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.
Nathan M. Nonconforming Gender Expression, Mental Distress, and Substance Abuse in Adolescents. JAMA Pediatr. 2019;173(4):399–400. doi:10.1001/jamapediatrics.2019.0012
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