PLOS ONE

RESEARCH ARTICLE

Poorer subjective mental health among girls:

Artefact or real? Examining whether
interpretations of what shapes mental health
vary by sex
Susan P. Phillips1, Fiona Costello1, Naomi Gazendam1, Afshin Vafaei ID2*

1 Department of Family Medicine, Queen’s University, Kingston, ON, Canada, 2 School of Health Studies,
Western University, London, ON, Canada
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a1111111111 * avafaei2@uwo.ca
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Abstract

OPEN ACCESS
Citation: Phillips SP, Costello F, Gazendam N,
Vafaei A (2023) Poorer subjective mental health
among girls: Artefact or real? Examining whether
interpretations of what shapes mental health vary
by sex. PLoS ONE 18(12): e0295704. https://doi.
org/10.1371/journal.pone.0295704
Background
Despite reporting poorer self-rated mental health (SRMH) than boys, girls exhibit greater
resilience and academic achievement, and less risk taking or death by suicide. Might this
apparent paradox be an artefact arising from girls’ and boys’ different interpretations of the
meaning of SRMH? We examined whether the indicator, SRMH, had a different meaning for
girls and boys.

Editor: Soumitra Das, The Royal Melbourne

Hospital, AUSTRALIA
Methods
In 2021–2, we circulated social media invitations for youth age 13–18 to complete an online
Received: August 13, 2023
survey about their mental health, and which of 26 individual and social circumstances
Accepted: November 23, 2023
shaped that rating. All data were submitted anonymously with no link to IP addresses. After
Published: December 27, 2023 comparing weightings for each characteristic, factor analyses identified domains for the
Peer Review History: PLOS recognizes the whole group and for girls and boys.
benefits of transparency in the peer review
process; therefore, we enable the publication of
all of the content of peer review and author Results
responses alongside final, published articles. The
Poor SRMH was reported by 47% of 506 girls and 27.8% of 216 boys. In general, circum-
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0295704
stances considered important to this rating were similar for all, although boys focussed more
on sense of identity, self-confidence, physical well-being, exercise, foods eaten and screen
Copyright: © 2023 Phillips et al. This is an open
access article distributed under the terms of the
time, while girls paid more attention to having a boyfriend or girlfriend, comparisons with
Creative Commons Attribution License, which peers, and school performance. With factor analysis and common to boys and girls,
permits unrestricted use, distribution, and domains of resilience, behavior/community, family, relationships with peers and future vision
reproduction in any medium, provided the original
emerged. Girls’ poorer SRMH did not arise from a more expansive interpretation of mental
author and source are credited.
health. Instead, it may reflect perceived or real disadvantages in individual or social circum-
Data Availability Statement: Data will be available
stances. Alternatively, girls’ known greater resilience may propel lower SRMH which they
upon reasonable request to the corresponding
author. Requests can also be sent to Mary Martin, use intuitively to motivate future achievement and avoid the complacency of thinking that ‘all
Research Manager, Department of Family is well’.

PLOS ONE | https://doi.org/10.1371/journal.pone.0295704 December 27, 2023 1 / 14

PLOS ONE
Medicine, Centre for Studies in Primary Care,
Queen’s University at mary.martin@queensu.ca
who acts as the institutional representative for this
study.
Funding: Two authors (NG and FC) were supported
by a summer studentship from a CIHR grant.
(161787).
Competing interests: None of the authors declared
any competing interest.
Abbreviations: SRMH, self-rated mental health; QR
code, quick response code; CI, confidence interval;
KMO, the Kaiser–Meyer–Olkin measure for
sampling adequacy.
PLOS ONE | https://doi.org/10.1371/journal.pone.0295704 December 27, 2023
Subjective mental health in youth
Conclusions
The relative similarity of attributes considered before rating one’s mental health suggests
validity of this subjective measure among girls and boys.
Background
Are consistent poorer ratings of mental health among girls relative to boys trustworthy? These
ratings need to be juxtaposed with objective measures of girls’ greater academic achievement,
less risk-taking behavior, and lower suicide rates [1–4]. The paradox of girls’ apparent poorer
mental health alongside greater well-being is unexplained. We will explore whether the frame-
works, circumstances and characteristics considered when subjectively rating mental health
differ for girls and boys. If so, then SRMH could be measuring different constructs in each
group and would, as a result, differentially reflect actual mental health. This matters for several
reasons. If SRMH rests on girls’ and boys’ different interpretations of what constitutes good or
poor mental health, it will not be a homogeneous measure and thus will be invalid [1, 5]. Statis-
tical findings of a growing mental health crisis among youth, and especially girls are shaping
health and education policies (e.g. calls for more mental health professionals, return to school
plans post-pandemic, or ‘accommodations’ in higher education) [6–9]. If these interventions
respond to unreliable information they risk being misdirected and might actually undermine
rather than foster strengths and resilience.
Whether self or media reported, mental health of adolescents and particularly girls is
increasingly said to be poor and declining [7, 10]. Administrative data capturing clinical diag-
noses of anxiety and depression over two decades reveal a similar albeit weaker trend. In Can-
ada, from 1997–2017 the rate of physician diagnosed anxiety and depression among girls
exceeded that for boys, with small increments for all beginning in 2012 [11]. Subjective indica-
tors are more compelling. In numerous, high-income countries, girls consistently and increas-
ingly report greater anxiety, depression, stress, and psychological distress than do boys [12–
16].
Apparent poorer mental health among girls exists alongside their greater (relative to boys)
adaptability, resilience, academic achievement, self-control and less frequent risk-taking [17].
By resilience we mean positive adaptation in the face of adversity [18]. How might the inverse
relationship, seen in girls, between mental health and these indications of well-being be recon-
ciled? This is not a question that has been researched. In particular, there has been no consid-
eration of whether this paradox could arise from gender divergence embedded in youth’s
interpretation of the measure, SRMH.
What, then, is gender and how is it different from sex? We define sex as a set of biological
attributes based on chromosomes, gene expression, hormones, and reproductive anatomy,
and gender as the way life is shaped by socially constructed roles, behaviors, and expressions
ascribed on the basis of sex [19]. We recognize the importance of the psychological and mate-
rial in constituting the gendered person [3]. When we use the term, gender, we acknowledge
that sex and gender are interconnected in how lives are lived, and in shaping and rating health.
Finally, we differentiate gender, a social determinant of health, from the individual-level char-
acteristic of gender identity.
To identify what is actually being measured when youth are asked to rate their mental
health it would be useful to explore differences in meanings attributed to this measure [20].
For example, girls’ apparent poorer SRMH might arise from gender differences in
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PLOS ONE Subjective mental health in youth

interpretations, approaches, and expansiveness with which the question is viewed, or from
greater willingness to examine and name weaknesses. Previous research has demonstrated that
adolescent girls are more alert to stressors and describe lower life satisfaction than do boys [21,
22]. Girls’ internalization of reactions to lived problems, and higher expectations for them-
selves may produce anxiety. In contrast, boys tend to focus more on external circumstances
such as life events that they cannot control and from which they, therefore, can absolve them-
selves of responsibility [16]. Although stigma around mental health is decreasing overall, girls’
apparent introspection and reflection could heighten their insights about and willingness to
name weaknesses [23]. In contrast, less reflective and more externalized traditional male
responses could translate into a subjective rating of ‘I am fine’. In keeping with resilience the-
ory, it may be that more self-reflective youth and those with greater self-mastery and control
hesitate to rate their MH highly, using a lower rating to push themselves to achieve [24].
To the best of our knowledge there have been no attempts to tease apart whether attributing
different meanings to subjective measures of mental health underpin gender disparities in
responses. Might the internalizing and externalizing described above lead each group (boys,
girls) to weigh aspects of their lives (social supports, family relationships, etc.) differently? For
example, if a girl considered family discord as a precursor of SRMH and her twin brother did
not, despite similar lived realities their subjective mental health rating might be quite different.
The girl and boy would, in effect, be answering different questions when asked to rate their
mental health. A single indicator used for a complex health outcome such as mental health
may in fact measure different constructs for different groups. This will possibly induce a mea-
surement validity issue. Our aim was to determine what personal and social characteristics or
experiences youth consider when making subjective mental health ratings, and whether these
vary with for boys and girls. Such variation could partially explain girls’ apparent SRMH disad-
vantage in the face of their greater academic and general well-being.

Methods
This observational study was conducted via an online survey of > 700 youth age 13–18. We
examined descriptive data, and then undertook factor analysis to identify latent factors that
youth consider in rating their mental health.

Data collection, study population, and the survey instrument

Data were collected from August 2021 to February 2022 via a 10-minute online survey created
using the Qualtrics platform. To be included in this study participants had to be 13–18 years
old and proficient in reading English. Although there were no geographic restrictions on par-
ticipation, we specifically targeted Canadian youth in advertising.
This was a sample of convenience. Posters describing the survey were displayed (with
school consent) in larger Canadian cities including Toronto and Vancouver. Additionally,
recruitment occurred in Kingston, ON via posters on the Queen’s University campus (i.e., resi-
dences, athletics centre, libraries), Kingston public libraries, cafés, community centres and
Kingston’s Limestone District School Board. These posters included a QR code to bring partic-
ipants to the online questionnaire. Invitations to participate were also circulated electronically
via social media. Specific invitations were sent to a small number of youth groups. The sample
size used for analysis was 765, including 216 boys, 506 girls and 43 youth self-identified as
non-gender binary.
Before distribution the survey was pilot tested and revised. The survey questionnaire, itself,
was distributed primarily through the social media platform, Instagram. This was accom-
plished by creating an Instagram account page for the survey with a link to the questionnaire

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PLOS ONE Subjective mental health in youth

on it, and by following youth accounts. The questionnaire, itself, could be completed on a
mobile device, or using a laptop/computer.
Collected data will be stored on secure servers for 5 years and are only accessible by the
research team.

Survey description
The survey began with participants’ consent, and then asked for age (13–18) and for self-iden-
tity in terms of gender with options, ‘boy’, ‘girl’, or ‘I do not identify with the gender binary’.
The survey included 4 sections each covering one aspect of subjective health (physical health,
mental health, life satisfaction, and body image). This article focuses on findings for the indica-
tor of mental health which was defined explicitly for survey participants as a “feeling of well-
being that includes believing you are capable of achieving what you hope to achieve, dealing
with stresses in life, going to school and working with enjoyment, being productive, and func-
tioning as a part of your community” [20]. Then, participants rated their mental health by
selecting one option: ‘Excellent’, ‘Very good’, ‘Good’, ‘Fair’, or ‘Poor’. Guided by existing evi-
dence as to individual and social circumstances that determine adolescent mental health we
developed a list of circumstances that participants have been thought to consider while rating
their mental health and asked them directly how important each was for this rating via a
4-point scale from ‘not important at all’ to ‘very important’. The main categories of such cir-
cumstances included, family (e.g., relationship with parents, family’s access to money) [25],
peer relationships (e.g., how my peers treat me) [14], personal factors (e.g., future plans, self-
acceptance) [25], community involvement (e.g., being part of my community) [26], health
behaviors (e.g., exercise routine) and physical health (e.g., physical activities) [27] (see Box 1).

Box 1
We want to know what you thought about when making this rating. For each example
given below, please tell us how important it was to YOUR rating.
1. My relationships with my parents (ex. loving or challenging, accepting or rejecting,
etc.)
2. How my family interacts with each other (ex. feeling connected to my family, family
conflict)
3. The way my parents treat me (ex. parental warmth, strictness)
4. My family’s access to money
5. How my peers treat me (ex. friendships, bullying/rejection)
6. Comparing myself to my peers
7. Pressure I feel from my peers
8. Having a boyfriend or girlfriend
9. My school performance (ex. grades)
10. Pressures from school (ex. homework)
11. Extracurricular activities (ex. Music or drama clubs, student government, sports)
12. My plans for the future (ex. future opportunities, stresses)

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PLOS ONE Subjective mental health in youth

13. My involvement in community activities

14. Being part of my community (ex. how I am treated because of my race, religion, sex-
ual orientation, gender, etc.)
15. My self confidence (ex. how confident I feel that I can accomplish things and express
myself)
16. Sense of identity (ex. knowing who I am and what I believe in)
17. My ability to cope with things that happen in my life
18. Self-acceptance (ex. how well I like myself)
19. Physical well-being (ex. physical illnesses, how my body feels)
20. A mental health diagnosis
21. My emotional wellbeing (ex. How I deal with different emotions, ongoing effects
from bad past experiences)
22. My exercise routine
23. How well I sleep
24. Screen time (ex. amount of time I spend on my phone, computer, video games, etc.)
25. The food I eat
26. The substances I use (ex. alcohol, weed)

Data analysis
We first compiled descriptive analyses of sex and age distributions as well as the differences in
what participants indicated as high- or low-weighted factors in their consideration of SRMH.
The average importance of each item for inclusion in rating of SRMH was estimated and com-
pared via student t-tests.
Second, to represent participants’ interpretations of meanings of the SRMH measure a fac-
tor analysis was conducted. The goal was to determine which factors were most important and
to identify groupings of factors that shape the outcomes for everyone and for girls and boys
separately. Factor analysis performs the latter by identifying the potential latent factors within
the items that participants considered important in rating their mental health. The principal
components method was used to extract potential underlying components (latent factors), fol-
lowed by an orthogonal rotation. The reason for choosing an orthogonal over oblique solution
was that the initial extracted components in data were not correlated. In initial exploratory
analyses we followed Kaiser Criterion [28] and retained factors with eigenvalues greater than
1, and also Cattell’s Scree test [29], which involves an examination of a plot of the eigenvalues
for breaks or discontinuities, to determine the number of components to retain. In interpret-
ing the component structure, an item was said to load onto a given component if factor load-
ing was greater than or equal to 0.50 and lower than 0.30 to the other component. The
difference between loadings onto the two components also needed to be greater than 0.2. To
establish a priori decision guidelines, components that did not meet the above criteria were
excluded from analysis. The robustness of this exploratory factor analysis was assessed by esti-
mating diagnostic measures of sampling adequacy (the Kaiser–Meyer–Olkin measure) and by

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PLOS ONE Subjective mental health in youth

Bartlett’s test of sphericity (to determine whether the correlations between the variables, exam-
ined simultaneously, do not differ significantly from zero, in other words to evaluate if the two
retained components together are sufficient to explain correlations between items). To identify
possible differences in extracted domains across sex and age groups, we repeated the factor
analyses in boys and girls and also in the age groups of 13–16 and 17–18 years old separately.
Final scores of retained components for each participant were calculated via linear regression
models. 95% CI intervals around the average of these scores were calculated by bootstrapping
with 1000 iterations and compared between sex and age groups. All analyses used SPSS, ver-
sion 27.

Ethical considerations
Ethics approval was obtained from the Queen’s University Health Sciences and Affiliated
Teaching Hospitals Research Ethics Board. Consent was demonstrated by participants’ con-
tinuing from the information provided in the pre-amble, to the questionnaire and to submis-
sion of it. There were several points at which non-consent could be demonstrated. Those who
accessed the online invitation could opt out of participation by not proceeding to the question-
naire. The questionnaire, itself, explained that one could opt out at any point by not submitting
the questionnaire. The questionnaire was anonymous and confidentiality was ensured by pre-
venting generation of any link between participants’ IP addresses, emails or any online indi-
vidual presence. Participants could choose to not answer specific questions and opt out at any
time. Exiting the browser would remove all prior answers.
A small incentive was used for participants, this was a 1/250 chance to win a $100 gift card
upon survey completion. Those who entered the prize draw did so via a separate platform to
which they were directed after they exited the questionnaire.

Results
The 506 girls surveyed were almost twice as likely as were the 216 boys to state that their
SRMH was poor (47.8% girls versus 27.8% boys) (Table 1).
Those identifying as non-binary (n = 43) were too small in number for sub-analysis but are
included when data for all participants are analysed. All participants contemplated similar cir-
cumstances in making their determination of SRMH (Table 2). A few notable sex/gender dif-
ferences did, however, emerge. Boys were more likely to take into account sense of identity
and self-confidence, physical well-being, exercise, foods eaten and screen time, while girls paid
more attention to having a boyfriend or girlfriend, comparisons with peers, and school pres-
sure and performance than did boys.
With factor analysis five components emerged for the group as a whole (Table 3). The first,
which we will refer to as resilience, combined ‘self confidence’, ‘sense of identity’, ‘ability to
cope’ and ‘self-acceptance’. The second component, behavior/community, merged ‘exercise’,
‘screentime/use’, ‘sleep patterns’, ‘substance use’, and ‘type of food eaten’ along with commu-
nity engagement. Third was family (including relationship with and treatment by parents,
family interactions, and sense of family financial resources) and fourth was relationships with
peers. The fifth component is one we will call future vision and included items such as ‘future
plans’ and ‘performance at school’.
Stratification by sex or age prior to factor analyses yielded similar component to those
found for the whole sample (Table 4).
While items making up these components did not change when the whole group was subdi-
vided by age (13–16, 17–18) (S1 Table) a few sex/gender differences surfaced. Overall, boys
and girls considered similar components when rating their mental health and there were no

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PLOS ONE Subjective mental health in youth

Table 1. Frequency distributions of self-reported health outcomes in boys, girls and non-binary participants; n (column percentage).
Boy Girl Non Binary P. value*
Age ANOVA
Mean (SD) 16.4 (1.5) 16.1 (1.4) 16.1 (1.3) 0.045
Self-Reported Mental Health <0.001
Good 156 (72.2) 264 (52.2) 11 (25.6)
Bad 60 (27.8) 242 (47.8) 32 (74.4)
Self-Reported Health <0.001
Good 183 (85.1) 389 (75.5) 24 (55.8)
Bad 32 (14.9) 113 (22.5) 19 (44.2)
Body Image <0.001
Good 145 (67.4) 254 (50.2) 18 (41.9)
Bad 70 (32.8) 252 (49.8) 25 (58.1)
Life Satisfaction High 41 (20.3) 51 (11.1) 1 (2.4) <0.001
Average 73 (36.1) 165 (35.6) 10 (23.8)
Low 88 (43.6) 247 (53.3) 31 (73.8)

*p values are from Chi-square except for age

https://doi.org/10.1371/journal.pone.0295704.t001

significant differences between the importance of these, as demonstrated by comparable aver-

age scores of extracted components (Fig 1).
In absolute terms, however, resilience was more important (showing higher score) for girls
whereas family, peer, and future were more important for boys. We also observed minor varia-
tions by sex in the items that loaded onto components. Screen time was part of the domain,
peers, for girls but behaviour for boys, while treatment by peers contributed to the peers
domain only among girls. Plans for the future emerged as a component of ‘future’ for girls but
not boys. Among boys, only, being part of a community contributed to the ‘community’
domain, a mental health diagnosis was an element of ‘family’, and sleep was a component of
resilience. All five-component solutions seemed sufficient to explain correlations between
items (p. values for the Barlett’s test of sphericity <0.001) and larger than 0.60 estimates of the
Kaiser–Meyer–Olkin test suggested adequate sample size—both evidence of the robustness of
the models. No differences in the perception of the importance of extracted components were
observed between age groups and comparing average scores did not show any pattern (Fig 2)

Discussion
We examined whether girls and boys are answering the same question when they rate their
mental health, that is, does this measure mean the same thing to male and female groups of
participants. Underlying and shaping the research question was strong and consistent evidence
of a paradox—that girls generally report lower SRMH but other broad markers of well-being
such as academic achievement, resilience, less risk-taking behavior and lower rates of suicide
all favor girls [11, 30]. Of further importance is methodologic accuracy; for survey data to be
trustworthy each respondent must be independent. If clustering based on group characteristics
(such as being a girl or a boy) shapes responses, these clusters must be identified and multilevel
analyses performed.
Consistent with previous findings female participants reported poorer mental health than
did boys, while those whose gender identity did not fit either of these categories reported the
poorest SRMH [2, 14, 31]. These ratings did not, however, arise substantially from girls reflect-
ing upon more or different life circumstances than boys. Instead, both boys and girls (and

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PLOS ONE Subjective mental health in youth

Table 2. Average ratings of importance of characteristics when considering SRMH (range 1 to 4).
Characteristics considered in rating mental health (SRMH)
Characteristics Average overall Average (Boys) Average (Girls) Average (Good SRMH) Average (Bad SRMH)
Relationship with Parents† 3.14 3.11 3.14 3.37 2.86
How treated by parents† 3.14 3.10 3.16 3.29 2.94
†
Interactions within family 2.97 2.97 3.00 3.19 2.69
Family access to money† 2.56 2.67 2.52 2.72 2.36
Comparing to peers*† 2.95 2.75 3.03 2.82 3.12
Pressure from peers 2.49 2.39 2.53 2.45 2.55
Having a boy/girl friend* 2.07 2.31 1.98 2.08 2.07
How treated by peers† 2.89 2.89 2.90 2.96 2.81
Plans for future† 2.48 3.45 3.51 3.54 3.41
Extracurricular activities† 2.70 2.83 2.67 2.91 2.42
School Pressure* 3.20 3.04 3.28 3.16 3.26
School performance* 3.38 3.17 3.47 3.41 3.34
Being part of a community† 2.54 2.64 2.47 2.71 2.32
Involvement in community*† 2.24 2.37 2.20 2.48 1.91
Self_acceptance† 3.30 3.27 3.31 3.36 3.22
Ability to cope† 3.28 3.27 3.27 3.33 3.22
Sense of identity*† 2.99 3.15 2.92 3.10 2.85
Self confidence† * 2.27 3.32 3.26 3.37 3.14
Emotional wellbeing 3.26 3.26 3.24 3.31 3.19
A mental health diagnosis 2.58 2.59 2.54 2.54 2.62
Physical wellbeing*† 2.91 3.09 2.87 3.12 2.63
Exercise routine*† 2.56 2.82 2.49 2.88 2.13
Sleeping well† 2.93 2.98 2.93 3.09 2.72
Substance use*† 1.95 2.12 1.91 2.04 1.83
Food eaten† * 2.81 2.86 2.78 2.95 2.62
Screen time*† 2.55 2.68 2.51 2.68 2.37

*t-test significant at the level of α = 0.05 between boys and girls

†
t-test significant at the level of α = 0.05 between good and bad SRMH

https://doi.org/10.1371/journal.pone.0295704.t002

younger and older participants) contemplated relationships with family and friends, individual
traits that collectively suggest resilience, behaviors, and their futures [32]. Contrary to what we
expected, the explanation for girls’ poorer mental health did not appear to stem from their dis-
playing a broader view of the circumstances that shape SRMH.
As a sensitivity analysis to better explain gender differences within age groups, we com-
pared average scores of extracted components in four groups defined by sex and age (S1 Fig).
Results mirrored the individual interactive contributions of age and sex. For example, younger
boys compared to other groups showed higher average scores of the peer component which
was due to higher scores in boys (compared to girls) and in 13–16 years compared to 17–18
years.
We hypothesize that although life circumstances that underpin subjective ratings were simi-
lar, lived or perceived realities for each domain somehow disadvantage the mental health of
girls relative to boys. For example, although all consider the same underlying characteristics,
girls’ perceptions or realities of relationships with family or friends may be more negative than
is the case for boys. In other words, the discrepancy in boys’ and girls’ mental health seems to
be unrelated to sex/gender differences in contemplation of meanings prior to reporting

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PLOS ONE Subjective mental health in youth

Table 3. Factor loadings analysis of SRH_MH, 5-items solution, the whole sample.
Factor 1 Resilience Factor 2 Behaviours Factor 3 Family Factor 4 Peers Factor 5 Future
Relationship with Parents .150 .108 :768 -.065 .142
How treated by parents .128 .061 :796 .005 .113
Interactions within family .110 .086 :721 -.012 .162
Family access to money -.092 .283 :525 .288 -.128
Comparing to peers* .030 -.013 -.214 :648 .307
Pressure from peers -.135 .016 .106 :735 .159
Having a boy/girl friend .107 .179 -.044 :525 -.157
How treated by peers .144 .040 .329 :522 .158
Plans for future .155 .273 .119 -.041 :549
Extracurricular activities* -.075 :625 .141 -.117 .292
School Pressure .087 .033 .024 .156 :714
School performance .164 .040 .173 .072 :733
Being part of a community .117 .399 .469 .139 -.083
Involvement in community .007 :659 .301 .031 -.040
Self_acceptance :799 .072 -.013 .021 .100
Ability to cope :789 .014 .115 .039 .136
Sense of identity :544 .258 .253 .059 .006
Self confidence* :761 .179 -.012 -.011 .154
Emotional wellbeing :758 .025 .140 .035 .008
A mental health diagnosis .260 .184 .335 .414 -.313
Physical wellbeing .488 .501 .255 .143 -.011
Exercise routine* .151 :742 .117 -.034 .027
Sleeping well .391 .484 .018 .083 .145
Substance use .044 .407 .066 .323 -.192
Food eaten* .244 :567 .148 .170 .044
Screen time .090 .515 -.126 .188 .194
Average score with 95%CI (via linear regression) 0.75 (0.70–0.80) 0.83 (0.78–0.88) 0.79 (0.75–0.86) 0.84 (0.78–0.89) 0.86 (0.80–0.92)

KMO measure for sampling adequacy = 0.842

p. value for Barlett’s test of sphericity = 0.000
Total percentage of variance explained by five components: 52%

https://doi.org/10.1371/journal.pone.0295704.t003

SRMH. Girls’ poorer SRMH may, instead, reflect individually or socially mediated inequities
in lived experiences and how these work their way ‘under the skin’.
There is, however, a second possible hypothesis. The definition of mental health we pre-
sented to participants was: “a feeling of well-being that includes believing you are capable of
achieving what you hope to achieve, dealing with stresses in life, going to school and working
with enjoyment, being productive, and functioning as a part of your community”. There is
some evidence that adversity is not only a source of poorer mental health but also a driver of
resilience and success in academic and work arenas [24]. When youth were questioned about
responses to a resilience scale some noted that their sense of optimism and drive to always do
better made them avoid rating their current function too highly [24]. Other studies have con-
sistently demonstrated that girls’ resilience (as demonstrated by attributes such as self-control,
empathy, optimism, self-efficacy) exceeds boys [33]. Entwined with these attributes may be
greater introspection and a cautiousness about overstating that all is well. Perceiving or

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PLOS ONE Subjective mental health in youth

Table 4. Factor loadings analysis of SRHMH, 5-items solution, sex stratified.

Girls Boys
Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 1 Factor 2 Factor 3 Factor 4 Factor 5
Resilience Behaviours Family Peers Future Resilience Behaviours Family Peers Future
Relationship with Parents .149 .090 :772 -.083 .039 .200 .202 :711 -.092 .296
How treated by parents .109 .001 :774 -.003 .020 .115 .242 :793 -.096 .310
Interactions within family .082 .055 :717 -.062 .151 .176 .225 :694 -.005 .245
Family access to money -.134 .281 :499 .275 -.005 .079 .175 :711 .273 -.136
Comparing to peers* .018 -.033 -.315 :547 .220 -.057 .047 -.079 :776 .302
Pressure from peers -.177 -.012 .066 :710 .130 -.182 -.018 .192 :690 .289
Having a boy/girl friend .089 .092 -.066 :507 -.068 .263 .044 .092 :659 -.120
How treated by peers .121 -.007 .313 :551 .145 .129 -.032 .420 .377 .338
Plans for future .116 .288 .109 -.136 :547 .436 .077 .141 .099 .413
Extracurricular activities* -.118 :656 .082 -.143 .188 .102 :527 .108 .024 .563
School Pressure .043 .007 .004 .163 :751 .262 .012 .024 .150 :711
School performance .147 -.048 .109 .062 :752 .291 .198 .174 .088 :663
Being part of a community .068 .380 .476 .229 -.018 .118 :598 .365 .000 .039
Involvement in -.035 :644 .282 .025 -.035 .025 :827 .217 .098 .137
community
Self_acceptance :838 .059 -.053 -.026 .033 :669 .107 .072 .100 .136
Ability to cope :814 -.060 .076 .007 .134 :630 .180 .215 .068 .207
Sense of identity :521 .218 .259 .112 .085 :566 .379 .170 -.048 .136
Self confidence* :791 .120 -.018 -.006 .147 :747 .173 .001 -.035 .085
Emotional wellbeing :794 .047 .116 .045 .015 :621 -.125 .325 .063 .022
A mental health diagnosis .259 .179 .255 .479 -.242 .201 .206 :625 .281 -.186
Physical wellbeing :513 .437 .262 .245 -.087 :559 .432 .238 .122 .271
Exercise routine* .150 :727 .105 .030 -.021 .319 :661 .151 .058 .029
Sleeping well .399 .469 .027 .051 .044 :557 .343 .045 .294 .134
Substance use .035 .384 -.043 .322 -.124 .176 .291 .389 .374 -.243
Food eaten* .277 :530 .134 .203 -.033 .295 :620 .147 .256 .067
Screen time .136 :521 -.133 .035 .300 .139 .165 .026 :555 -.011
Average score with 95%CI 0.84 (0.78– 0.83 (0.79– 0.70 0.70 0.79 0.75 (0.70– 0.83 (0.78– 0.80 0.84 0.86
(via linear regression) 0.90) 0.88) (0.65– (0.65– (0.74– 0.80) 0.88) (0.75– (0.78– (0.80–
0.75) 0.74) 0.84) 0.86) 0.89) 0.92)

KMO measure for sampling adequacy for girls = 0.808; for boys = 0.836
p. value for Barlett’s test of sphericity for both girls and boys <0.001
Total percentage of variance explained by five components for girls = 50%; for boys = 58%

https://doi.org/10.1371/journal.pone.0295704.t004

reporting less than perfect SRMH may actually propel girls’ greater resilience and academic
accomplishment. The direction of this possible association is difficult to determine. Does
poorer SRMH lead to greater resilience, does greater resilience colour the reporting of subjective
mental health, or is the relationship bidirectional? Of course, even though adversity may be a
necessary precursor of resilience this does not justify allowing children or youth to suffer when
that suffering can be alleviated. At the same time the strength that arises from facing adversity
and navigating it suggests that trying to shelter youth from distressing circumstances may harm
as well as help by diminishing self-mastery, self-efficacy, or other components of resilience
[34, 35].

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PLOS ONE Subjective mental health in youth

Fig 1. Average scores of extracted components for boys and girls.

https://doi.org/10.1371/journal.pone.0295704.g001

Limitations
Social media recruiting targeted Canadian youth, and despite the large sample size, we cannot
assume external validity. The minority of Canadian youth who lack access to social media
would have been excluded. As with most surveys, girls were twice as likely as boys to partici-
pate. Cross-sectional data can identify associations but not directionality or causation. We
listed characteristics known to be of relevance and asked participants whether and to what
degree they considered each before rating their mental health. There may have been over-
reporting about any of these, particularly among less introspective respondents who, in

Fig 2. Average scores of extracted components for 13–16 years and 17–18 years.
https://doi.org/10.1371/journal.pone.0295704.g002

PLOS ONE | https://doi.org/10.1371/journal.pone.0295704 December 27, 2023 11 / 14

PLOS ONE Subjective mental health in youth

retrospect, may have thought each characteristic was a reasonable one to have considered. As
boys are generally thought to be less introspective than girls it is possible that they (boys) dis-
proportionately over-reported weightings of the various characteristics listed. Finally, qualita-
tive research would be needed to identify characteristics we did not list as options.

Conclusions
In summary, we examined whether the paradox of girls’ poorer self-reported mental health
might arise from differences in what boys and girls consider as the meanings behind the mea-
sure, SRMH. In keeping with others’ findings, girls surveyed had much poorer SRMH than
did boys. However, both groups considered relatively similar lived circumstances in making
their rating. This suggests that SRMH is a valid measure across groups defined by sex. It would
appear either that girls realities are more challenging, or that they perceive them as more chal-
lenging, perhaps to drive the greater achievement and success they attain. Although our find-
ings allow for hypotheses, empirical explanations for girls’ poorer SRMH but greater well-
being remain a paradox. To deepen understanding of this paradox further studies of diverse
populations and analysis of representative data is warranted. Such studies should include the
collection of qualitative as well as quantitative data.

Supporting information
S1 Fig. Average scores of extracted components in the four age and sex groups.
(TIF)
S1 Table. Factor loadings analysis of SRH_MH, 5-items solution. Stratified by age groups.
(DOCX)

Author Contributions
Conceptualization: Susan P. Phillips, Fiona Costello, Naomi Gazendam.
Data curation: Susan P. Phillips, Fiona Costello, Naomi Gazendam.
Formal analysis: Susan P. Phillips, Fiona Costello, Afshin Vafaei.
Funding acquisition: Susan P. Phillips.
Methodology: Susan P. Phillips, Afshin Vafaei.
Project administration: Susan P. Phillips.
Writing – original draft: Susan P. Phillips, Fiona Costello, Naomi Gazendam, Afshin Vafaei.
Writing – review & editing: Susan P. Phillips, Fiona Costello, Naomi Gazendam, Afshin
Vafaei.

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