Socially assigned gender expression and health-related quality of life in a cohort of young adults

Background: Violating societal norms for masculine and feminine appearance and behavior puts one at heightened risk of harassment and discrimination, but the impact of these adverse experiences on health-related quality of life (HRQL) is unknown.

Purpose: To examine the relationship between gender expression and HRQL in a U.S. cohort.

Methods: Using data from the Growing Up Today Study (n=4,769), a prospective cohort of young adults, we assessed socially assigned gender expression with a self-report measure on how others perceive one’s appearance and mannerisms, from very feminine to very masculine.  A gender-specific continuous summary score was created (range: 1 [most conforming] to 7 [most nonconforming]). To assess HRQL, we used the EQ-5D, a population standardized instrument recommended in health economics (range: 0 [low] to 1 [high]). We used multivariable linear models, adjusted for age, race/ethnicity, and sexual orientation, to model the relationship between socially assigned gender expression and HRQL.

Results: Among women, mean HRQL ranged from 0.881 (SD=0.097) for those reporting greatest gender nonconformity to 0.927 (SD=0.090) for those reporting greatest conformity. Disparities were similar among men. In adjusted models, greater gender nonconformity was associated with a statistically significant decrement in HRQL for both women and men (women: β=-0.016, SE=0.002, p<0.001; men: β=-0.014, SE=0.004, p<0.001).

Discussion: This is the first study to document decrements in HRQL associated with socially assigned gender nonconformity and use a measure suitable for cost-effectiveness analysis. Our findings will inform future research on the degree to which these disparities may be explained by gender-related stigma and discrimination.