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Comment & Response
February 25, 2019

Nonconforming Gender Expression, Mental Distress, and Substance Abuse in Adolescents

Author Affiliations
  • 1Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, Connecticut
JAMA Pediatr. 2019;173(4):399-400. doi:10.1001/jamapediatrics.2019.0012

To the Editor I read with interest the article on mental distress and substance abuse in gender nonconforming (GNC) youths.1 I thank the authors for exploring this association and for highlighting the importance of inclusivity and gender diversity, particularly in adolescence.

The study was based on data collected from 3 large urban US school districts, 2 in California and 1 in Florida. Some studies have shown an indirect association between population density and depression rates in sexual minority groups.2 I ask the authors to what extent their findings, which are independent of sexual orientation, could be applied to or perhaps amplified in adolescents living in rural communities.

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