A year into our relationship, my boyfriend confided in me about his desire to wear clothes traditionally associated with women, such as a dress. After trying it out, he looked at me with visible anxiety, fearing that I might stop liking him because his behaviour didn’t align with conventional notions of masculinity. The fear lingered, and made me deeply reflect on the powerful influence of societal gender norms on mental health.
Just as my boyfriend felt anxious about displaying gender non-conformity, research has shown that people who view themselves as gender non-conforming have worse psychological adjustment and lower levels of mental health than their peers do (Egan & Perry, 2001; Perry et al., 2019). Those who have different gender expression not in harmony with accepted societal norms may always experience some sort of conflict within, thus putting them at greater risk for mental health disorders (Menon & Hannah-Fisher, 2019). Conversely, those who perceive themselves as gender conforming are more likely to feel socially integrated, enjoy a stronger sense of belonging, and demonstrate better mental health outcomes (DiDonato & Berenbaum, 2013; Egan & Perry, 2001; Loso et al., 2023). This evidence suggests that conformity to gender norms may act as a buffer, while non-conformity can trigger internal and external distress.
Building on the literature that has explored various possible explanations for the association between gender nonconformity and psychopathology, Yin Xu and her colleagues examined the associations between gender nonconformity and common mental health outcomes. To do so, they conducted an extensive meta-analysis that synthesizes existing research findings.
Gender non-conformity is consistently linked with lower mental well-being, largely due to social and internalised conflict.
Methods
This review and meta-analysis tested the suggested association between gender non-conformity and common mental health problems. Researchers searched four academic databases using a comprehensive string of keywords related to gender nonconformity and mental health conditions. These would include a set of inclusion criteria for studies that would be included in the analysis: being peer-reviewed, not specifically samples of transgender and gender-diverse populations alone, and having data on the variable of interest adequate to estimate effect sizes.
Studies were coded by variables such as data collection method (cross-sectional or longitudinal) and sampling type (probability vs. non-probability). During the meta-analysis, researchers accounted for heterogeneity across studies and calculated pooled effect sizes using random-effects models. Statistical measures, including t-values, F-values, and Cohen’s d, were converted into correlation coefficients (r), and Fisher’s transformation was applied to aggregate effect sizes.
Results
This study analysed the association between gender non-conformity and mental health outcomes by highlighting a few disturbing trends. Findings showed clear, albeit modest, associations between greater gender non-conformity and poorer mental health indicators. In fact, the findings demonstrated that individuals who do not act according to the traditional gender role are more vulnerable to having mental health problems. In particular:
- Generalised anxiety and depression: Symptoms slightly increased with higher levels of gender non-conformity. The numbers may be small (r = 0.06 for anxiety and r = 0.11 for depression), but they reflect a clear trend, with being different from the majority promoting feelings of worry, sadness, and hopelessness.
- Self-esteem: Gender non-conformity was related to lower self-esteem (r = -0.18), which means poor self-acceptance or confidence in one’s self, possibly due to pressures from society to be different.
- Self-harm and suicide attempts: The same study found that gender non-conforming individuals had higher risks related to self-harm (r = 0.17) and suicide attempts (r = 0.14). These findings underpin the psychological burden of living in a society that does not respect all forms of gender expression.
The study also investigated potential moderators for these associations and found significant differences in terms of gender, age, sampling, and designs:
- Gender: Stronger associations were found for men who were gender nonconforming with anxiety, depression, and low self-esteem compared with women. This may implicate that the demands of traditional masculinity place additional stressors on men.
- Age: Adolescents showed stronger associations between gender non-conformity and depressive symptoms than children. This is often a very socially pressurising stage in life, which could elevate the effects of gender nonconformity.
- Sampling methods and measurements: Stronger effects were found in non-probability samples, suggesting that the research contexts themselves can either artificially inflate or deflate the effect sizes that would be observed in the real world. Moreover, observable behaviour-based measures of gender non-conformity showed stronger correlations with mental health than self-reported traits.
Interestingly, broader societal factors, such as a country’s gender inequality index, had little bearing on these relationships. Similarly, sexual orientation also proved not to play a moderating role in these associations.
Greater gender non-conformity consistently correlated with increased emotional distress, lower self-worth, and self-harming behaviours.
Conclusions
The findings paint a discouraging picture: higher levels of gender non-conformity are associated with increased anxiety and depressive symptoms, lower self-esteem, as well as a greater risk related to self-harm and attempts to take their lives. Men seem to experience a heavier psychological toll; likely due to harsher societal penalties for violating traditional masculinity (Egan & Perry, 2001; Vandello & Bosson, 2013). Adolescents also face heightened challenges, with stronger links between gender non-conformity and depressive symptoms compared to children, reflecting the high pressures of this developmental stage (Jackson et al., 2021).
In addition to this, the authors found that behavior-based measures of gender nonconformity have stronger associations with mental health outcomes than traits-based measures, emphasising how visible non-conformity can attract more social stigma and psychological distress (Hu et al., 2024).
Visible gender non-conformity, especially among men and adolescents, is strongly tied to emotional distress due to societal expectations.
Strengths and limitations
This meta-analysis makes a significant contribution to understanding the relationship between gender non-conformity and mental health. It provides robust evidence of the links between gender nonconformity and various mental health outcomes. The authors themselves describe it as “the most exhaustive meta-analysis of the association between gender nonconformity and common mental health outcomes to date.” Additionally, the study provides insight into the nuanced effects of key moderating factors like gender, age, and measurement types on these associations.
However, the research has its limitations. While the authors attempt to explain the high variability across studies by analysing specific moderating factors such as gender, age, and measurement types, they can only account for a small portion of the differences. Other influential factors, such as culture, race, and socioeconomic status, remain underexplored and warrant further investigation.
Most of the studies included in the meta-analysis are based in Western countries (e.g., the US and Western Europe). This Western-centric sample reduces the generalisability of the findings, as they may not accurately reflect experiences in regions like Asia or Africa. Thus, the conclusion regarding the Gender Inequality Index may be incomplete and culturally narrow.
Finally, the study’s framework largely treats gender as a binary concept, focusing on men and women. In contemporary contexts, gender identity is increasingly recognised as a spectrum. Non-binary individuals, who face unique identity-based stigma, are underrepresented in this research.
While methodologically strong, the study’s binary gender lens and Western focus limit its cultural inclusiveness and broader relevance.
Implications for practice
While the study differentiates between behaviour-based and trait-based measures of gender nonconformity, its binary conceptualisation of gender overlooks the experiences of nonbinary and gender-fluid individuals. Future research should adopt a more inclusive approach, reflecting the full spectrum of gender identities to ensure findings resonate with contemporary realities.
Additionally, extending this research to a setting other than a Western country, where general cultural expectations and pressures are very strongly different, would enhance the global relevance of interventions for gender-nonconforming individuals. From my personal experience living in both China and the UK, I’ve seen firsthand how deeply rooted Confucian values, collectivist ideals, and patriarchal structures in China intensify societal and communal pressures to conform to traditional gender norms. Unlike the relatively more inclusive environment in the UK, these cultural factors in China often heighten the psychological struggles of gender nonconformity while providing limited social support systems to address them. This cross-cultural contrast underscores the need for culturally adaptive mental health interventions.
In terms of policymaking, research has shown that reducing stigma through laws, policies, and societal attitudes toward sexual and gender minorities can lower victimisation risks for these groups (Bränström, Fellman, & Pachankis, 2023). Governments should prioritise inclusive laws and gender-affirmative care to protect mental health.
For mental health practitioners, these findings underscore the importance of providing tailored support, particularly for high-risk groups such as adolescents and men. These populations may be more resistant to traditional mental health services or hesitant to seek help independently. Offering informal, stigma-free environments could be essential to reaching and supporting them effectively.
Final reflections
Reflecting on my own experience, I recall my boyfriend’s fear and anxiety when he revealed his desire to wear skirts; a choice that defied conventional masculine norms. He worried this might alter how I saw him. However, I chose to support him in exploring his authentic self. That choice deepened our bond and showed me how critical acceptance is in alleviating the mental weight of nonconformity. People should feel safe to express their true selves without fear of shame or rejection. By validating and amplifying these lived experiences, we take a vital step toward a more empathetic, inclusive society.
Inclusive policies and culturally sensitive, gender-affirmative care are critical to addressing the mental health disparities faced by gender-nonconforming individuals.
King’s MSc in Mental Health Studies
This blog has been written by a student on the Mental Health Studies MSc at King’s College London. A full list of blogs by King’s MSc students from can be found here, and you can follow the Mental Health Studies MSc team on Twitter.
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Links
Primary paper
Xu, Y., Feng, J., & Rahman, Q. (2024). Gender nonconformity and common mental health problems: A meta-analysis. Clinical Psychology Review, 114, 102500.https://doi.org/10.1016/j.cpr.2024.102500
Other references
Bränström, R., Fellman, D., & Pachankis, J. (2023). Structural stigma and sexual minority victimization across 28 countries: The moderating role of gender, gender nonconformity, and socioeconomic status.Journal of Interpersonal Violence, 38(3–4), 3563–3585.
DiDonato, M. D., & Berenbaum, S. A. (2013). Predictors and consequences of gender typicality: The mediating role of communality. Archives of Sexual Behavior, 42(3), 429–436.
Egan, S. K., & Perry, D. G. (2001). Gender identity: A multidimensional analysis with implications for psychosocial adjustment. Developmental Psychology, 37(4), 451–463.
Hu, T., Jin, F., & Deng, H. (2024). Association between gender nonconformity and victimization: A meta-analysis. Current Psychology, 43(1), 281–299.
Jackson, E. F., Bussey, K., & Myers, E. (2021). Encouraging gender conformity or sanctioning nonconformity? Felt pressure from parents, peers, and the self. Journal of Youth and Adolescence, 50(4), 613–627.
Loso, H. M., Locke Dube, S., Chaarani, B., Ivanova, M., Garavan, H., Johns, M. M., & Potter, A. S. (2023). Associations between gender nonconformity, school environments, family conflict, and emotional and behavioral health among children ages 10–11. The Journal of Adolescent Health, 72(6), 869–876.
Menon, M., & Hannah-Fisher, K. (2019). Felt gender typicality and psychosocial adjustment in Indian early adolescents. International Journal of Behavioral Development, 43(4), 334–341.
Perry, D. G., Pauletti, R. E., & Cooper, P. J. (2019). Gender identity in childhood: A review of the literature. International Journal of Behavioral Development, 43(4), 289–304.
Thoma, B. C., Eckstrand, K. L., Montano, G. T., Rezeppa, T. L., & Marshal, M. P. (2021). Gender nonconformity and minority stress among lesbian, gay, and bisexual individuals: A meta-analytic review.Perspectives on Psychological Science, 16(6), 1165–1183.
Vandello, J. A., & Bosson, J. K. (2013). Hard won and easily lost: A review and synthesis of theory and research on precarious manhood. Psychology of Men & Masculinity, 14(2), 101–113.
