a large, diverse, sample of youth, and examined associations between diverse gender experiences and mental health. METHODS: The ABCD study is an ongoing, longitudinal, US cohort study. Baseline data (release 2.0) include 11,873 youth age 9/10 (48% female); and the 4,951 1-year follow-up visits (age 10/11; 48% female) completed prior to data release. A novel gender survey at the 1-year visit assessed felt-gender, gender noncontentedness, and gender nonconformity using a 5-point scale. Mental health measures included youth- and parent-reports. RESULTS: Roughly half a percent of 9/10-year-olds (n = 58) responded 'yes' or 'maybe' when asked, 'Are you transgender' at baseline. Recurrent thoughts of death were more prevalent among these youth compared to the rest of the cohort (19.6% vs. 6.4%, χ2  = 16.0, p < .001). At the 1-year visit, when asked about the three dimensions of gender on a 5-point scale, 33.2% (n = 1,605) provided responses that were not exclusively and totally aligned with one gender. Significant relationships were observed between mental health symptoms and gender diversity for all dimensions assessed. CONCLUSIONS: Similar to adult studies, early adolescents identifying as transgender reported increased mental health symptoms. Results also point to considerable diversity in other dimensions of gender (felt-gender, gender noncontentedness, gender nonconformity) among 10/11-year-olds, and find this diversity to be related to critical mental health symptoms. These findings add to our limited understanding of the relationship between dimensions of gender and wellness for youth.

Gender Expression among Transgender Women in Japan: Support Is Needed to Improve Social Passing as a Woman.

Gender expression is important for transgender women to improve their social passing as women. Herein, a questionnaire about the status of gender expression and support needs was distributed to 54 transgender women aged 17-71 in Japan. Most of the respondents noted that they had found it relatively difficult to handle physical changes and weight gain due to hormone treatment. They also found it difficult to enact and sustain practices such as a feminine use of voice and to use women-only services, whereas practicing and continuing with routine skin and hair care and feminine mannerisms were relatively easy for them. In the questionnaire regarding the support for gender transitioning, many items showed only a small percentage of the transgender women had received the support that they were looking for, and most of their needs for support were not addressed. Some of the factors that increased the respondents' needs and achievement of gender expression as women included estrogen treatment, sex reassignment surgery, and living as a woman; these aspects met their support needs as well. Gender support professionals need to coordinate and collaborate with specialists in areas such as nutritional guidance and voice training to enable transgender women to improve the extent to which they can socially 'pass' as women.

Femininity, masculinity, and body image in a community-based sample of lesbian and bisexual women.

This study expands the literature on body image among lesbian and bisexual women by examining the relationship between self-perceived gendered personality traits and expressions (i.e., sense of self in relation to cultural constructions of femininity and masculinity) and body satisfaction, a key body image construct. We used data from Wave 3 (2010-2012) of the Chicago Health and Life Experiences of Women (CHLEW) study. The CHLEW includes a novel measure of gender expression, with masculinity and femininity as distinct but overlapping constructs. In the large analytic sample (N = 553), we found both similarities and differences in the association between femininity/masculinity and body image in lesbian and bisexual women. Bisexual women reported significantly lower body satisfaction than lesbian women. Higher masculinity was associated with greater body satisfaction in the full sample, but the association was stronger for bisexual than lesbian women. Femininity was positively associated with body satisfaction only for bisexual women. These findings suggest that masculinity and femininity play different roles in body satisfaction for lesbian and bisexual women and highlight the importance of disaggregating sexual identity in studies of sexual minority women's health. Clinicians should routinely ask about sexual identity and gender expression, especially when presenting concerns involve body image or disordered eating.

Lesbians in work settings: Identity, visibility, and strategy.

This is the foreward to this special issue of the Journal of Lesbian Studies on Lesbians in Work Settings: Identity, Visibility, and Strategy. The article briefly provides a context for the issue, and includes the proposed questions for consideration that were included in its call for papers. There is a need for continued research on lesbians in work settings, and this special issue contains articles that interrogate issues of lesbian presence, rights, access, identity, and visibility.

Gender Variance and Sexual Orientation Among Male Spirit Mediums in Myanmar.

This article describes the gender identity, gender expression, and sexual orientation of male spirit mediums in Myanmar. Our analysis is based on ethnographic work, field observation, and 10 semi-structured interviews. These observations were conducted from 2010 to 2015, mostly in Mandalay, with some fieldwork in Yangon and Bagan. The focus of this investigation was specifically on achout (gender variant individuals) who were spirit mediums (nat kadaw). Semi-structured interviews explored the ways that participants understood their gender identity, gender expression, and sexuality in relation to their work as spirit mediums and broader social life. Myanmar remains quite a homophobic and transphobic culture but is undergoing rapid economic and social change. Therefore, it provides an interesting context to study how safe spaces are produced for sexual/gender minorities amidst broader social change. We find that, through the animistic belief structure, there is a growing space for gender nonconforming people, gender variant, and same-sex-oriented individuals (achout) to neutralize their stigmatized status and attain a level of respect and economic advantage. Their ability to become nat kadaw (mediums of spirits) mitigates or trumps their stigmatized status.

"I walked into the industry for survival and came out of a closet": How gender and sexual identities shape sex work experiences among men, two spirit, and trans people in Vancouver.

BACKGROUND/OBJECTIVES: This paper seeks to examine how gender and sexual identities shape sex work experiences among men, two spirit, and/or trans people in Vancouver. METHODS: In-depth, semi-structured interviews were conducted with men and trans people in Metro Vancouver from CHAPS (Community Health & HIV Assessment of Men Who Purchase and Sell Sex). An intersectional critical feminist perspective guided the thematic analysis of interview transcripts, and ATLAS.ti 7 was used to manage data analysis. RESULTS: Three themes emerged from the data: (1) the diversity of sexual and gender identities among sex workers and clients, (2) the expression and exploration of sexual and gender identities through sex work, (3) the migration of sexual and gender minorities to urban centres to escape discrimination in their places of origin. DISCUSSION: These findings complicate existing narratives of sex work, demonstrating the need for policies and services that reflect the diversity of sex work experiences.

Supporting the Health and Well-Being of Transgender Students.

Throughout the United States, there has been a rise in public discourse about transgender people and transgender issues. Much of this attention stems from passed and proposed anti-LGBTQ (lesbian, gay, bisexual, transgender, queer or questioning) legislation, including "bathroom bills" that would require transgender people to use public facilities corresponding with the sex designated on their birth certificates. With the recent discussion and legislation impacting school-aged children and adolescents, what does this mean for school nurses and how can they care and advocate for their transgender students? In this article, we aim to empower school nurses to join the discussion, advocate for inclusive and equitable school policies, and deliver gender-affirming care to transgender students. We will explain transgender identities; transgender-related stigma, prejudice, discrimination, and health concerns; gender-affirming approaches in caring for transgender youth; and implications for school nurses. School nurses play a key role in creating a space that is welcoming and affirming where transgender students can thrive.

Health, disability and quality of life among trans people in Sweden-a web-based survey.

BACKGROUND: Swedish research concerning the general health of trans people is scarce. Despite the diversity of the group, most Swedish research has focused on gender dysphoric people seeking medical help for their gender incongruence, or on outcomes after medical gender-confirming interventions. This paper examines self-rated health, self-reported disability and quality of life among a diverse group of trans people including trans feminine, trans masculine, and gender nonbinary people (identifying with a gender in between male of female, or identify with neither of these genders) as well as people self-identifying as transvestites. METHODS: Participants were self-selected anonymously to a web-based survey conducted in 2014. Univariable and multivariable regression analyses were performed. Three backward selection regression models were conducted in order to identify significant variables for the outcomes self-rated health, self-reported disability and quality of life. RESULTS: Study participants included 796 individuals, between 15 and 94 years of age who live in Sweden. Respondents represented a heterogeneous group with regards to trans experience, with the majority being gender nonbinary (44 %), followed by trans masculine (24 %), trans feminine (19 %) and transvestites (14 %). A fifth of the respondents reported poor self-rated health, 53 % reported a disability and 44 % reported quality of life scores below the median cut-off value of 6 (out of 10). Nonbinary gender identity (adjusted Odds Ratio (aOR) = 2.19; 95 % CI: 1.24, 3.84), negative health care experiences (aOR = 1.92; 95 % CI: 1.26, 2.91) and not accessing legal gender recognition (aOR = 3.06; 95 % CI: 1.64, 5.72) were significant predictors for self-rated health. Being gender nonbinary (aOR = 2.18; 95 % CI: 1.35, 3.54) and history of negative health care experiences (aOR = 2.33; 95 % CI: 1.54, 3.52) were, in addition, associated with self-reported disability. Lastly, not accessing legal gender recognition (aOR = 0.32; 95 % CI: 0.17, 0.61) and history of negative health care experiences (aOR = 0.56; 95 % CI: 0.36, 0.88) were associated with lower quality of life. CONCLUSIONS: The results of this study demonstrate that the general health of trans respondents is related to vulnerabilities that are unique for trans people in addition to other well-known health determinants.

Gender dysphoria in adolescence.

Adolescents presenting with gender-related concerns are increasingly seeking support from providers from a variety of disciplines within health care settings across the world. For those treating young people who meet the criteria for the DSM 5 diagnosis of gender dysphoria (GD), complex decisions in clinical care are common. Defining best practice with this population with respect to interventions that span mental health, physical, and surgical domains can be challenging, given a relative dearth of empirical data available; yet practice guidelines have emerged from different professional organizations which can aid with this. For this review paper, a broad literature search was performed to identify relevant studies pertaining to the care of adolescents with GD. In addition, an overview of trends in clinical practice, including shifts in conceptualization of how clinicians and patients define care that is considered affirming when working with this population, is described. This paper explores the characteristics of referral patterns to specialized clinics, provides a brief overview of gender identity development in adolescence, and then describes the phenomenology of known aetiological factors and co-occurring psychiatric issues in adolescents with GD. Additionally, clinical management considerations that detail assessment aims and common treatment interventions across disciplines will be explored.

Understanding Teachers' Responses to Enactments of Sexual and Gender Stigma at School.

Although teachers may be in a position to address enactments of sexual and gender stigma among their students, little is known about their motivations to intervene in such situations. We surveyed secondary school teachers in the Netherlands, assessing how beliefs, norms, and self-efficacy were related to their intentions to intervene in two hypothetical situations that involved bullying of lesbian/gay or gender non-conforming students. We found significantly stronger intentions to intervene among teachers who were more confident in their abilities to intervene successfully and who had stronger beliefs that intervening in the situation would produce a positive outcome.

Associations of Adolescent School Social Networks, Gender Norms, and Adolescent-to-Young Adult Changes in Male Gender Expression With Young Adult Substance Use.

PURPOSE: Male gender expression (MGE), which is shaped by sociocultural pressures around masculinity, has been previously associated with health. This study examines associations of adolescent social network variables and school gender norms with MGE changes from adolescence to young adulthood, and associations of these changes with young adult substance use. METHODS: Analyzing data from Waves I (1994-95, adolescents, aged 12-18) and IV (2008-09, young adults, 24-32) of a nationally representative longitudinal cohort study, male participants' MGE was assessed in each wave using a validated, empirically derived measure. Linear regression was used to evaluate associations of adolescent-to-young adult MGE changes between waves with adolescent social network characteristics and school gender norms. Logistic regression was used to examine associations between adolescent-to-young adult MGE changes and young adult substance uses (cigarette, marijuana, heavy alcohol, and recreational drug use, and prescription drug misuse). RESULTS: Among 4,776 male participants, adolescent-to-young adult MGE changes were significantly associated with school gender norms such that adolescents whose MGE markedly departed from their schools' average exhibited greater MGE changes in the direction of their schools' average (ß = -0.83, p < .01) relative to those who were more similar to school means. Adolescent-to-young adult increases in MGE were significantly associated with greater odds of all young adult substance use behaviors except prescription drug misuse. DISCUSSION: Adolescents' MGE relative to other males at their school was associated with MGE changes toward school norms, with implications for young adult substance use. Adolescent gender norms may be an underexplored strategy for interventions to reduce substance misuse.

Nonconforming gender expression and adolescent anabolic-androgenic steroids misuse.

BACKGROUND: Gender nonconformity (GNC) is an under-researched area of adolescent health that is of increasing interest to researchers and general public. However, little is known about whether it is associated with anabolic-androgenic steroids (AAS) misuse. We aimed to investigate the association among high school students using a cross-sectional design. METHODS: We pooled the 6 school districts data from the Youth Risk Behavior Survey in 2017 and 2019. We compared the prevalence of AAS misuse among gender nonconforming and conforming students. AAS misuse was determined on the reported experience of lifetime non-prescription steroid use. GNC was derived from perceived gender expression and sex. We estimated the sex-stratified adjusted odds ratios (AORs) for the association of GNC with AAS misuse after adjusting for race/ethnicity, grade, and sexual orientation. RESULTS: The study population consisted of 17,754 US high school students including 9143 (49.67%) female students. Among female students, GNC was significantly associated with moderate (AOR, 3.69; 95% CI 1.28-10.62; P = 0.016) and severe (AOR, 5.00; 95% CI 1.05-23.76; P = 0.043) AAS misuse, but not with any AAS misuse (AOR, 0.85; 95% CI 0.34-2.14; P = 0.734). Among male students, GNC was significantly associated with any (AOR, 4.75; 95% CI 2.93-7.69; P < 0.001), moderate (AOR, 4.86; 95% CI 2.66-8.89; P < 0.001) and severe (AOR, 4.13; 95% CI 1.43-11.95; P = 0.009) AAS misuse. We did not observe a dose-response relationship between GNC and any AAS misuse in female and male students. CONCLUSIONS: This study suggests that AAS misuse is associated with GNC among female and male adolescents.