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

  • Richard Lowry
    Address correspondence to: Richard Lowry, MD, MS, Division of Adolescent and School Health, Centers for Disease Control and Prevention, 1600 Clifton Road, NE (Mail stop E-75), Atlanta GA 30329.
    Division of Adolescent and School Health, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
    Search for articles by this author
  • Michelle M. Johns
    Division of Adolescent and School Health, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
    Search for articles by this author
  • Leah E. Robin
    Division of Adolescent and School Health, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
    Search for articles by this author


      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).


      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]).


      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).


      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.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Fenway Health
        Glossary of gender and transgender terms.
        Published 2010
        • Institute of Medicine
        The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding.
        National Academies Press, Washington, DC2011
        • Lowry R
        • Johns MM
        • Gordon AR
        • Austin SB
        • Robin LE
        • Kann LK
        Nonconforming gender expression and associated mental distress and substance use among high school students.
        JAMA Pediatr. 2018; 172: 1020-1028
        • Gill AM
        • Frazer MS
        Health Risk Behaviors Among Gender Expansive Students: Making the Case for Including a Measure of Gender Expression in Population-Based Surveys.
        Advocates for Youth, Washington, DC2016
        • Reisner SL
        • Greytak EA
        • Parsons JT
        • Ybarra ML
        Gender minority social stress in adolescence: disparities in adolescent bullying and substance use by gender identity.
        J Sex Res. 2015; 52: 243-256
        • National Institute on Drug Abuse
        Principles of adolescent substance use disorder treatment: a research-based guide.
        NIH, National Institute on Drug Abuse, Rockville, MDPublished 2014
        • Meyer IH
        • Frost DM
        Minority stress and the health of sexual minorities.
        in: Patterson CJ D'Augelli AR Handbook of Psychology and Sexual Orientation. Oxford University Press, New York, NY2013: 252-266
        • Herek GM
        Sexual stigma and sexual prejudice in the United States: a conceptual framework.
        in: Hope DA Contemporary Perspectives on Lesbian, Gay, and Bisexual Identities. Springer, New York, NY2009: 65-111
        • Gordon AR
        • Conron KJ
        • Calzo JP
        • White MT
        • Reisner SL
        • Austin SB
        Gender expression, violence, and bullying victimization: findings from probability samples of high school students in 4 U.S. school districts.
        J Sch Health. 2018; 88: 306-314
        • Toomey RB
        • Card NA
        • Casper DM
        Peers’ perceptions of gender nonconformity: associations with overt and relational peer victimization and aggression in early adolescence.
        J Early Adolesc. 2014; 34: 463-485
        • Lowry R
        • Johns MM
        • Robin LE
        • Kann LK
        Social stress and substance use disparities by sexual orientation among high school students.
        Am J Prev Med. 2017; 53: 547-558
        • Link BG
        • Phelan JC
        Stigma and its public health implications.
        Lancet. 2006; 367: 528-529
        • Pascoe EA
        • Richman LS
        Perceived discrimination and health: a meta-analytic review.
        Psychol Bull. 2009; 135: 531-554
        • Finkelhor D
        • Ormrod RK
        • Turner HA
        Poly-victimization: a neglected component in child victimization.
        Child Abuse Negl. 2007; 31: 7-26
        • Ford JD
        • Elhai JD
        • Connor DF
        • Frueh BC
        Poly-victimization and risk of posttraumatic, depressive, and substance use disorders and involvement in delinquency in a national sample of adolescents.
        J Adolesc Health. 2010; 46: 545-552
        • Gordon AR
        • Meyer IH
        Gender nonconformity as a target of prejudice, discrimination, and violence against LGB individuals.
        J LGBT Health Res. 2007; 3: 55-71
        • Gordon AR
        • Conron KJ
        • Calzo JP
        • Reisner SL
        • Austin SB
        Nonconforming gender expression is a predictor of bullying and violence victimization among high school students in four U.S. school districts.
        J Adolesc Health. 2016; 58: S1-S2
        • Roberts AL
        • Rosario M
        • Slopen N
        • Calzo JP
        • Austin SB
        Childhood gender nonconformity, bullying victimization, and depressive symptoms across adolescence and early adulthood: an 11-year longitudinal study.
        J Am Acad Child Adolesc Psychiatry. 2013; 52: 143-152
        • D'haese L
        • Dewaele A
        • Van Houtte M
        The relationship between childhood gender nonconformity and experiencing diverse types of homophobic violence.
        J Interpers Violence. 2016; 31: 1634-1660
        • Schope RD
        • Eliason MJ
        Sissies and tomboys: gender role behaviors and homophobia.
        J Gay Lesbian Soc Serv. 2004; 16: 73-97
        • Sirin SR
        • McCreary DR
        • Mahalik JR
        Differential reactions to men and women's gender role transgressions: perceptions of social status, sexual orientation, and value dissimilarity.
        J Mens Stud. 2004; 12: 119-132
        • Coyle EF
        • Fulcher M
        • Trübutschek D
        Sissies, mama's boys, and tomboys: is children's gender nonconformity more acceptable when nonconforming traits are positive?.
        Arch Sex Behav. 2016; 45: 1827-1838
        • Courtenay WH
        Constructions of masculinity and their influence on men's well-being: a theory of gender and health.
        Soc Sci Med. 2000; 50: 1385-1401
        • Wylie SA
        • Corliss HL
        • Boulanger V
        • Prokop LA
        • Austin SB
        Socially assigned gender nonconformity: a brief measure for use in surveillance and investigation of health disparities.
        Sex Roles. 2010; 63: 264-276
        • Greytak EA
        • Gill AM
        • Conron KJ
        Identifying transgender and other gender minority respondents on population-based surveys: special considerations for adolescents.
        in: Herman JL Best Practices for Asking Questions to Identify Transgender and Other Gender Minority Respondents on Population-Based Surveys. The Williams Institute, Los Angeles. CA2014: 29-34
        • Huselid RF
        • Cooper ML
        Gender roles as mediators of sex differences in expressions of pathology.
        J Abnorm Psychol. 1994; 103: 595-603
        • Toomey RB
        • Ryan C
        • Diaz RM
        • Card NA
        • Russell ST
        Gender-nonconforming lesbian, gay, and transgender youth: school victimization and young adult psychological adjustment.
        Dev Psychol. 2010; 46: 1580-1589
        • Kann L
        • Olsen EO
        • McManus T
        • et al.
        Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9-12 - United States and selected sites, 2015.
        MMWR Surveill Summ. 2016; 65: 1-202
        • Johns MM
        • Lowry R
        • Andrzejewski J
        • et al.
        Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students - 19 states and large urban school districts, 2017.
        MMWR Morb Mortal Wkly Rep. 2019; 68: 67-71
        • Coulter RWS
        • Bersamin M
        • Russell ST
        • Mair C
        The effects of gender- and sexuality-based harassment on lesbian, gay, bisexual, and transgender substance use disparities.
        J Adolesc Health. 2018; 62: 688-700
        • Day JK
        • Fish JN
        • Perez-Brumer A
        • Hatzenbuehler ML
        • Russell ST
        Transgender youth substance use disparities: results from a population-based sample.
        J Adolesc Health. 2017; 61: 729-735
        • DePedro KT
        • Gilreath TD
        • Jackson C
        • Esqueda MC
        Substance use among transgender students in California public middle and high schools.
        J Sch Health. 2017; 87: 303-309
        • Burton CM
        • Marshal MP
        • Chisolm DJ
        School absenteeism and mental health among sexual minority youth and heterosexual youth.
        J Sch Psychol. 2014; 52: 37-47
        • Brener ND
        • Kann L
        • McManus T
        • Kinchen SA
        • Sundberg EC
        • Ross JG
        Reliability of the 1999 Youth Risk Behavior Survey questionnaire.
        J Adolesc Health. 2002; 31: 336-342
        • Cimpian JR
        • Timmer JD
        • Birkett MA
        • Marro RL
        • Turner BC
        • Phillips 2nd, GL
        Bias from potentially mischievous responders on large-scale estimates of lesbian, gay, bisexual, or questioning (LGBQ)–heterosexual youth health disparities.
        Am J Public Health. 2018; 108: S258-S265
        • Greytak EA
        • Kosciw JG
        • Boesen MJ
        Putting the “T” in “Resource”: the benefits of LGBT-related school resources for transgender youth.
        J LGBT Youth. 2013; 10: 45-63
        • Johns MM
        • Beltran O
        • Armstrong HL
        • Jayne PE
        • Barrios LC
        Protective factors among transgender and gender variant youth: a systematic review and socioecological synthesis.
        J Prim Prev. 2018; 39: 263-301