A Call to Analyze Sex, Gender, and Sexual Orientation in Psychopathology Research: An Illustration with ADHD and Internalizing Symptoms in Emerging Adults

Abstract

We have historically ignored sex/gender and conducted sex- and gender-neutral psychopathology research. There is a clear need to analyze potential differences and similarities between individuals with various sexes, genders, and sexual orientations in psychopathology research. Specifically, we need to stop ignoring sex, gender, and sexual orientation, conduct analyses that go beyond the binary, and analyze these important variables for generalizability even when the primary research question is not about sex, gender, and sexual orientation. In the current study we examined ADHD and internalizing symptoms in a community sample to compare different ways to analyze data and better understand differences and similarities across groups. We predicted that a richer understanding of sex/gender differences would emerge when we compared sex and gender minority (SGM) participants to cisgender heterosexual women (CHW) and men (CHM) rather than conducting binary analyses. Emerging adults (N = 2,938; ages 18–29 years) completed an online survey, responding to demographic items, as well as ADHD and internalizing symptoms. Binary analyses using biological sex and gender identity yielded no differences in ADHD symptoms, and the expected female preponderance in internalizing symptoms. However, when analyzed across three groups, individuals in the SGM group reported higher levels of ADHD and internalizing symptoms compared with the other two groups. Notably, no differences emerged for internalizing symptoms across CHW and CHM when the SGM group was included. This is compelling evidence that analyzing sex, gender, and sexual orientation more systematically and precisely in psychopathology research is warranted.

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Vol.:(0123456789)
Journal of Psychopathology and Behavioral Assessment (2025) 47:18
https://doi.org/10.1007/s10862-024-10188-3
A Call toAnalyze Sex, Gender, andSexual Orientation
inPsychopathology Research: AnIllustration withADHD
andInternalizing Symptoms inEmerging Adults
CynthiaM.Hartung1 · ElizabethK.Leer2 · TamaraM.Abu‑Ramadan3 · AnneE.Stevens1 ·
JudahW.Serrano4 · EmilyA.Miller1 · ChristopherR.Shelton5
Accepted: 21 October 2024
© The Author(s) 2025
Abstract
We have historically ignored sex/gender and conducted sex- and gender-neutral psychopathology research. There is a clear
need to analyze potential differences and similarities between individuals with various sexes, genders, and sexual orientations
in psychopathology research. Specifically, we need to stop ignoring sex, gender, and sexual orientation, conduct analyses
that go beyond the binary, and analyze these important variables for generalizability even when the primary research ques-
tion is not about sex, gender, and sexual orientation. In the current study we examined ADHD and internalizing symptoms
in a community sample to compare different ways to analyze data and better understand differences and similarities across
groups. We predicted that a richer understanding of sex/gender differences would emerge when we compared sex and gen-
der minority (SGM) participants to cisgender heterosexual women (CHW) and men (CHM) rather than conducting binary
analyses. Emerging adults (N = 2,938; ages 18–29years) completed an online survey, responding to demographic items, as
well as ADHD and internalizing symptoms. Binary analyses using biological sex and gender identity yielded no differences
in ADHD symptoms, and the expected female preponderance in internalizing symptoms. However, when analyzed across
three groups, individuals in the SGM group reported higher levels of ADHD and internalizing symptoms compared with
the other two groups. Notably, no differences emerged for internalizing symptoms across CHW and CHM when the SGM
group was included. This is compelling evidence that analyzing sex, gender, and sexual orientation more systematically and
precisely in psychopathology research is warranted.
Keywords Sexual and gender minorities· ADHD· Depression· Anxiety· Emerging adults
Historically, psychopathology researchers have given
short shrift to understanding differences (and similari-
ties) between men’s and women’s experiences of mental
illness (Hartung & Widiger, 1998; Hartung & Lelfer 2019;
Howard etal., 2017). Hartung and Lefler (2019) argued
that studies of mental illness have suffered from a type of
sampling bias: the tendency to select samples composed
of only those most prototypical of a disorder (e.g., studies
of only boys with autism), leading to diagnostic criteria/
symptoms, theories of etiology, and treatment strategies
that may only pertain to one group or may be more rel-
evant for one group. There has also been a tendency to
conflate sex and gender terms in research studies (Har-
tung & Lefler, 2019; Howard etal., 2017), leading to: (a)
unclear conclusions about how biological/genetic and/or
societal/environmental roles contribute to the develop-
ment of mental illness and differential sex/gender preva-
lence rates; and (b) unclear treatment recommendations
for diverse individuals, among other concerns. When
researchers do include both men and women or boys and
girls (which they are doing at increasing rates), data ana-
lytic bias remains (i.e., a bias toward not running analyses
* Cynthia M. Hartung
chartung@uwyo.edu
1 University ofWyoming, Laramie, WY, USA
2 University ofOregon, Portland, OR, USA
3 Children’s National Hospital, Washington,DC, USA
4 University ofDenver, Denver, CO, USA
5 Pennsylvania State University, The Behrend College, Erie,
PA, USA
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Journal of Psychopathology and Behavioral Assessment (2025) 47:18 18 Page 2 of 10
to compare sex or gender groups; Hartung & Lefler, 2019).
Furthermore, when sex/gender are considered in psycho-
pathology research, which is not often, a binary approach
is almost always used. When the binary approach is used,
sex/gender are often conflated, as mentioned earlier, and
this approach systematically ignores the experiences of
sexual and gender minorities (SGM1; i.e., lesbian, gay,
bisexual, transgender, queer [LGBTQ +]; National Insti-
tutes of Health [NIH], 2024).
For example, Hartung and Lefler (2019) reviewed all
studies published in the Journal of Abnormal Psychol-
ogy (now the Journal of Psychopathology and Clinical
Science) from 2010 to 2017 and found that while 80%
of studies included both males and females, only 41.7%
of those study authors conducted analyses to deter-
mine whether their findings generalized to both binary
sex groups (i.e., analyzed sex/gender as an independ-
ent, moderator, or mediator variable) whereas 44.4% of
authors ignored sex/gender in the preliminary and pri-
mary analysis, and 13.8% of authors included sex/gender
as a covariate which ignores sex/gender rather than help-
ing us determine whether our findings apply to both men
and women. This is not even to mention the erasure of
non-binary, transgender, intersex, and queer people from
psychopathology research entirely. Very few studies, with
the exception of those directly studying LGBTQ + expe-
riences, analyze results with these groups in mind, let
alone list rates of these identities in their participants'
sections. The problem is far-reaching; when we fail to
understand psychopathology in girls/women, boys/men,
and individuals with diverse sexual and gender identities,
we will fail to accurately and appropriately diagnose and
treat them.
It is clear that we need to stop ignoring sex/gender in
psychopathology research. However, possible approaches
to analyzing sex, gender, and sexual orientation (S/G/
SO) have not been extensively explored. Thus, in the cur-
rent paper we use attention-deficit/hyperactivity disorder
(ADHD) and internalizing symptoms to call attention to
this problem and explore analytic options for researchers
to better capture potential S/G/SO differences (and simi-
larities) in their studies. Prior to describing our current
study in more detail, we briefly discuss what we know
about S/G/SO differences and similarities in ADHD and
internalizing symptoms.
Sex, Gender, andSexual Orientation
inADHD andInternalizing Symptoms
Both ADHD and internalizing symptoms (i.e., depression
and anxiety symptoms) have long-established sex/gender
differences. Per the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition, Text-Revision (DSM-5-TR;
American Psychiatric Association [APA], 2022), ADHD
shows a male preponderance for adults of 1.6:1, major
depressive disorder (MDD) shows a female preponder-
ance of 1.5:1 to 3:1, generalized anxiety disorder (GAD) a
female preponderance of 2:1, and panic disorder a female
preponderance of 2:1. These numbers are supported by vari-
ous worldwide meta-analyses and large-scale studies of sex/
gender differences in these common disorders. For example,
Salk etal. (2017) conducted a worldwide meta-analysis of
95 studies which confirmed that women self-reported higher
levels of depression symptoms than men. This sex/gender
difference was shown to peak in adolescence, decline in
emerging adulthood, and remain relatively stable through-
out adulthood. Next, Willcutt (2012) conducted a worldwide
meta-analysis that included 96 studies. This analysis con-
cluded that the ratio of ADHD in adults was 1.6M:1F. More
recently, a review by Hinshaw etal. (2022) suggested that
the rates of ADHD in adults might be less discrepant and
approaching a 1:1 ratio. Finally, in a study of over 20,000
participants (i.e., Collaborative Psychiatric Epidemiology
Study [CPES]) McLean etal. (2011) concluded that the life-
time female:male prevalence ratio of any anxiety disorder to
be 1.7F:1M, and found that women reported higher illness
burdens than men. This suggests that women outnumber
men in anxiety diagnoses, and may also be more impaired
by their anxiety. In all, these studies tell us that ADHD
and several common internalizing disorders have well-
documented sex/gender differences. While this amount of
empirical data on sex/gender differences in prevalence rates
is heartening, it is nonetheless limited. Indeed, these studies
may have conflated and/or poorly operationalized sex and
gender on their demographics forms, few studies account
for LGBTQ + experiences, and it is still not the norm for
research teams to include any analyses that consider sex,
gender, or sexual orientation.
Data on SGM mental health has focused on internalizing
symptoms, substance use, and suicide risk (e.g., Marshal
etal., 2011). For example, in a meta-analysis of depres-
sion and anxiety, Ross etal. (2018) found that heterosexual/
straight-identified individuals had the lowest rates of depres-
sion/anxiety, LGB-identified people had higher rates, and
bisexual participants reported similar or even higher rates
than lesbian and gay participants. Moreover, Borgogna
etal. (2019) found that trans and gender non-conforming
(TGNC) college students had higher rates of depression and
1 For this paper, we will use both the terms SGM (NIH Sexual &
Gender Minority Research Office, 2024) and LGBTQ+to refer to
people who identify as lesbian, gay, bisexual, asexual, transgender,
Two-Spirit, queer, and/or intersex, etc. We recognize that language is
constantly evolving, and we strive to use accurate, appropriate, and
affirming terminology.
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Journal of Psychopathology and Behavioral Assessment (2025) 47:18 Page 3 of 10 18
anxiety than cisgender participants. The authors also noted
that those in emerging identity categories (e.g., demisexual,
asexual, TGNC) reported the highest rates of depression and
anxiety. Less research has been conducted on the rates of
ADHD in SGM populations. In one study by Dawson etal.
(2017), transgender participants had higher rates of ADHD
(in addition to anxiety and depression) as compared to cis-
gender participants. Likewise, Strange etal. (2014) found
that children with an ADHD diagnosis were 6.64 times more
likely than controls to have their parents indicate some gen-
der variance on their behalf. While this area of research is
growing, there is still much to learn.
It is important to study SGM samples because of these
higher rates of disorders. Indeed, minority stress theory
states that individuals with a minoritized identity (or more
than one such identity) are subject to micro- and macro-
aggressions that result in stress, and confer additional risk
for mental health concerns (Meyer, 2003). This may also
lead to internalized homophobia and/or transphobia (Hen-
dricks & Testa, 2012; Herek etal., 1997) which can cause
people in the LGBTQ + community to harbor negative
beliefs about their own sexual or gender minority status,
which can in turn lead to additional risk for internalizing
problems (Newcomb & Mustanski, 2010). This population is
also important to understand because more and more people
are identifying in these ways (Lefler etal., 2023). In fact,
22.7% of emerging adults (in this case defined as ages 18 to
25years) reported an SGM identity as compared to 1.3% of
older adults (ages 65 to 84years; Lefler etal., 2023). Taken
together, there is a need for additional research on emerging
adult mental health, with an eye toward better understand-
ing S/G/SO.
The Current Study
There is a clear need for psychopathology research that
directly investigates potential differences and similarities
between individuals with various sexes, genders, and sexual
orientations. Progress has been made in recent decades in that
more and more studies include individuals from “both” binary
sex/gender categories. However, this is still limiting for sev-
eral reasons as outlined above. What is needed next is more
S/G/SO research, less focus on only the binary, and more stud-
ies that examine these important variables even when these
identities are not thecentral research question. To this end,
in the current study we examined ADHD and internalizing
symptoms in a community sample to illustrate the importance
of finding creative ways to analyze data and better understand
differences and similarities across groups. We chose to focus
on emerging adults given that this group is more likely to
endorse SGM identities than other groups of adults (Lefler
etal., 2023). Specifically, our research question was whether
established sex/gender differences would change if SGM par-
ticipants were removed from these binary groups and analyzed
separately. We predicted that a richer understanding of sex/
gender differences would emerge when we carefully examined
SGM participants and compared them to cisgender hetero-
sexual women (CHW) and men (CHM). In the current study,
we used a large emerging adult sample (2,900 +) to examine
this research question. We conducted analyses on broad inter-
nalizing symptoms, which might be more obviously elevated
for SGM participants, but also ADHD symptoms, which have
been under-studied in this population.
Method
Participants
Participants were 2,938 emerging adults who resided in the
United States and completed an online survey via Ama-
zon’s Mechanical Turk (MTurk; https:// www. mturk. com).
Participants ranged in age from 18 to 29years (M = 24.77,
SD = 3.03) and provided demographic information regarding
age, biological sex, gender identity, sexual orientation, race/
ethnicity, and highest level of education completed.
First, we describe participants in terms of their self-
reported biological sex, gender identity, and sexual orienta-
tion. For biological sex, participants endorsed the following:
female (n = 1,801; 61.3%), male (n = 1,078; 36.7%), intersex
(n = 54; 1.8%), not listed/missing (n = 5; 0.1%). Next, for
gender identity, participants endorsed the following: female/
woman (n = 1,706; 58.1%), male/man (n = 1,059; 36.0%),
non-binary/fluid queer/gender queer (n = 143; 4.9%), not
sure/exploring (n = 16; 0.5%), not listed/missing (n = 14;
0.5%). Finally, for sexual orientation, participants endorsed
the following: heterosexual/straight (n = 2,084; 70.9%), gay/
lesbian (n = 194; 6.6%), bisexual (n = 410; 14.0%), queer
(n = 48; 1.6%), pansexual (n = 90, 3.1%), asexual (n = 41,
1.4%), not sure/exploring (n = 56; 1.9%), not listed/missing
(n = 15; 0.5%).
Next, we describe participants in terms of race/eth-
nicity, level of education, and self-reported lifetime
diagnosis of ADHD, depression, or anxiety. For race/
ethnicity,participants responded in the following ways:
Asian/Asian American (n = 377; 12.8%), Black or Afri-
can American (n = 322; 11.0%), Latinx/Hispanic (n = 316;
10.8%), Native American/American Indian/Alaska Native/
Indigenous (n = 59; 2.0%), Middle Eastern/North African
(n = 28; 1.0%), Pacific Islander/Native Hawaiian (n = 12;
0.4%), White (n = 1,744; 54.4%), multiracial (n = 70;
2.4%), and not listed /missing (n = 10; 0.3%). For level of
education, participants endorsed the following: doctoral
degree (n = 46; 1.6%), master’s degree (n = 327; 11.1%),
bachelor's degree (n = 1,123; 38.2%), associate’s degree
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Journal of Psychopathology and Behavioral Assessment (2025) 47:18 18 Page 4 of 10
(n = 398; 13.5%), high school diploma or GED (n = 1021;
34.8%), less than high school or GED (n = 16; 0.5%), and
prefer not to answer, not listed, or missing (n = 7; 0.3%).
In terms of self-reported lifetime diagnosis (for our
variables of interest), our participants reported ADHD
(n = 552; 18.8%), depression (n = 1,016; 34.6%), and anxi-
ety (n = 1,286; 43.8%. Additionally, the sample as a whole
had an average of 18.03 (SD = 11.81) for ADHD severity
score, and an average of 24.33 (SD = 15.18) for internal-
izing total score (more on how these were calculated in
Measures below).
Measures
The Depression, Anxiety, and Stress Scale (DASS; Lovi-
bond & Lovibond, 1995) is a 21-item self-report measure
designed to assess symptoms of depression, anxiety, and
stress. Individuals reported the extent to which they expe-
rienced each symptom in the past week using a four-point
Likert scale (0 = Never to 3 = Almost Always). The DASS
produces a total score and three subscale scores. This
measure has been shown to have acceptable to excellent
reliability and validity (Antony etal., 1998) as evidenced
by strong convergent validity and the ability to distinguish
features of depression and anxiety. In the current study, we
used the total score ranging from 0 to 63as a measure of
overall internalizing symptoms, internal consistency was
excellent(α = 0.95).
The Diagnostic and Statistical Manual of Mental Dis-
orders-Fifth Edition (DSM-5) ADHD symptom checklist
is a self-report measure containing the 18 ADHD items
from the DSM-5 (American Psychiatric Association
[APA], 2013). This measure includes 9 inattention and
9 hyperactivity/impulsivity items. Participants indicated
whether they experienced each item on a 4-point Likert
scale (0 = Never or rarely to 3 = Very often) based on the
past six months. By virtue of this list of items being pulled
directly from the DSM-5, it is considered a valid measure-
ment of DSM-5-defined ADHD. For the current study, a
total severity score was calculated ranging from 0 to 54,
and internal consistency was excellent (α = 0.93).
Procedure
All study procedures were approved by the Institutional
Review Board at the first author’s university. Participation
in this study occurred through MTurk, an online crowd-
sourcing platform. Participants completed an online survey
created using the Qualtrics Research Suite. After providing
informed consent, participants completed the demographic
items, the DSM-5 ADHD Checklist, and the DASS-21. The
survey consisted of a total of 56 items, including two atten-
tion check items, and was took 3–5min to complete. When
a participant failed either attention check item (2.5%), their
participation was automatically discontinued. Participants
who completed the study were compensated with $0.20,
which is considered fair compensation for MTurk surveys
of this length (Moss etal., 2023).
Data Preparation & Analytic Plan
Prior to analysis, the dataset was screened for missing
data, duplicate participation, and for potential issues with
univariate normality and outliers. Data from participants
who had any data missing on the variables of interest was
deleted from the dataset. The final sample was N = 2,938.
For the current study, we compared levels of ADHD and
internalizing symptoms across two sex/gender groups and
three sex/gender/sexual orientation groups. We conducted
two, two-group analyses; one for biological sex and one for
gender identity. For our first two-group analysis, we com-
pared biological females (n = 1,801) to biological males
(n = 1,078; Table1), and for our second two-group analy-
sis we compared those who identified as woman/female
(n = 1,706) to those who identified as men/male (n = 1,059;
Table2). For the three-group approach, we compared cis-
gender heterosexual women (CHW; n = 1,168), cisgender
heterosexual men (CHM; n = 895), and a sexual and gender
minority (SGM; n = 869) group. The SGM group consisted
of individuals who endorsed: (a) intersex on the biological
sex item; (b) non-binary/fluid queer/gender/queer, not sure/
exploring, or not listed/missing on the gender identity item;
(c) gay/lesbian, bisexual, queer, pansexual, asexual, not sure/
exploring, or not listed/missing on the sexual orientation
Table 1 Two-Group Analysis:
Biological Sex
Notes. N = 2,879; ADHD range = 0–54; Internalizing range = 0–63; For Cohen’s d, 0.2 to 0.4 is a small, 0.5
to 0.7 is a medium, and >= 0.8 is a large effect. The sample size for this table is smaller than the full sam-
ple because only binary respondents were included
Females Males t p Cohen’s d
n = 1,801 n = 1,078 (1, 2877)
M SD M SD
ADHD dimension 18.04 11.94 17.66 11.49 0.84 .401 -.03 (-.04-.11)
Internalizing dimension 25.16 15.20 22.47 15.00 4.62 < .001 -.18 (.10-.25)
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Journal of Psychopathology and Behavioral Assessment (2025) 47:18 Page 5 of 10 18
item; (d) female on the biological sex item and male on the
gender identity item; or (e) male on the biological sex item
and female on the gender identity item. When three group
analyses were significant, we conducted pairwise post-hoc
Games-Howell analyses. This procedure was chosen because
the equal variance assumption was violated in some of these
analyses. Power analyses conducted using G-Power 3.1.9.7
(Faul etal., 2009) indicated that at least 64 participants per
group were needed to achieve adequate power (0.80) to
detect a medium effect (d = 0.50) with a standard signifi-
cance level (p = 0.05) using independent samples t-tests. For
one-way ANOVAs with three groups, at least 80 participants
per group were needed to achieve adequate power (0.80) to
detect a medium effect (f = 0.25) with a standard significance
level (p = 0.05). Thus, all of our analyses were adequately
poweredto detect medium effects.
Results
Two‑Group Analyses
Biological Sex We first conducted two independent samples
t-tests to examine potential differences by biological sex in
ADHD and internalizing symptoms based on self-report
(Table1). For ADHD symptoms, the mean for biological
females was 18.04 (SD = 11.94), and the mean for biologi-
cal males was 17.66 (SD = 11.49). This difference was not
statistically significant (t = 0.84, p = .401, d = 0.03). For
internalizing symptoms, the mean for biological females
was 25.16 (SD = 1.36), and the mean for biological males
was 22.47 (SD = 15.00). This difference was statistically sig-
nificant (t = 4.62, p < .001, d = 0.18) and approaching a small
effect with females reporting more internalizing symptoms
than males.
Gender Identity Next, we conducted two independent
samples t-tests to examine potential differences by gen-
der identity in ADHD and internalizing symptoms based
on self-report (Table2). For ADHD symptoms, the mean
for those who identified as women was 17.73 (SD = 11.89),
and the mean for those who identified as men was 17.66
(SD = 11.57). This difference was not statistically signifi-
cant (t = 0.16, p = .872, d = 0.01). For internalizing symp-
toms, the mean for those who identified as women was 24.57
(SD = 15.12) and those who identified as men was 22.44
(SD = 15.11). This difference was statistically significant
(t = 3.77, p < .001, d = 0.15) and approached a small effect,
with women reporting more internalizing symptoms than
men.
Three‑Group Analyses
We conducted two one-way univariate analyses of vari-
ance tests (i.e., 3 × 1 ANOVAs) to examine potential sex/
gender/sexual orientation differences in ADHD and inter-
nalizing symptoms (Table3). For ADHD symptoms, the
mean for CHW was 15.93 (SD = 11.61), the mean for CHM
was 16.72 (SD = 11.24), and the mean for SGM was 22.19
Table 2 Two-Group Analysis:
Gender Identity
Notes. N = 2,879; ADHD range = 0–54; Internalizing range = 0–63; For Cohen’s d, 0.2 to 0.4 is a small, 0.5
to 0.7 is a medium, and >= 0.8 is a large effect. The sample size for this table is smaller than the full sam-
ple because only binary respondents were included
Women Men t p Cohen’s d
n = 1,706 n = 1,059 (1, 2763)
M SD M SD
ADHD dimension 17.73 11.89 17.66 11.57 0.16 .872 -.01 (-.07-.08)
Internalizing dimension 24.67 15.12 22.44 15.11 3.77 < .001 -.15 (.07-.22)
Table 3 Three-Group Analysis:
Sex/Gender/Sexual Orientation
Notes. N = 2,932; CHM = cisgender heterosexual men; CHW = cisgender heterosexual women; SGM = sex-
ual and gender minority; ADHD range = 054; Internalizing range = 0–63; For partial eta squared, .01 to
.05 is a small, .06 to .13 is a medium, and > = .14 is a large effect. Intersex individuals are included in the
SGM group
CHW
n = 1,168
CHM
n = 895
SGM
n = 869
F
(2, 2929)
pPartial η2
M SD M SD M SD
ADHD dimension 15.93a11.61 16.72a11.24 22.19b11.59 82.33 < .001 .05 (.04-.07)
Internalizing dimension 22.20a14.81 21.15a14.87 30.50b14.18 110.60 < .001 .07 (.06-.09)
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Journal of Psychopathology and Behavioral Assessment (2025) 47:18 18 Page 6 of 10
(SD = 11.59). This difference was statistically significant
(F = 82.33, p < .001, partial η2 = 0.05) and corresponded
to a small effect. Post-hoc Games-Howell paired compari-
sons demonstrated that there was no significant difference
between CHW and CHM (p = .260); however, there were
significant differences between CHW and SGM (p < .001)
and between CHM and SGM (p < .001) such that the SGM
group reported higher ADHD symptoms.
For internalizing symptoms, the mean for CHW was 22.20
(SD = 14.81), the mean for CHM was 21.15 (SD = 14.87),
and the mean for SGM was 30.50 (SD = 14.18). This dif-
ference was statistically significant (F = 110.60, p < .001,
partial η2 = 0.07) and corresponded to a medium effect.
Post-hoc Games-Howell paired comparisons demonstrated
that there was no significant difference between CHW and
CHM (p = .247); however, there were significant differences
between CHW and SGM (p < .001) and between CHM and
SGM (p < .001) such that the SGM group reported higher
internalizing symptoms.
Exploratory Analyses: Four‑Group Analyses
Given that the SGM group reported much higher levels of
ADHD and internalizing symptoms than either of the cis-
gender heterosexual groups, we conducted additional explor-
atory analyses to examine subgroups of individuals within
the SGM group. For these four-group analyses, we com-
paredparticipants who identified as: (a) cisgender and heter-
osexual (men and women combined due to no significant dif-
ferences in previous analyses; n = 2,317), (b) cisgender and
gay/lesbian (n = 141), (c) cisgender and bisexual (n = 365),
and (d) TGNC and any sexual orientation (n = 115). There
were two reasons that we did not divide the TGNC group
into smaller groups based on sexual orientation. First, the
distinction between heterosexual and gay/lesbian is based on
a binary that does not apply to those who identify as non-
binary. Second, we conducted an additional power analysis
for one-way ANOVAs with four groups. We found that at
least 90 participants per group were needed to achieve ade-
quate power (0.80) to detect a medium effect (f = 0.25) with
a standard significance level (p = .05) Table4.
For these exploratory analyses, we again conducted
two one-way univariate analyses of variance tests (i.e.,
4 × 1 ANOVAs) to examine S/G/SO differences in ADHD
and internalizing symptoms. For ADHD symptoms, the
mean for the cisgender and heterosexual group was 16.88
(SD = 11.60), the mean for the cisgender and gay/lesbian
group was 21.92 (SD = 11.84), the mean for the cisgender
and bisexual group was 22.10 (SD = 11.67), and the mean for
the TGNC group was 23.48 (SD = 11.12). This ANOVA was
statistically significant (F = 36.28, p < .001, partial η2 = 0.04)
and corresponded to a small effect. Again, we conducted
post-hoc Games-Howell analyses; all three post-hoc paired
comparisons between the cisgender/heterosexual group and
each of the SGM groups were significant (ps < .001) such
that SGM participants reported higher levels of ADHD
symptoms than their cisgender/heterosexual peers. None
of the comparisons among the three SGM groups were
significant.
For internalizing symptoms, the mean for the cisgender
and heterosexual group was 22.75 (SD = 15.11), the mean for
the cisgender and gay/lesbian group was 28.00 (SD = 14.66),
the mean for the cisgender and bisexual group was 30.64
(SD = 14.23), and the mean for the TGNC group was 31.75
(SD = 11.74). This ANOVA was also statistically significant
(F = 43.15, p < .001, par tial η2 = 0.04) and corresponded to a
small effect. Again, all three post-hoc Games-Howell paired
comparisons between the cisgender/heterosexual group and
each of the SGM groups were significant (ps < .001) such
that SGM participants reported higher levels of internal-
izing symptoms than their cisgender/heterosexual peers.2
None of the comparisons among the three SGM groups were
significant.
Table 4 Four-Group Analysis: Sex/Gender/Sexual Orientation
Notes. TGNC = transgender or gender non-conforming; SO = sexual orientation; N = 2,938; ADHD range = 0–54; Internalizing range = 0–63; For
partial eta squared, .01 to .05 is a small, .06 to .13 is a medium, and > = .14 is a large effect
Cisgender +
Heterosexual
n = 2,317
Cisgender +
Gay/Lesbian
n = 141
Cisgender +
Bisexual
n = 365
TGNC
+ Any SO
n = 115
F
(3, 2934)
pPartial η2
M SD M SD M SD M SD
ADHD dimension 16.88a11.60 21.92b11.86 22.10b11.67 23.48b11.12 36.28 < .001 .04 (.02-.05)
Internalizing dimension 22.75a15.11 28.00b14.66 30.64b14.23 31.75b11.74 43.15 < .001 .04 (.03-.05)
2 We repeated all analyses (i.e., Tables 1-4) while controlling for
the other DV (i.e., controlled for INT in the ADHD analyses and
controlled for ADHD in the INT analyses). For INT symptoms,
the results always remained the same in terms of significance and
effect size. For ADHD, there were two instances where the ANOVA
became significant (i.e., both binary analyses) and two instances
where the results stayed the same. Thus, the females/women being
higher on ADHD is not a result of comorbid internalizing symptoms.
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Journal of Psychopathology and Behavioral Assessment (2025) 47:18 Page 7 of 10 18
Discussion
In psychopathology research, we have historically ignored
sex/gender and conducted sex- and gender-neutral research
(Hartung & Lefler, 2019; Howard etal., 2017; Lefler etal.,
2023). In most studies, we do not analyze sex, gender, or
sexual orientation. For studies in which sex/gender are
analyzed, a binary approach is almost always used (Hyde
etal., 2019; Keyes & Platt, 2023). The goal of the cur-
rent study was to compare several different approaches to
conducting psychopathology analyses with S/G/SO in an
emerging adult sample.
When two-group (i.e., binary) analyses were con-
ducted, with both sex and gender, there was no significant
between-group difference for ADHD symptoms. Although
ADHD has traditionally been shown to be more common
in boys and men, our results are consistent with more
recent studies suggesting that the sex ratio in adults is
closer to 1:1 (Hinshaw etal., 2022), and this is especially
true when examining symptom levels, rather than preva-
lence rates, in emerging adult and college samples (e.g.,
Fedele etal., 2012). Next, regarding the two-group analy-
ses for internalizing symptoms (with both binary sex and
gender identity analyses), females/women reported higher
levels than males/men. This finding is consistent with past
research suggesting that women are more likely to be diag-
nosed with depression and anxiety, and that they report
higher levels of depression symptoms (Keyes & Platt,
2023; McLean etal., 2011; Salk etal., 2017).
When three-group analyses were conducted, we found
that the SGM group reported significantly higher levels of
both ADHD and internalizing symptoms, and there was
no difference between cisgender-heterosexual (cis-hetero)
men and women. For both symptom dimensions, the SGM
group was significantly higher than both the CHW and
CHM with medium effects. Although research has dem-
onstrated that SGM individuals report higher levels of
anxiety and depression than their cis-hetero peers (Fish &
Pasley, 2015; Kattari etal., 2020; King, etal., 2008), there
has been very little research on ADHD in SGM individu-
als. For example, in a systematic review of neurodevel-
opmental disorders in individuals with gender dysphoria,
Thrower etal. (2020) found that autism spectrum disorders
occur more frequently in this group; however, they did not
find sufficient studies examining ADHD.
In the current study, the differences between the SGM
and cis-hetero groups appeared to be practically and
clinically significant. For example, the mean severity of
ADHD symptoms for the SGM group was 22.19, and the
means for the CHW and CHM groups were 15.93 and
16.72, respectively. These severity scores were based
on a 4-point Likert scale (0 = Never or rarely to 3 = Very
often). Clinically, a score of 2 (Often) or 3 (Very often) is
typically interpreted to mean that the symptom is present.
Thus, a mean of 22.19 would be consistent with endorsing
11 of 18 symptoms as occurring often or 7 of 18 symptoms
as occurring very often; whereas a mean of 15.93 would be
consistent with endorsing 8 of 18 symptoms as occurring
often or 5 of 18 symptoms as occurring very often. Thus,
individuals in the SGM group are endorsing 2 to 3 more
symptoms, on average, than members of either cis-hetero
group. Given that a diagnosis of ADHD requires 5 of 9
symptoms of inattention and/or 5 of 9 symptoms of hyper-
activity/impulsivity in adulthood, and diagnostic decisions
often come down to just a symptom or two, this difference
is clinically significant. Although our INT measure does
not lend itself to a symptom analysis, the magnitude of the
differences for ADHD and INT were similar. Specifically,
those in the SGM group reported 33–39% more ADHD
and 37–44% more INT than either cis-hetero group.
These findings for the SGM group are consistent with
minority stress theory, which would suggest that individuals
in the SGM group reported higher levels of ADHD and INT
symptoms because of the additional stress that they expe-
rience in our society as members of this group. Although
we expected this finding for INT, we were surprised at the
magnitude of the difference in a highly heritable, neurode-
velopmental disorder like ADHD (Brikell etal., 2015).
Additional analyses showed that our findings held for ADHD
when we controlled for INT and vice versa. Nonetheless,
future research (and clinical work) should examine, via clini-
cal interviews, whether our participants might be endors-
ing ADHD symptoms that would be better accounted for
by other factors (e.g., endorsing difficulty paying attention
as an ADHD symptom which may actually be due to anxi-
ety, depression, or stress; endorsing disorganization as an
ADHD symptom which may be caused by general cognitive
overload).
Another finding that was surprising was that there were
no sex/gender differences between CHW and CHM for
INT symptoms. Higher rates of anxiety and depression
diagnoses and symptoms in women is a well-established
finding (McLean etal., 2011; Salk etal., 2017). The differ-
ences between our two- and three-group findings for INT
suggest that three-group analyses are potentially impor-
tant. As expected, females/women reported higher levels
of INT symptoms than males/men when binary analyses
were conducted. However, in the three-group analyses, the
SGM group was statistically and meaningfully significantly
higher than either of the cis-hetero groups, and the differ-
ences that were previously attributed to binary sex/gender
disappeared. Given that a higher percentage of biological
females identify as SGM than biological males (Lefler
etal., 2023), it is possible that higher rates of INT in SGM
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Journal of Psychopathology and Behavioral Assessment (2025) 47:18 18 Page 8 of 10
have been misattributed to sex/gender. However, given that
identification with SGM status is increasing generationally,
with individuals in younger cohorts being much more likely
to identify as SGM than individuals in older cohorts, it is
unlikely that higher rates of INT in females/women would
have completely been accounted for by SGM historically.
This certainly warrants more research attention.
Given that our three-group analyses produced statistically
and clinically significantly higher endorsement of ADHD
and INT in the SGM group and that we had a large enough
sample, we conducted additional exploratory analyses with
four groups to determine whether there were any differ-
ences among more specific SGM identities. We found that
all three SGM groups (i.e., cisgender + gay/lesbian, cisgen-
der + bisexual, and TGNC) reported significantly higher lev-
els of ADHD and INT than their cis-hetero peers with small
to medium effects. Furthermore, there were no statistically
significant differences among the three SGM groups. Thus,
minority stress may be impacting gay/lesbian, bisexual, and
TGNC individuals at similar levels, though more research
is needed to confirm this, especially given the paucity of
research on and the anti-transgender laws that target TGNC
individuals.
Limitations andFuture Directions
As with any paper, the current study had limitations that
should be considered. First, it is important that researchers
consider not only S/G/SO more systematically but also vari-
ables related to race and ethnicity. It was beyond the scope
of this project for us to also address race and ethnicity, but
similar problems exist with this other set of demographic var-
iables (Eaton, 2019). That is, race and ethnicity are often con-
flated as are sex and gender, and researchers tend to ignore
these variables as they often do with sexual orientation (i.e.,
race/ethnicity are more often included in participants sections
to describe the sample than are sex/gender/sexual orienta-
tion; however, similar to the latter, they are rarely analyzed;
Eaton, 2019). In the current study, we focused on S/G/SO
and examined several approaches to analyzing these individ-
ual difference variables. Future research aimed at doing the
same for race and ethnicity variables is certainly warranted,
especially given the disparities in people of color accessing
mental health services (Lu etal., 2021).
Second, even in our attempts to analyze groups beyond
the binary (i.e., our three- and four-group analyses), we still
grouped participants together in ways that have limitations.
For example, in our three-group analyses, we grouped all
SGM individuals together in a way that might suggest that
they are a homogeneous group when they certainly are not.
Likewise, in our four-group analyses, we separated the SGM
individuals into three groups, but we still grouped all cis-gen-
der gay and lesbian participants and all TGNC participants
together. This might ignore important nuances, such as
whether transwomen have substantially different experiences
from transmen or how trans individuals who “pass” might be
impacted, both of which are certainly areas for further study.
While we maintain that these groupings are superior to ignor-
ing SGM participants and their experiences, we understand
that some nuance is lost. In the future, researchers should
over-select for specific SGM subpopulations.
Next, in the current study we focused on only two sets of
symptoms (i.e., ADHD and internalizing), used only online
self-report of these symptoms in a community sample, and
did not assess diagnosis. While we made these choices to
provide a simple demonstration of our point regarding S/G/
SO analyses with a large sample, we understand that these
are limitations. We are unable to comment on how this
would play out with evidence-based assessment of ADHD,
depression, and anxiety, and we recognize that self-report
of symptoms in a quick, online survey may be suspect. For
instance, a person in our sample may have endorsed symp-
toms such as frequent worry and poor concentration for a
myriad of reasons. Future researchers may want to test our
analytic approach in other ways.
Finally, we acknowledge that the terminology in this
area is quickly changing. While we attempted to use up-
to-date terms, we recognize that these may be out of date
in just a matter of months. For example, when we designed
the study we used “biological sex” as a category instead of
“sex assigned at birth.” In the intervening months we have
learned more and have updated our own language, and we
will continue to do so. We encourage researchers to carefully
consider the language in their demographics sections with
an emphasis on inclusion, and we point to several excellent
resources (Beischel etal., 2022; Broussard etal., 2018; Hyde
etal., 2019; Lowik etal., 2022).
Research Recommendations
We recommend that psychopathology researchers use
a three-group approach (i.e., including an SGM group)
when sample size allows. This may change conclusions
about binary sex differences, including those that are
well-established in the literature. The utility of analyzing
data with a separate SGM group has become even more
pertinent given that more individuals are identifying as
SGM in younger generations (Lefler etal., 2023). We also
recommend that researchers conduct preliminary analyses
with S/G/SO. These preliminary analyses, and possible
follow-up analyses, should be conducted even if there is
not a specific hypothesis related to S/G/SO. The goal is to
determine whether results generalize across S/G/SO and
to avoid sex- and gender-neutral research. When the pre-
liminary analyses show no differences by S/G/SO on study
variables, then no additional analyses are needed; however,
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Journal of Psychopathology and Behavioral Assessment (2025) 47:18 Page 9 of 10 18
researchers should note whether there was enough power
to rule out S/G/SO differences.
When the preliminary analyses show S/G/SO differ-
ences, then researchers should consider whether to: (a)
include S/G/SO as an independent, mediator, or moderator
variable in their primary analyses (covarying lacks eco-
logical validity and erases group identities) or (b) con-
duct exploratory analyses with S/G/SO. Finally, if S/G/
SO from primary or exploratory analyses are significant,
researchers should discuss these results using context from
previous findings in the literature which may not have been
reviewed in the introduction due to the lack of specific
hypotheses about S/G/SO. Finally, if S/G/SO analyses
demonstrate SGM differences, researchers should consider
analyses that divide this group into more specific groups
(e.g., sexual minorities, gender minorities) if they have a
large enough sample to do so.
Insufficient power to detect potential differences is an
important consideration, and may preclude three-group
analyses. Thus, when sample sizes are small, as is often
the case in clinical studies, we recommend: (a) describing
S/G/SO in the participants section, (b) conducting pre-
liminary analyses with biological sex and gender identity
for males/females and men/women, respectively, and (c)
mentioning the importance of examining the findings in
SGM group(s) as a limitation and future direction. If pre-
liminary analyses show sex or gender differences, then we
recommend the procedure described above.
Overall Conclusion
In the current study, we demonstrated the importance of
analyzing psychopathology data by sex, gender, and sexual
orientation. In a large community sample of emerging adults
who self-reported ADHD and internalizing symptoms, we
found increasing levels of complexity and nuance at each
level of data analysis. Specifically, our data had very little
nuance when we ignored sex and gender, more when we
analyzed using binary sex and gender groups, and even more
when we considered SGM status.In conclusion, the three-
group approach, although not ideal in terms of lumping sex-
ual and gender minorities, is superior to the traditional sex-
and gender-neutral and binary approaches. Furthermore, the
three-group approach may represent current best practice
given that: (a) few samples will have a large enough gender
minority group to separate from the sexual minority group
and (b) these preliminary results did not show differences
between sexual and gender minorities.
Funding Open access funding provided by the University of Wyoming
Libraries. The first author was supported by an Institutional Develop-
ment Award (IDeA) from the NationalInstitute of General Medical
Sciences (2P20GM103432).
Declarations
Conflict of Interest The authors have no relevant financial or non-fi-
nancial interests to disclose.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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