We identify gender nonconformity as an important indicator of children at increased risk of sexual, physical, and psychological abuse and of lifetime probable PTSD in early adulthood, both among children who will be heterosexual and children who will have a minority sexual orientation. PTSD is associated with serious sequelae, including health risk behaviors, such as unprotected sex43
and involvement with interpersonal violence,44
and physical sequelae, including dysregulated immune function,45
cardiovascular risk indicators,46
and chronic pain.48
National surveys indicate that no more than half of people with PTSD seek treatment,49
therefore identifying individuals at increased risk for PTSD is crucial for prevention of PTSD sequelae.
Prior research describes possible pathways linking gender nonconformity to abuse. Some parents may be uncomfortable with gender nonconformity in their children,50,51
possibly increasing their likelihood of being abusive toward gender-nonconforming children. Parents may also see gender nonconformity as an indicator of same-sex sexual orientation or think others will assume their child will be gay or lesbian.50,52
If parents are uncomfortable with homosexuality, nonconformity may lead to the child being targeted for abuse. Some parents also believe their own parenting can shape their child’s gender nonconformity and future sexual orientation50,52
; thus, their parenting may become more physically or psychologically abusive in an attempt to discourage their child’s gender nonconformity or same-sex orientation. In terms of sexual abuse, children who appear to be different from typical children are at higher risk of being targeted. For example, children with physical disabilities and cognitive impairments are at increased risk of sexual abuse.53
Sexual predators may similarly target gender nonconforming children.
Our study cannot determine the causal relationship between abuse and gender nonconformity; in other words, the extent to which nonconformity is a risk factor for abuse versus an indicator of abuse. Three prior studies have found evidence for genetic influences on gender nonconformity,54–56
however, suggesting that nonconformity is at least in part determined by factors unrelated to social environment. An analysis of gender nonconformity and negative parent-child relationship in a twin sample found that a bidirectional relationship between negative parenting and nonconformity fit the data best.12
Thus, gender nonconformity may also be a response to negative parenting, and therefore may be both an indicator of abuse and a risk factor for abuse, although evidence in favor of either causal direction is limited.
We did not find an interaction effect between gender nonconformity and sex in risk of physical abuse, psychological abuse, or PTSD; however, gender nonconforming males versus females had elevated risk of sexual abuse compared, respectively, with gender conforming males and females. Prior research generally indicates gender nonconformity may be less socially accepted in boys than girls,9,51,57
with boys receiving more disapproval for gender nonconformity at a younger age from parents6
although studies also report mixed findings.58,59
Thus, prior research suggests gender nonconformity may have a stronger relationship to child maltreatment and its sequelae in boys versus girls; however, our results on the whole do not support this hypothesis.
Our findings should be considered in light of 3 limitations. First, we relied on retrospective reporting of childhood gender nonconformity and abuse, therefore recall error could bias estimates. A study comparing adulthood reporting of childhood nonconformity with independent ratings based on childhood home video recordings found good concordance, however.60
Second, persons willing to describe themselves as having gender nonconforming behaviors in childhood may also be more willing to report abuse victimization histories compared with persons not willing to describe themselves as gender nonconforming,61
which would inflate estimates of the association between nonconformity and abuse. Third, our sample was predominantly white (93%); thus, findings may not apply to other groups.
Our study has implications for pediatricians, teachers, and others who work with children. Childhood abuse is associated with a host of detrimental sequelae, including smoking,13
alcohol abuse, drug addiction,14
HIV risk behaviors,15
elevated BMI, hypertension,19
among others. Three of the 4 components of our measure of childhood nonconformity queried observable behaviors, suggesting that parents, teachers, and health care providers may be able to identify children at possible increased risk of abuse by observation. Identifying children at risk for abuse may facilitate prevention measures, intervention to stop abuse if needed, or treatment following abuse. Further research to understand how gender nonconformity might increase risk of abuse and to develop family interventions to reduce abuse risk is needed.