Gender Expression, Discrimination, and Health Among U.S. Adolescents and Young Adults

Young people who are perceived as transgressing societal gender norms—that is, who have a nonconforming gender expression—are at heightened risk of discrimination and violence victimization in the U.S., which can adversely impact health. However, gender expression has been under-examined in public health, a gap this dissertation sought to address. The first two studies draw on the Growing Up Today Study (GUTS), an ongoing cohort of the children of women in the Nurses’ Health Study II. The objective of the first study was to examine the relationship between gender nonconformity and health-related quality of life (HRQL), measured when participants were ages 18-31 years (n=8977). In multivariable regression models, higher levels of gender nonconformity were associated with higher risk of poor HRQL. Gender nonconforming young women had higher risk of functional limitations and pain relative to more conforming women, after adjusting for sexual orientation identity and potential confounders. Gender nonconformity was also associated with elevated risk of depression/anxiety among men and women. The second study extends this work by examining associations between gender nonconformity, reported gender expression-related discrimination, and depressive symptoms among GUTS sexual minority participants (e.g., lesbian, gay, bisexual, mostly heterosexual; n=1328). High levels of gender expression discrimination were reported by both sexual minority women and men, particularly among the most gender nonconforming. Among women, discrimination modestly attenuated the association between gender nonconformity and depressive symptoms. The third study is a qualitative study of disordered eating and weight and shape control behaviors among young transgender women (i.e., individuals who were assigned a male sex at birth and identify as women). Through in-depth interviews with 21 low-income, ethnically diverse transgender women, this study found that disordered weight and shape control behaviors occurred at the intersection of four key themes: (i) gender socialization processes and cultural femininity ideals, (ii) discrimination and unmet needs for gender affirmation, (iii) biological processes, and (iv) resilience processes. These three studies contribute to growing evidence that gender expression, in the context of societal intolerance for gender diversity and narrow cultural masculinity and femininity ideals, is an important dimension of gender and social determinant of health.