One in 10 children is at increased risk of abuse as well as post-traumatic stress disorder in adulthood because they are gender nonconforming, according to a new study.
Much of that abuse -- emotional, physical and even sexual -- is at the hands of their parents or other adults in the home, according to a study published today online, which will appear in the March issue of the journal Pediatrics.
Researchers at Harvard School of Public Health (HSPH) and the Division of Adolescent and Young Adult Medicine at Children's Hospital in Boston analyzed questionnaires from nearly 9,000 young adults with an average age of 23.
The children had enrolled in the longitudinal Growing Up Today study in 1996 and were asked a decade later in 2007 to recall their childhood experiences, including favorite games and toys, roles they took in play, media characters they admired and feelings of femininity and masculinity.
As young adults, they were also asked about physical, sexual or emotional abuse they experienced and were screened for post-traumatic stress disorder .
Rates of PTSD were almost twice as high among young adults who were gender nonconforming in childhood than among those who were not, according to researchers.
"The message of this study is discrimination towards these kids is pretty severe and it takes place in the home as well as outside the home," said lead author Andrea Roberts, a research associate in the Department of Society, Human Development and Health at Harvard.
"And it can have lasting health effects on kids -- PTSD is a very serious illness -- It's bad news."
PTSD has also been linked to risky behavior such as engaging in unprotected sex and medical symptoms such as cardiovascular problems and chronic pain.
"There are stereotypes and society is pretty intolerant of gender nonconformity," Roberts said.
An estimated 1 in 10 children younger than 11 display some degree of gender nonconformity in their behavior, dress and play, according to this study.
Transgenderism, where a child's biological gender and identity do not match up, occurs in an estimated 1 in 1,000 children.
This was the first study to use a population-based sample to look at gender nonconformity as a risk factor for abuse. Most other studies of this kind have been of LGBT youth.
The study sample was not selected on the basis of sexual orientation and comprised primarily white students.
Most of the focus today is about bullying in school, but this study looked at the home environment, asking subjects openly about psychological and physical abuse by parents and other adults in the home.
"Sex abuse could be perpetrated by someone outside home, but it was much more common in kids who were nonconforming," she said. "Two reasons might be the case: Kids who don't receive positive attention don't get support and protection from their parents and are at greater risk outside the home.
"Also, sexual predators are known to target kids who are different -- like the deaf and disabled," she said. "They know the kids are not protected."
Researchers asked subjects questions such as, "Did your parents hate you?" or "Did they kick you?" or "Were you being yelled at or screamed at or berated?"
Roberts suggested that parents who are uncomfortable with a child's gender expression might try to change the behavior.
Although gender identity and sexual orientation are different, families often assume that their child will be gay and they can change them. "They become more hard in their parenting," Roberts said.
The Family Acceptance Project at San Francisco State University confirms in its research that parental behaviors have an effect on their children's health and mental outcomes. Positive family responses to gender nonconforming children were "protective factors" for those risks.
Harvard researchers rated subjects to determine the degree of gender nonconformity in childhood. Men in the 10th percentile reported a higher incidence of sexual and physical abuse before age 11 and psychological abuse from 11 to 17, compared with those below the median percentile.
Women in the top 10th percentile reported a higher prevalence of all forms of abuse as children.
Boys, as a group, tend to be more gender-conforming in general. "There's a narrow band," Roberts said. "Girls ranged a bit more."
Dr. Madeline Deutsch, director of the transgender health program at the Los Angeles Gay and Lesbian Center, said that "recall" studies are often flawed.
"We just don't know," she said. "We don't know if it's possible that people who had not been nagged by their father for being effeminate may have forgotten, that it may not have been burned into their memory."
But Deutsch said she is "not surprised at all" by its findings based on her work with transgender youth, and said more research is critical.
"It really bothers people on a basic level when behavior is discordant with gender," Deutsch said. "When you have a child, the first thing people ask is not whether the baby has brown hair or how much the baby weighs, or whether there are birth marks. But is it a boy or is it a girl?"
She said that acceptance at home is "central" to a child's development. And those who do not conform to their gender can struggle with parental issues well into their 20s.
"I see so much substance abuse and anxiety and duress that is clearly fueled by a lifelong direct refusal by parents to validate or accept their identity or gender expression," she said. "Or there are kids who know how their parents feel and bottle it up inside. The damage is already done, there is so much internalized phobia."
The Harvard study found that 85 percent of the participants who were gender nonconforming in childhood said they were heterosexual in adulthood.
"Our findings suggest that most of the intolerance toward gender nonconformity in children is targeted toward heterosexuals," Roberts said.
"We did find a strong relationship between nonconformity and sexual orientation," she said. "They were more likely to be LGBT."
Other studies have shown that children who are perceived as gay and bullied are at greater risk for physical violence and for depression and suicide.
Biased remarks and homophobia adversely affect students' educational outcomes and personal development at every grade level, according to a study by the Gay, Lesbian and Straight Educational Network (GLSEN) in its most recent report, "Playgrounds and Prejudice."
GLSEN research reveals that gender nonconforming students are less likely than other students to feel safe at school. They also are more likely than others to be called names, made fun of or bullied.
The Harvard study also emphasizes the need for elementary schools to do more to address issues of homophobia, gender expression and family diversity.
More research is needed to understand why gender nonconforming kids experience greater risk of abuse, and to develop interventions to prevent abuse, the researchers said.
They recommend that pediatricians and school health providers consider abuse screening for this vulnerable population.
Deutsch agrees that there should be secondary protections for gender nonconforming people in the schools and in the workplace, and institutions "at the top" should set the tone for nondiscriminatory policies.
But, she said, "They have finally started looking at places outside school, in the home."