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Associations of nonconforming gender expression and gender identity with bullying victimization: an analysis of the 2017 youth risk behavior survey



Although gender nonconformity (GNC) and transgender identity are both linked to bullying victimization, few studies have examined them with bullying victimization simultaneously. Using a sample of Youth Risk Behavior Survey, we investigated the associations of GNC and transgender identity with bullying victimization within the same study.


We analyzed data from the cross-sectional school-based Youth Risk Behavior Survey in 2017 (n = 25,378). The exposures were GNC and transgender identity. The main outcomes were traditional victimization, cyber victimization, and combined victimization. We calculated adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) using Poisson regression models.


There were 22.15% of high school students with GNC, and 1.61% identified themselves as transgender. GNC is associated with traditional (APR,1.45;95%CI, 1.21–1.73), cyber (APR,2.00; 95%CI, 1.66–2.40) and combined victimization (APR,1.61;95%CI, 1.42–1.83) respectively among assigned male at birth (AMAB) students only. Transgender male and female students are both at higher risk of bullying victimization for all the three outcomes than cisgender peers.


AMAB GNC and transgender identity are associated with a higher risk of bullying victimization. Providing support systems and celebrating gender diversity within and outside schools are important.

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Bullying victimization negatively affects the health of about 20% of American high school students [1], including suicidal thoughts and behaviors [2], making it a serious public health concern for adolescents in the United States and a high priority in Healthy People 2020 [3]. Adolescents with gender nonconformity (GNC) report elevated rates of negative health outcomes, including bullying victimization [4,5,6,7].

Preventing school bullying is a fundamental human rights issue, and any form of bullying infringes the fundamental right to education. Sexual and gender minority adolescents are more likely to experience school bullying [8]. Although many studies consider lesbian, gay, bisexual (LGB), and transgender(T) as an umbrella term LGBT, “LGB” and “T” are different in nature: the former refers to sexual orientation while the latter refers to gender identity. A growing body of research suggests that transgender adolescents experience substantial disparities in bullying victimization [7, 9,10,11,12]. For example, in 2012, a New Zealand nationally representative survey found that transgender students and those unsure about their gender identity were more prone to be bullied than their cisgender peers [12].

There are also a few studies that have examined bullying victimization across the full spectrum of gender expression [4, 13,14,15]. For example, a study based on the 2013 Youth Risk Behavior Survey (YRBS) suggested that there was a linear association between GNC score and bullying victimization among U.S. high school students, and each additional unit of GNC score is associated with a 15% risk increase in traditional or cyber victimization [15].

Transgender identity is gender identity that differs from assigned sex at birth (ASAB), while GNC is gender expression (eg, in clothing or mannerisms) that differs from societal expectations of the gender (eg, boys like blue and girls like pink) [6]. Considering that transgender students often have experiences that highly overlap with those of cisgender, gender nonconforming peers [6], it is important to investigate whether the associations of bullying victimization with gender identity are similar to the findings with gender nonconforming students. Few existing studies, however, were available on the measures of both gender expression and gender identity. Fortunately, both GNC and transgender identity were collected in a partial sample of 2017 YRBS, which provides us a unique opportunity to address this gap.

Leveraging the data from 2017 YRBS, the objective of this study was to investigate the association of bullying victimization with GNC and transgender identity among U.S. high school students.


This cross-sectional secondary data analysis of a sample of YRBS was not considered human subject research, because YRBS datasets are de-identified and publicly available (

Data sources

The YRBS, developed by the U.S. Centers for Disease Control and Prevention, is conducted every two years to collects priority risk behaviors, including bullying victimization, that contribute to social problems, disabilities, and even death among high school students in United States [1].

About 20 large urban school districts in the U.S. conduct YRBS biennially using a 2-stage cluster sampling strategy to guarantee a representative sample of students in grades 9–12 within each jurisdiction [1, 6]. In 2017, nine U.S. school districts included the items to measure gender expression and gender identity simultaneously, and the data from these 9 school districts (1 in Illinois, 1 in California, 1 in Florida, and 6 in New York) were combined into a single sub-data (N = 25,378) for further analysis in the present study. The overall response rates ranged between 61 and 89%[1], and the sample size ranged between 938 and 10,191 students. The surveys were reviewed and approved within each jurisdiction using its local procedure. Detailed information concerning the large urban school district YRBS has been provided elsewhere [16].


The perceived gender expression was measured with one validated item developed for adolescents in school contexts [17]. Students were asked: “A person’s appearance, style, dress, or the way they walk or talk may affect how people describe them. How do you think people at school would describe you?” Response options followed with a 7-point scale: “very feminine,” “mostly feminine,” “somewhat feminine,” “equally feminine and masculine,” “somewhat masculine,” “mostly masculine,” and “very masculine.” A continuous GNC score that measures the degree of nonconformity to gender norms was created by combining the responses to the gender expression and ASAB, with 1 indicating most gender conforming (very feminine girls and very masculine boys) and 7 indicating most gender non-conforming (very masculine girls and very feminine boys) [6]. Then a binary GNC variable was generated: gender conformity (GC) (GNC score: 1–3) and GNC (GNC score: 4–7) (Table 1) [6].

Table 1 Definitions of variables, questionnaire items and analytic coding

Gender identity was measured with the item: “Some people describe themselves as transgender when their sex at birth does not match the way they think or feel about their gender. Are you transgender?” Response options were “No (Cisgender)”, “Yes, I am transgender (Transgender)”, and “Not sure if I am transgender (Not sure)”.

Traditional victimization was measured with the item: “During the past 12 months, have you ever been bullied on school property?” (No = 0, Yes = 1). Cyber victimization was measured with the item: “During the past 12 months, have you ever been electronically bullied? (Count being bullied through texting, Instagram, Facebook, or other social media.)” (No = 0, Yes = 1). Then combined victimization was computed to indicate if the participants experienced traditional or cyber bullying during the past 12 months before the survey (No = 0, Yes = 1).

Demographic characteristics that were assessed in this study included ASAB (assigned female at birth (AFAB) and assigned male at birth (AMAB)), race/ethnicity (White, Black or African American, Hispanic/Latino and all other races), sexual orientation (heterosexual, gay or lesbian, bisexual, and unsure), and grade (9th, 10th, 11th, and 12th).

Statistical analysis

We estimated the prevalence of GNC and transgender identity and tested the differences by ASAB using χ2 statistics. We investigated associations of GNC and non-cisgender identity with bullying victimization, controlling for the grade, race/ethnicity, and sexual orientation. We calculated the adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) using Poisson regression models [19], with GC and cisgender identity as reference groups respectively, because APRs are more interpretable than adjusted odds ratios in cross-sectional studies [19, 20].

All statistical analyses were weighted and performed using Stata/SE 15.1 (StataCorp LLC) to account for the complex survey design. The tests were considered to be statistically significant if two-tailed P < 0.05.


The weighted percentage (unweighted number) of participants in the current study was 49.17% (n = 13,035) AFAB and 50.83% (n = 12,343) AMAB. There were 23.14% (n = 5,728) of students identified as sexual minority (lesbian or gay: 3.13%, bisexual: 7.61%, and unsure: 1.24%). For gender identity, 3.31% (n = 728) identified as transgender or unsure (transgender: 1.61% and unsure: 1.70%). And 22.15% (n = 5,224) of students were labeled with GNC. As shown in Table 2, sexual minority was more prevalent among AFAB than AMAB participants (AFAB: 28.63% vs. AMAB: 17.80%, P < 0.001) while transgender or unsure identity was more prevalent among AMAB than AFAB participants (AFAB: 2.88% vs. AMAB: 3.73%, P < 0.05). No statistically significant ASAB differences were observed for GNC.

Table 2 Descriptive statistics of demographic characteristic

ASAB differences were observed in the associations of GNC with three outcomes of bullying victimization. Table 3 shows that associations of GNC with traditional victimization (APR,1.45;95%CI, 1.21–1.73), cyber victimization (APR,2.00; 95%CI, 1.66–2.40) and combined victimization (APR,1.61;95%CI, 1.42–1.83) were all statistically significant among AMAB students only. None of the three outcomes of bullying victimization was associated with GNC among AFAB students.

Table 3 Associations between gender expression and bullying victimization

Table 4 shows that students who were transgender male, transgender female, and unsure about their gender identity all reported higher risks of three outcomes of bullying victimization compared with their cisgender peers. And all the associations were statistically significant. For example, 13.47% of cisgender male students reported being bullied traditionally, while the prevalence rose up to 33.38% among transgender males. Transgender males were more likely to experience traditional victimization than their cisgender male peers (APR, 2.10;95%CI, 1.42–3.12).

Table 4 Associations between gender identity and bullying victimization


Reducing bullying of transgender students is a high-priority public health issue, and may be considered to become a core Healthy People 2030 objective when reliable baseline data are available [21], and essential in order to achieve the Sustainable Development Goals for children and adolescents. This study expands the existing literature on the differences and similarities of the associations of bullying victimization with GNC and transgender identity. We found that the impact of gender nonconformity is different depending on ASAB (but not on transgender identity) after adjusting the grade, race/ethnicity, and sexual orientation.

A previous study revealed that a higher score on verbal bullying scale demonstrated a linear increase with increasing GNC scores for both ASAB, while this linear association was stronger for AMAB students than for AFAB students [22]. In our study, GNC is regarded as more acceptable for AFAB students than for AMAB students, while transgender identity is discriminated against for both male and female students.

These findings indicate the ASAB differences in discrimination, stigmatization, and marginalization related to GNC. The major reason for the ASAB differences, as previous studies indicated [23,24,25], is the social negative views on GNC are meted out unequally to the AMAB and AFAB students. AFAB GNC is often treated much less harshly than AMAB GNC although both AMAB GNC and AFAB GNC are less valued among their peers [23, 26] and predict low self-perceived social competence [27]. This phenomenon roots in higher tolerance of gender non-conforming behaviors among AMAB students [28] and highly valued masculinity in our society [29]. Thus the prejudice toward students with GNC largely depends on their ASAB and gender expression [23]. Besides, the ASAB bias in reporting bullying could possibly attenuate the ASAB difference. Compared with gender nonconforming AFAB peers, AMAB students with GNC may be less likely to report being bullied, given that masculinity is associated with a reticence to disclose being bullied for fear of being seen as ‘weak’ [6].

Important similarities and differences emerged across gender when we examined the association between transgender identity and bullying victimization. We found that compared with cisgender peers, transgender students were more likely to be bullied, traditionally and electronically, among both male and female students. Additionally, students who were unsure about their gender identity were also at higher risk of experiencing traditional or cyber bullying.

Prior research has found that compared with cisgender peers, transgender students experienced higher risk of bullying victimization [7] and gender-based bullying victimization [9]. The unique strength of the present study is its capability to compare the associations of bullying victimization with GNC and transgender identity, given that transgender students often shared similar risk factors and experiences with peers with GNC [6]. We noted that AMAB GNC is associated with a higher risk of bullying victimization, while AFAB GNC is not. However, transgender identity is associated with bullying victimization for not only males but also females. This finding highlights that AMAB GNC and transgender identity could be monitored as risk factors of bullying victimization among U.S. high school students.


Our findings appear to have essential practical implications. Transgender youth in U.S. are facing an unprecedented number of anti-transgender legislations. In just the first week of 2022, at least seven U.S. states have proposed bills undermining the rights of transgender youth [30], including restricting access to school sports teams and school restrooms, and gender-affirming medical care (e.g., puberty blockers). The transgender stigma may even lead transgender or unsure youth in the future to conceal their gender identity [31].

Our study suggests that transgender and gender nonconforming (TGNC) students are both more vulnerable to bullying victimization than cisgender peers. TGNC students are also more likely to miss days of school [32] and experience poorer mental health outcomes [33]. The states and schools could implement policies that protect TGNC youth from these life adverse experiences. Anti-bullying and nondiscrimination policies on gender identity/expression are associated with lower prevalence of bullying victimization [34]. Besides, teacher training on gender identity/expression may be scaled up as it could help decrease school-based victimization [35].


The findings in this study are subject to at least four limitations. First, YRBS data are school-based, which means our findings might not be generalizable to out-of-school adolescents[6]. Given that transgender and gender non-conforming students are more likely to drop out than cisgender peers, this group may be underestimated herein[36]. Second, YRBS data are self-reported under conditions of assured confidentiality, so the experience of being bullied and gender identity/expression may be affected by the retrospective recall and social desirability biases. Third, YRBS data are cross-sectional, which hinders us to study the health of gender-fluid students whose gender identity varies over time and prevents us from discerning the directionality of the associations of GNC and gender minority with bullying victimization. Fourth, YRBS data did not include information on gender-based bullying victimization, general bullying indicators in YRBS might overestimate the risk of bullying victimization.


Given the similarities and differences in bullying victimization between transgender identity and GNC, educators and parents should be more supportive of variety of gender identity and expression, especially for AMAB adolescents. Policymakers and child health advocates should make the programs more accessible and equitable for all the adolescents.

Availability of data and materials

Data is available at



Gender nonconformity


Gender conformity


Lesbian, gay, bisexual


Youth Risk Behavior Survey


Adjusted prevalence ratio


Confidence interval


Assigned sex at birth


Assigned female at birth


Assigned male at birth


Transgender and gender-nonconforming


  1. Kann L, McManus T, Harris WA, Shanklin SL, Flint KH, Queen B, Lowry R, Chyen D, Whittle L, Thornton J, et al. Youth Risk Behavior Surveillance - United States, 2017. MMWR Surveill Summ. 2018;67(8):1–114.

    Article  Google Scholar 

  2. Geoffroy MC, Boivin M, Arseneault L, Turecki G, Vitaro F, Brendgen M, Renaud J, Seguin JR, Tremblay RE, Cote SM. Associations Between Peer Victimization and Suicidal Ideation and Suicide Attempt During Adolescence: Results From a Prospective Population-Based Birth Cohort. J Am Acad Child Adolesc Psychiatry. 2016;55(2):99–105.

    Article  Google Scholar 

  3. Koh HK. A 2020 Vision for Healthy People. N Engl J Med. 2010;362(18):1653–6.

    CAS  Article  Google Scholar 

  4. Roberts AL, Rosario M, Corliss HL, Koenen KC, Austin SB. Childhood gender nonconformity: a risk indicator for childhood abuse and posttraumatic stress in youth. Pediatrics. 2012;129(3):410–7.

    Article  Google Scholar 

  5. 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(2, Supplement):S1–2.

    Article  Google Scholar 

  6. 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(11):1020–8.

    Article  Google Scholar 

  7. 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(3):243–56.

    Article  Google Scholar 

  8. Henderson ER, Sang JM, Louth-Marquez W, Egan JE, Espelage D, Friedman M, Coulter RWS: “Words Aren’t Supposed to Hurt, But They Do”: Sexual and Gender Minority Youth’s Bullying Experiences. J Interpers Violence 2020:0886260520978199.

  9. Day JK, Perez-Brumer A, Russell ST. Safe Schools? Transgender Youth’s School Experiences and Perceptions of School Climate. J Youth Adolesc. 2018;47(8):1731–42.

    Article  Google Scholar 

  10. Schuster MA, Bogart LM, Elliott MN, Klein DJ, Feng JY, Tortolero SR, Mrug S, Lewis TH. A longitudinal study of bullying of sexual-minority youth. N Engl J Med. 2015;372(19):1872–4.

    Article  Google Scholar 

  11. Russell ST, Everett BG, Rosario M, Birkett M. Indicators of victimization and sexual orientation among adolescents: analyses from Youth Risk Behavior Surveys. Am J Public Health. 2014;104(2):255–61.

    Article  Google Scholar 

  12. Clark TC, Lucassen MF, Bullen P, Denny SJ, Fleming TM, Robinson EM, Rossen FV. The health and well-being of transgender high school students: results from the New Zealand adolescent health survey (Youth’12). J Adolesc Health. 2014;55(1):93–9.

  13. 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(2):143–52.

    Article  Google Scholar 

  14. Jones A, Robinson E, Oginni O, Rahman Q, Rimes KA. Anxiety disorders, gender nonconformity, bullying and self-esteem in sexual minority adolescents: prospective birth cohort study. J Child Psychol Psychiatry. 2017;58(11):1201–9.

    Article  Google Scholar 

  15. 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 US School Districts. J Sch Health. 2018;88(4):306–14.

    Article  Google Scholar 

  16. Brener ND, Kann L, Shanklin S, Kinchen S, Eaton DK, Hawkins J, Flint KH. Methodology of the Youth Risk Behavior Surveillance System–2013. MMWR Recomm Rep. 2013;62(Rr-1):1–20.

    PubMed  Google Scholar 

  17. 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(3):264–76.

    Article  Google Scholar 

  18. Olweus D. School bullying: development and some important challenges. Annu Rev Clin Psychol. 2013;9(1):751–80.

  19. Barros AJD, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol. 2003;3:21–21.

    Article  Google Scholar 

  20. Vagi KJ, O’Malley Olsen E, Basile KC, Vivolo-Kantor AM. Teen Dating Violence (Physical and Sexual) Among US High School Students: Findings From the 2013 National Youth Risk Behavior Survey. JAMA Pediatr. 2015;169(5):474–82.

  21. Reduce bullying of transgender students — LGBT‑D01

  22. Beusekom G, Baams L, Bos HM, Overbeek G, Sandfort TG. Gender Nonconformity, Homophobic Peer Victimization, and Mental Health: How Same-Sex Attraction and Biological Sex Matter. J Sex Res. 2016;53(1):98–108.

    Article  Google Scholar 

  23. 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(7):1827–38.

    Article  Google Scholar 

  24. Blakemore JEO. Children’s Beliefs About Violating Gender Norms: Boys Shouldn’t Look Like Girls, and Girls Shouldn’t Act Like Boys. Sex Roles. 2003;48(9):411–9.

  25. Gower AL, Rider GN, Coleman E, Brown C, McMorris BJ, Eisenberg ME. Perceived Gender Presentation Among Transgender and Gender Diverse Youth: Approaches to Analysis and Associations with Bullying Victimization and Emotional Distress. LGBT health. 2018;5(5):312–9.

    Article  Google Scholar 

  26. Smetana JG. Preschool Children’s Conceptions of Sex-Role Transgressions. Child Dev. 1986;57(4):862–71.

  27. Yu L, Xie D. Multidimensional Gender Identity and Psychological Adjustment in Middle Childhood: A Study in China. Sex Roles. 2010;62(1):100–13.

    Article  Google Scholar 

  28. Killen M, Crystal DS, Watanabe H. Japanese and American children’s evaluations of peer exclusion, tolerance of differences, and prescriptions for conformity. Child Dev. 2002;73(6):1788–802.

  29. Feinman S. A status theory of the evaluation of sex-role and age-role behavior. Sex Roles. 1984;10(5):445–56.

    Article  Google Scholar 

  30. At least 7 states propose bills limiting rights of trans and nonbinary youth

  31. Bränström R, Pachankis JE. Country-level structural stigma, identity concealment, and day-to-day discrimination as determinants of transgender people’s life satisfaction. Soc Psychiatry Psychiatr Epidemiol. 2021;56(9):1537–45.

  32. McGuire JK, Okrey Anderson S, Michaels C. “I don’t think you belong in here:” The impact of gender segregated bathrooms on the safety, health, and equality of transgender people. J Gay Lesbian Soc Serv. 2022;34(1):40–62.

  33. Russell ST, Pollitt AM, Li G, Grossman AH. Chosen Name Use Is Linked to Reduced Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior Among Transgender Youth. J Adolesc Health. 2018;63(4):503–5.

    Article  Google Scholar 

  34. Watson RJ, Fish JN, Denary W, Caba A, Cunningham C, Eaton LA. LGBTQ state policies: A lever for reducing SGM youth substance use and bullying. Drug and Alcohol Dependence. 2021;221:108659.

    Article  Google Scholar 

  35. Ioverno S, Bishop MD, Russell ST. Does a Decade of School Administrator Support for Educator Training on Students’ Sexual and Gender Identity Make a Difference for Students’ Victimization and Perceptions of School Climate? Prev Sci. 2022;23(1):108–18.

    Article  Google Scholar 

  36. Burton CM, Marshal MP, Chisolm DJ. School absenteeism and mental health among sexual minority youth and heterosexual youth. J Sch Psychol. 2014;52(1):37–47.

    Article  Google Scholar 

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The authors would like to acknowledge the U.S. Centers for Disease Control and Prevention for publishing the data of the Youth Risk Behavior Survey and all students who participated in the project.


This research was supported by Sanming Project of Medicine in Shenzhen (SZSM201612036).

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ZD and SQ conceptualized and designed the study, interpreted the results, and revised the manuscript critically. LQ made a substantial contribution to the conception, designed the analysis plan, and drafted the manuscript. LR performed the literature review and revised the manuscript critically. LX and LZ assisted with the analysis and revised the manuscript for important intellectual content. All authors reviewed and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

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Correspondence to Qiru Su or Dongpeng Zheng.

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The study was carried out in accordance with all ethical guidelines. No ethical approval was required because all data were de-identified and publicly available.

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Lian, Q., Li, R., Liu, Z. et al. Associations of nonconforming gender expression and gender identity with bullying victimization: an analysis of the 2017 youth risk behavior survey. BMC Public Health 22, 650 (2022).

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  • Gender nonconformity
  • Transgender identity
  • Bullying victimization