Health Policy Fact Sheet December 2017 Characteristics and Mental Health of Gender Nonconforming Adolescents in California Bianca D.M. Wilson, Soon Kyu Choi, Jody L. Herman, Tara L. Becker, Kerith J. Conron L evels of gender conformity are known to be a particularly salient factor in the safety and well-being of youth.1 Yet, data that specifically prohibit discrimination against anyone who does not adhere to those stereotypes.4 People can defy gender about gender nonconforming (GNC) youth stereotypes in terms of gender identity remain rare, particularly regarding the size, and/or gender expression, but these are characteristics, and health of the population. distinct aspects of personal identity. Both In an effort to address this knowledge gap, transgender people (individuals for whom representative data on gender expression were gender identity and assigned sex at birth are collected from California youth during the two- not fully concordant) and cisgender people year 2015-2016 data cycle of the California (those for whom gender identity and assigned Health Interview Survey (CHIS). This is the sex at birth are concordant) may be either first representative survey of the adolescent nonconforming or conforming in their gender population of California that included a expression. People who are seen by others measure of gender expression, which allows as gender nonconforming, along with those youth to be identified as GNC. In this fact who are transgender or non-binary, fall under sheet, we describe findings related to the the umbrella of “gender minorities” – that demographics and mental health of GNC youth is, people who are seen as resisting dominant ‘‘ as compared to gender conforming youth. expectations around gender expression and identity according to assigned sex at birth. Gender Defining Adolescent Gender Nonconformity The California Health Interview Survey nonconforming In the U.S., there are dominant cultural expectations about who gets to express (CHIS) measured gender expression by asking youth…make masculinity and femininity, as well as every surveyed adolescent one question about up a significant about how best to do that.2 Although how people at school viewed their physical expression of femininity and masculinity. segment of there are variations in how femininity and masculinity are defined and expressed both the adolescent across cultural groups and over time, at A person’s appearance, style, dress, or population in the core of the dominant gender expression the way they walk or talk may affect how California. ’’ belief system is the expectation that people who are assigned female at birth should be “feminine,” and those assigned male at birth people describe them. How do you think other people at school would describe you? • Very feminine should be “masculine.”2,3 In essence, under these cultural expectations, individuals • Mostly feminine face social pressures to engage in gender- • Equally feminine & masculine stereotypical appearance and behaviors in • Mostly masculine social situations and are sanctioned when • Very masculine they do not. California is one of several states UCLA CENTER FOR HEALTH POLICY RESEARCH & THE WILLIAMS INSTITUTE, UCLA SCHOOL OF LAW Responses to this item were then analyzed Exhibit 1 California Adolescents Ages 12-17 by along with each adolescent’s response to the Gender Conformity Level, 2015-2016 CHIS CHIS adolescent measure for sex/gender: “Are Highly you male or female?” Based on these items, Gender we identified two groups of GNC youth, Nonconforming 6.2% “Highly GNC” and “Androgynous.” We categorized female youth as highly GNC if they responded with “mostly masculine” or “very masculine,” and we categorized male youth as highly GNC if they responded Androgynous with “mostly feminine” or “very feminine.” 20.8% We categorized GNC youth who reported being “equally feminine and masculine” Gender Conforming as androgynous, and the remaining youth 73.0% were categorized as gender conforming (see Exhibit 1 for population percentages of each group, and Exhibit 2 for demographic characteristics). We found that 27 percent of youth ages 12 to 17 in California, or about 796,000 youth, are GNC. Mental health The CHIS adolescent questionnaire included several indicators of mental health, including psychological distress, suicidal ideation, and suicide attempts. GNC and gender conforming youth did not statistically differ in their rates of lifetime suicidal thoughts Exhibit 2 Demographic Characteristics for Youth Ages 12-17 by Gender Conformity Level, 2015-2016 CHIS Gender Conforming Highly GNC (n=59) Androgynous (n=331) (n=1,204) 95% 95% 95% Measure Estimate Confidence Estimate Confidence Estimate Confidence Interval Interval Interval Population 6% (3%, 13%) 21% (15%, 28%) 73% (66%, 79%) Prevalence (477,400; (433,700; (1,970,700; Population Size 182,466 613,449 2,156,385 317,100) 793,200) 2,342,100) Mean Age 13.4 (12.1, 14.6) 14.1 (13.6, 14.6) 14.6 (14.4, 14.8) Gender Male 45% (11%, 85%) 37% (24%, 51%) 56% (51%, 61%) Female 55% (15%, 89%) 63% (49%, 76%) 44% (39%, 49%) Race Hispanic 50% (12%, 88%) 50% (36%, 65%) 51% (47%, 56%) Non-Hispanic 45% (10%, 86%) 25% (16%, 39%) 27% (22%, 32%) White Other 5% (1%, 25%) 24% (14%, 39%) 22% (18%, 26%) UCLA CENTER FOR HEALTH POLICY RESEARCH & THE WILLIAMS INSTITUTE, UCLA SCHOOL OF LAW Exhibit 3 Mental Health Indicators for Youth Ages 12 to 17 by Gender Conformity Level, 2015-2016 CHIS Androgynous Gender Conforming Highly GNC (n=59) All GNC (n=390) (n=331) (n=1,204) Measure Estimate 95% CI Estimate 95% CI Estimate 95% CI Estimate 95% CI Suicidal thoughts, 14% (4%, 41%) 21% (11%, 35%) 19% (11%, 31%) 11% (6%, 17%) lifetime Suicidal attempts, 3% (0%, 24%) 5% (1%, 19%) 5% (1%, 15%) 2% (1%, 6%) lifetime Severe psychological 15% (3%, 48%) 18% (9%, 34%) 17% (9%, 31%) 7% (4%, 12%) distress, past year and suicide attempts. However, GNC youth males were found to have higher levels of were significantly more likely to report suicide attempts than non-feminine males.6 severe psychological distress5 in the past year Given that the estimates of suicidality among compared to gender conforming youth (17 androgynous youth in this study were nearly percent vs. 7 percent) (Exhibits 3 and 4). twice that of gender conforming youth, it is possible that a larger sample size will later Discussion reveal more precise confidence intervals and Gender nonconforming youth, including both statistically significant differences. highly GNC and androgynous subgroups, make up a significant segment of the It is also possible that higher levels of social adolescent population in California. GNC acceptance and the presence of protective policies youth in our analyses did not have statistically in California may impact rates of victimization significant higher levels of lifetime suicidality. and bullying, which, in turn, may confer some This finding differs from an analysis of protection for gender minority youth in the representative samples across several states state. Future studies should look at these data and municipalities using a similar measure across several years and examine rates of of gender expression, in which feminine victimization and bullying in order to better Exhibit 4 Percent of Youth Ages 12-17 Identified as Having Severe Psychological Distress in the Past Year by Gender Conformity Level, 2015-2016 CHIS 30% 25% All GNC Youth* = 17% 20% 15% 10% 18% 15% 5% 7% 0% Highly Gender Nonconforming Androgynous Gender Conforming *Statistically significant difference from gender-conforming group, p < .05. UCLA CENTER FOR HEALTH POLICY RESEARCH & THE WILLIAMS INSTITUTE, UCLA SCHOOL OF LAW ‘‘ We must focus understand the relationships between laws and on continuing victimization and suicidality among GNC youth. to reduce known GNC youth were, however, more likely to be risk factors, severely psychologically distressed compared to gender conforming youth, a factor associated such as bullying with future levels of suicidality. This finding Jody L. Herman, PhD, is a Scholar of Public Policy at the Williams Institute, UCLA School of Law. Tara L. Becker, PhD, is a senior statistician for the California Health Interview Survey at the UCLA Center for Health Policy Research. Kerith J. Conron, ScD, is the Blachford-Cooper Distinguished Scholar and Research Director at the Williams Institute, UCLA School of Law. and bias, highlights the need to increase access to against gender affirming to educate parents, and other supports, as well as mental health care schools, and Acknowledgments The authors thank Dr. Allegra Gordon (Harvard nonconforming communities on the mental health needs of University) for serving as an external reviewer. people. ’’ gender nonconforming youth. It also makes it clear that we must focus on continuing to reduce known risk factors, such as bullying and The authors appreciate the support of the Arcus Foundation, the David Bohnett Foundation, the Gill Foundation, the California Community Foundation, The California Endowment, the Johnson Family bias, against gender nonconforming people. Foundation, Mr. Weston Milliken, and donors from the Williams Institute’s “UniTy” Events 2015-2017. Methods Note This fact sheet presents data from the new release Suggested Citation of the 2015-2016 cycle of the California Health Wilson BDM, Choi SK, Herman JL, Becker T, Interview Survey (CHIS), conducted by the UCLA Conron KJ. 2017. Characteristics and Mental Health Center for Health Policy Research (CHPR). CHIS is a of Gender Nonconforming Adolescents in California: telephone survey that uses a dual-frame, random-digit- Findings from the 2015-2016 California Health dial (RDD) technique. By using traditional landline Interview Survey. Los Angeles, CA: The Williams RDD and cell-phone RDD sampling frames, it is Institute and UCLA Center for Health Policy Research. representative of the state’s population. Survey items for the adolescent questionnaire are self-reported, and Endnotes data are collected by trained interviewers. CHIS data 1 See, for instance: D’Augelli AR, Grossman AH, Starks are collected continuously throughout the year, with MT. 2006. Childhood Gender Atypicality, Victimization, and PTSD Among Lesbian, Gay, and Bisexual Youth. each full cycle comprising two years. Data are based Journal of Interpersonal Violence 21: 1462-1482; Toomey on interviews conducted with adolescents in nearly RB, Ryan C, Diaz RM, Card NA, Russell ST. 2010. 1,600 California households and covering a diverse Gender Nonconforming Lesbian, Gay, Bisexual, and Transgender Youth: School Victimization and Young array of health-related topics, including health status Adult Psychosocial Adjustment. Developmental Psychology and behaviors and access to health care. For more 46: 1580-1589; Gordon AR, Conron KJ, Calzo JP, information about CHIS, please visit the CHIS website White M, Reisner SL, Austin SB. Gender Expression, Violence, and Bullying Victimization: Findings from at www.chis.ucla.edu. Probability Samples of High School Students in Four U.S. School Districts. Journal of School Health (in press). This publication contains All analyses presented in this fact sheet incorporate 2 West C, Zimmerman DH. 1987. Doing Gender. Gender and data from the California replicate weights to provide corrected confidence Society 1(2): 125–151. http://www.jstor.org/stable/189945 Health Interview Survey interval estimates and statistical tests. Differences 3 Connell RW. 1995. Masculinities. Berkeley, CA: (CHIS), the nation’s largest University of California Press. in binary or categorical outcomes between gender state health survey, which 4 California AB-887: http://www.leginfo.ca.gov/pub/11-12/bill/ nonconforming (GNC), androgynous, and gender asm/ab_0851-0900/ab_887_bill_20111009_chaptered.pdf is conducted by the UCLA conforming respondents were tested using the Rao- 5 Kessler 6-Item Psychological Distress Scale (K6), ranges Center for Health Policy Scott Chi-Square test, which accounts for the survey 0-24. We used a score of 13 or higher as a marker of Research. CHIS data give design’s use of replicate weights. severe psychological distress. a detailed picture of the 6 Gill AM, Frazer MS. 2016. Health Risk Behaviors Among Gender Expansive Students: Making the Case for Including a health and health care Author Information Measure of Gender Expression in Population-Based Surveys. needs of California’s large Bianca D.M. Wilson, PhD, is the Rabbi Barbara Washington, D.C.: Advocates for Youth. and diverse population. Zacky Senior Scholar of Public Policy at the Learn more at: Williams Institute, UCLA School of Law. www.chis.ucla.edu Soon Kyu Choi, MPP MSc, is a Policy Analyst at the Williams Institute, UCLA School of Law. Read this publication online FS2017-2