Rainbow resilience: Addressing the mental health needs of sexual- and gender-diverse youth

Contemporary PEDS JournalMarch 2024
Volume 40
Issue 02

Research has demonstrated that SGDY exhibit significantly elevated incidence of mental health diagnoses and conditions compared with their counterparts, including higher rates of suicidality, depressive and anxiety disorders, and substance misuse.

Sexual- and gender-diverse youth © Ajax9 - stock.adobe.com

Sexual- and gender-diverse youth © Ajax9 - stock.adobe.com

Sexual and gender-diverse youth (SGDY) are at the forefront of a burgeoning mental health crisis, navigating their formative adolescent years in a sociopolitical climate marked by both increased visibility and heightened vulnerability. Despite growing acceptance in some arenas, rampant anti-lesbian, gay, bisexual, transgender and queer (LGBTQ) legislation and societal discrimination pose daily challenges,1,2 exacerbating systemic and interpersonal stressors that significantly impact their mental health and well-being.3 At the same time, the prevalence of sexual and gender-diversity is growing rapidly; according to a recent Gallup poll, 1 in 5 young people in Gen Z (born in the years of 1997-2012) identify as SGDY,4 underscoring the importance of acknowledging and addressing the mental health needs of sexual and gender diverse youth. Research has demonstrated that SGDY–those who identify as LGBTQ+ or another non-heterosexual/cisgender identity–exhibit significantly elevated incidence of mental health diagnoses and conditions in comparison to their counterparts, including higher rates of suicidality, depressive and anxiety disorders, and substance misuse.5,6,7 The 2023 U.S. National Survey on Mental Health of LGBTQ Young People of over 28,000 SGMY (ages 13-24) indicated that 41% of participants seriously considered attempting suicide in the past year, while nearly 1 in 5 transgender/nonbinary youth attempted suicide.8 Transgender, non-binary and youth of color had higher rates of considered and attempted suicidality than their peers.8

These disparities in mental health are attributable to the experience of minority stressors, such as bullying and victimization, discriminatory practices, and internalized homo/trans-negativity.9 Minority stress theory posits that one’s experience of stigmatization within society is associated with increased risk of negative health outcomes.7,10,11 The health disparities between SGDY and their cisheterosexual counterparts is attributed to the additional burden associated with one’s minority status—in this case, related to sexual orientation, gender identity, and expression (SOGIE). Such stressors include both distal and proximal factors, resulting from political climates limiting affirming care for LGBTQ persons and direct victimization and internalized stigma.7,12,13 Health disparities contribute to health inequities, which encompass the unjust, preventable, and systematic variations in health outcomes that result as a consequence of systematic social, economic, and cultural exclusion due to factors such as race, gender, sexuality, socioeconomic status, and geographic location.14,15,16

Health disparities and inequities are compounded particularly for SGDY who exist within multiple marginalized identities. Intersectionality is a theoretical framework that suggests that multiple marginalized identities—for example, race, ethnicity, gender, and sexual orientation—intersect at the individual level of experience and reflects larger social–structural inequities experienced on the societal level.17,18 For Black and Latinx SGDY, the intersection of racial and LGBTQ+ identities intensify their experience of stress and discrimination, further exacerbating mental health disparities and hindering their access to mental health services.19 One study demonstrated that Black adolescent and young adult females who identified as SGDY faced an 80% greater likelihood of their mental health needs going unrecognized compared to their White counterparts,20 highlighting how intersectional factors contribute to disparities in accessing necessary mental health care among Black SGDY.

Adolescence represents a crucial developmental period of vulnerability due to individual experiences of rejection and victimization, interpersonal dynamics with peers and family, and systemic societal factors. The initial disclosure of sexual orientation and gender identity by SGDY frequently occurs during adolescence.21 The reactions elicited by such disclosure can engender stress and exacerbate mental health. Notably, SGDY who encounter adverse reactions following disclosure are more likely to suffer from mental health issues;22 and such youth frequently experience high rates of victimization, including family rejection, system involvement, precarious housing, unemployment, and arrest.10,11,23,24

Suicidality has been correlated with living in non-affirming environments,25 and family rejection increases one’s risk of suicidality and depression during young adolescence and adulthood.26 More than 60% of SGDY surveyed in the 2023 US National Survey on Mental Health of LGBTQ Young People reported that their home is not accepting of their SOGIE.8 Studies have demonstrated the potency of parental relationships on the well-being of SGDY.27-28 Family acceptance promotes self-esteem and protects against suicidality, depression, and substance use;28 while youth with higher levels of family rejection are 5.9 times more likely to report moderate/severe levels of depression, 3.4 times more likely to use substances, and 8.4 times more likely to attempt suicide.26

Beyond family of origin, relationships with non-parental adults and peers have significant impact, both as barriers and facilitators to mental health. For instance, the Trevor Project found a lower percentage of students reported having considered suicide if they felt their school was gender-affirming,8 highlighting the protective power of inclusive environments. In contrast, in a study of 800,000 California students, fewer than half of SGDY felt safe at school, and were more than twice as likely to report experiencing bullying, harassment, and threat of physical violence.29 Another study found that over 95% of SGDY have heard homophobic/transphobic slurs used in school, with 56% of homophobic remarks and 71% of transphobic remarks coming from school staff; 57% of SGD students were sexually harassed in the past year at school, and though 55% didn’t report incidents at all, 60% of the students who did said that school staff did nothing in response or told the student to ignore it.30 An example of this is the recent murder of Nex Benedict, a nonbinary teenager who was assaulted in an Oaklahoma school bathroom aligned with their assigned sex at birth, was attributable not only to direct violence enacted by their peers but also by the negligence of school officials, who failed to contact medical authorities.

Other studies suggest that the mental health of SGDY is influenced by broader societal attitudes towards SOGIE. A recent study found that most transgender and nonbinary youth were worried about transgender people being denied access to gender-affirming medical care (93%), access to bathrooms (91%) and sports participation (83%) due to state or local laws.31 Neighborhood-level LGBTQ hate crimes, for example, have been associated with higher rates of suicide, bullying, and marijuana use.32-34 Whereas, residing in counties with a more supportive environment for sexual and gender diversity (evidenced by a higher proportion of same-sex couples, more schools implementing anti-bullying policies, and the presence of gender and sexuality alliances) has been associated with lower instances of victimization, suicidality, and depressive symptoms.35 The impact of anti-LGBTQ policies is heightened for Black SGDY youth due to the additive impact of structural racism on anxiety and depression.36

The COVID-19 pandemic further exacerbated anxiety, depression, and poor mental health.37 Over half (56%) of SGDY surveyed in the 2022 National Survey on LGBTQ Youth Mental Health reported that their mental health was poor most of the time or always due to the COVID-19 pandemic.31 Approximately 3 out of 5 transgender and 2 out of 5 cisgender youth reported wanting mental health care in the past year were unable to get it.31 Contextual factors that contributed to higher rates included social isolation, lack of family support and limited access to services.38-40 Shelter-in-place orders during COVID-19 curtailed community connectedness and confined youth to environments that were potentially harmful. Youth with intersectional identities, such as Black, indigenous, and youth of color who experience other social determinants of health including low socioeconomic status, unstable housing and unemployment were particularly vulnerable to higher rates of anxiety and depression during COVID due to diminished access to services.41

Despite facing significant challenges during the pandemic, SGDY exhibit remarkable resilience and resourcefulness in navigating their mental health. A key source of strength lies in positive supports, fostering environments that affirm their identities and offer avenues for growth. These include chosen families, self-made networks of peers, mentors, and allies who offer acceptance, belonging, and emotional validation.42 These chosen families, often formed online or within supportive school communities, provide safe spaces for authentic self-expression and combat feelings of isolation or rejection, especially when biological families are unsupportive. Supportive school communities can also play a vital role, offering safe spaces for authentic self-expression and combating feelings of isolation or rejection. Robust literature demonstrates the benefits of mentorship, with concomitant positive socio-emotional, cognitive, and identity development. For youth who face minority stress, these protective factors are more imperative; moreover, a non-parental adult providing attunement might mitigate detrimental effects of non-affirming environments.

SGDY also demonstrate positive coping skills, employing strategies like mindfulness, creative expression, and connecting with nature to manage stress and anxiety.43 Recent scholarship has demonstrated the potency of positive storytelling of gender euphoria, rather than merely focusing on pathology; celebrating and nurturing joy can be a vital form of resistance for marginalized communities.44 Importantly, seeking professional help from LGBTQ-affirming mental health services is encouraged whenever needed. By harnessing their inner strength, fostering supportive communities, and utilizing positive coping mechanisms, SGDY actively navigate the challenges of the pandemic and build a brighter future for themselves.

Pediatricians are uniquely positioned to intercede, thereby mitigating the negative impacts of minority stress.45 Healthcare providers also run the risk of exacerbating the detrimental effects of homo/transphobia and heterosexism; according to a survey conducted by the Human Rights Campaign encompassing over 10,000 SGDY aged 13 to 17 years old, 67% of LGB and 61% of transgender youth opted not to disclose their sexual orientation or gender identity to their healthcare providers. Furthermore, 80% of the SGDY who identified as racial/ethnic minorities reported experiences of racial discrimination within healthcare settings.46 SGDY who have postponed the disclosure of their sexual orientation or gender identity have reported instances of discrimination, denial, and inferior quality of care as direct consequences of their sexual orientation or gender identity.47 Such experiences can culminate in delayed medical attention, inadequate access to treatment,48,49 and can potentially exacerbate, rather than alleviate, the disproportionate risk of depression, suicidal ideation, poor sexual and reproductive health outcomes, and substance use that SGDY face relative to their heterosexual cisgender counterparts.23

The mental health crisis among SGDY necessitates a comprehensive, inclusive approach to address the deep-rooted societal and structural barriers that perpetuate disparities in care. Pediatricians play a crucial role in educating and supporting families, fostering environments of acceptance and affirmation, and ensuring every young person has access to the care they need to thrive. To accomplish this, providers will need enhanced training around the unique challenges faced by SGDY, emphasizing the critical importance of intersectionality and the tools needed to systematically collect information on sexual orientation and gender identity and incorporate mental health screening into electronic health records.50 Pairing routine collection with physical symbols that indicate affirming environments, with easily-accessible community resources, can enable a more streamlined approach in linking patients with mental health providers who have LGBTQ+ expertise.51 Such strategies support patient-centered care, enabling timely, safe, self-determined and tailored interventions. The development of community and school-based resources that promote acceptance and support, alongside programs that educate and support families, can significantly reduce rates of depression and suicidality among SGDY. More legislation and funding are needed to remove structural barriers and ensure equitable access to mental health services.


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