The Prevalence of Gender-Diverse Youth in a Rural Appalachian Region

Gender-diverse youth (GDY) are those whose gender identity and sex assigned at birth do not align. This group has demonstrated health disparities, including increased depression and suicidality compared with non-GDY.¹ The prevalence of this population is largely unknown, especially in rural areas like the Appalachian region, where youth already face long-standing health inequities.² A prior study³ exploring the prevalence of gender diversity among youth in the Appalachian state of West Virginia estimated that roughly 1% identified as transgender but did not collect data from youth themselves. In 2017, the Youth Risk Behavior Survey (YRBS) asked a nationally representative sample of youth if they identified as transgender, and found that 1.8% of US high school students responded affirmatively.¹ Many GDY do not identify with the word transgender, potentially underestimating the true prevalence of gender diversity.⁴ Recently, a more inclusive 2-step question was included in the Pittsburgh YRBS and found that 9.2% of youth reported an incongruence between their gender identity and sex assigned at birth.⁴ The current study sought to assess the prevalence of GDY in a rural region in Appalachia.

After passive parental consent, youth in grades 7 through 12 in 16 Appalachian public schools were anonymously surveyed online during school hours through the Integrated Community Engagement Collaborative prevention effort (response rate, 71.4%). West Virginia University institutional review board approval is on file. A 2-step question⁴ assessing gender identity and sex assigned at birth was included in this survey. Youth who selected a gender-diverse identity (eg, trans girl, nonbinary, etc) and those with incongruence between gender identity and sex assigned at birth (eg, assigned male, girl for gender identity) were considered GDY. The GDY were sorted into groups based on gender identity being binary (trans girl, trans boy, girl, or boy), nonbinary (nonbinary, genderqueer, agender, or two-spirit), or both. Youth provided demographic information including race, ethnicity, and age. Analysis was performed using SPSS 28.0. Results reported per American Association for Public Opinion Research guidelines.

A total of 2921 youth completed the survey and 2822 participants (96.6%) answered both the gender identity and sex assigned at birth questions (65.8% of participants were assigned female at birth and 34.2% of participants were assigned male at birth) leading to inclusion in this analysis. Among this sample, 202 participants (7.2%) were gender diverse. Of the GDY, 46 participants (22.8%) expressed an exclusively binary identity and 128 participants (63.3%) expressed an exclusively nonbinary identity. The remaining 28 participants (13.9%) expressed both binary and nonbinary identities. By age group, the prevalence of GDY was fairly consistent, ranging from 5.7% (17-18 years old) to 7.7% (12-14 years old) (Table 1). Prevalence of GDY by race and ethnicity ranged from 4.8% to 25.7% (Table 2).

This survey assessed prevalence of GDY in a rural region of the US. While less than the estimated 10% in Pittsburgh,⁴ we found a 4-fold increase in prevalence of gender diversity in our sample compared with the 2017 YRBS survey.¹ We posit this is partly due to the use of a more inclusive gender identity question. The findings that more GDY had nonbinary than binary identities and over 7% of 13- to 14-year-olds expressed a gender-diverse identity were noteworthy, as nonbinary GDY have been presumed to be less prevalent than binary GDY and prior studies have focused exclusively on older teens.¹

There are few resources available for GDY and their families in rural Appalachia, especially for racial and ethnic minority Appalachians who are often further marginalized through invisibility and assumed racial homogeneity.^5,6 This is notable given the higher prevalence of gender diversity found among youth from racial and ethnic minority groups and prior research suggesting that intersecting minority identities compound health disparities.⁶

Future studies are needed to determine if this prevalence of GDY, and higher-than-expected rates of nonbinary youth and GDY from racial and ethnic minority groups, is consistent in other regions. Organizations conducting national surveys of youth populations may also consider adding the more inclusive 2-step gender identity question in order to better understand the prevalence of GDY.

Accepted for Publication: May 25, 2022.

Published Online: August 8, 2022. doi:10.1001/jamapediatrics.2022.2768

Corresponding Author: Kacie M. Kidd, MD, MS, Department of Pediatrics, West Virginia University School of Medicine, PO Box 9214, Morgantown, WV 26506 (kacie.kidd@hsc.wvu.edu).

Author Contributions: Dr Kristjansson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kidd.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Kidd, Mann, Benton.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kidd, Sequeira, Smith, Kristjansson.

Obtained funding: Mann, Smith, Kristjansson.

Administrative, technical, or material support: Mann, Smith, Benton.

Supervision: Kristjansson.

Conflict of Interest Disclosures: Dr Sequeira reported grants from Agency for Healthcare Research and Quality (5K12HS026393-03) during the conduct of the study. Dr Kristjansson reported grants from Centers for Disease Control and Prevention (U48DP006391) during the conduct of the study. No other disclosures were reported

Funding/Support: This study was funded by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health (R01 AA0272).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.