In Reply Thank you for the opportunity to respond to the Letter to the Editor regarding our article, “Nonconforming Gender Expression and Associated Mental Distress and Substance Use Among High School Students.”1 We would like to address, in turn, each of the 3 issues raised in that letter.
Our findings are based on data collected from high school students attending large urban school districts. As such, it is appropriate to consider the extent to which our findings “could be applied to or perhaps amplified in adolescents living in rural communities.” Research on LGBT youths indicates that those in rural communities face more hostile school climates than those in urban areas,2 and environmental stressors are known to affect substance use and mental health.3 Although the patterns observed in our analysis are independent of sexual identity, often bullying/harassment directed toward adolescents for sexual orientation and gender identity/expression overlap.4 Against this backdrop it stands to reason that the association between gender nonconformity (GNC) and mental distress/substance use may be amplified for rural youth; however, the scientific literature would benefit from direct examination of these associations in rural areas.
Lowry R, Johns MM, Robin LE. Nonconforming Gender Expression, Mental Distress, and Substance Abuse in Adolescents—Reply. JAMA Pediatr. 2019;173(4):400–401. doi:10.1001/jamapediatrics.2019.0018
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