To understand the context of a person’s life course, it is critical to understand the age cohort to which that individual belongs. Youth growing up today will see changes that earlier generations of lesbians and gay men would never have expected in their lifetimes, including politicians, business leaders, and educators who are openly gay; marriage between same-sex couples; and an evolving popular and artistic culture that provides many positive portrayals of lesbian and gay characters in movies and plays, on television, and in literature. Today’s youth are able to use the Internet to retrieve online information about LGBT issues, providing social networking opportunities and access to knowledge in a way that was not available to older cohorts. At the same time, young LGBT people searching the Internet and interacting with their peers will be aware of the pervasive negative views of sexual and gender minorities.
Likewise, many transgender elders did not even know as children that other transgender people existed, and certainly received little acknowledgment of their transgender feelings. By contrast, many transgender children and adolescents today have role models (either in the media or in real life), and their gender-variant expression is often sufficient for parents to obtain more information and access existing networks of families with gender-variant children. Moreover, transgender youth today have access to early medical intervention to alleviate any gender dysphoria (defined as discomfort with one’s sex assigned at birth) they might experience.
In this report, childhood and adolescence encompasses the life course through the emergence of adulthood, generally understood by the committee to occur in the early 20s. During this phase of life, a person, regardless
of his or her sexual orientation or gender identity, develops from a child who must be cared for to a self-reliant individual. The developmental changes that occur are complex, particularly with the onset of puberty. LGBT youth face the same challenges as their heterosexual peers, but also stigma that may contribute to the identified disparities in health status between sexual- and gender-minority youth and heterosexual youth.
The ability to address these disparities is hampered by our lack of knowledge about LGBT youth. One of the challenges of discussing the development of children and adolescents who are LGBT is that beliefs and biases have often precluded substantive research. Not long ago, for example, a prevailing notion was that one’s sexual identity and orientation did not emerge until late adolescence and that an attraction to people of the same sex was likely a passing phase (Money, 1990). Moreover, efforts to survey young people about their sexual orientation have been fraught with difficulties at both the institutional review board and community levels. These barriers have impeded important developmental research.
While the current state of knowledge regarding the health of LGBT youth is derived from limited research, it is worth noting that much of this research has focused on mental health; little research has been conducted on the physical health of LGBT youth because, like most other youth, they generally do not struggle with chronic diseases that impact their physical health. As mentioned in previous chapters, the disparities in both mental and physical health that are seen between LGBT and heterosexual and non-gender-variant youth are influenced largely by their experiences of stigma and discrimination during the development of their sexual orientation and gender identity and throughout the life course.
This chapter begins with a discussion of the development of sexual orientation and gender identity in LGBT youth. The chapter then reviews the research on mental health and then physical health in these youth. Risk and protective factors and health services are then addressed in turn. The chapter next examines contextual influences, such as demographic characteristics and the role of the family. The chapter concludes with a summary of key findings and research opportunities. Of note, the chapter emphasizes adolescence rather than childhood because of the limited research available on younger children’s and pre-adolescents’ awareness of, feelings about, and experiences with being LGBT.
DEVELOPMENT OF SEXUAL ORIENTATION AND GENDER IDENTITY
Adolescents are engaged in an ongoing process of sexual development (Rosario et al., 2008); many adolescents may be unsure of their sexual orientation, while others have been clear about it since childhood. This ongo-
ing process suggests that for some adolescents, self-identification of sexual orientation and the sex of sexual partners may change over time and may not necessarily be congruent (Saewyc et al., 2004).
The development of sexual identity in lesbian, gay, and bisexual individuals is a unique process that has been widely reported in the scientific literature and popular culture but has received surprisingly little empirical attention. Early models of sexual identity development were generated on the basis of retrospective descriptions by adults. Models of homosexual identity development proposed by Cass (1979) and Troiden (1989) describe a staged process that (1) recognizes the impact of stigma that affects both the formation and expression of homosexual identity, (2) unfolds over a period of time, (3) involves increasing acceptance of a homosexual identity, and (4) includes disclosure to other persons. However, these models were developed at a time in which access to information about sexual orientation was limited; negative attitudes about homosexuality were more prevalent; and few resources existed for the study of LGB populations, particularly adolescents. Furthermore, the development of these theoretical models was based on the retrospective experiences of white adults.
The first study to explore the development of adolescent lesbian and gay identity in depth included 202 LGB adolescents, more than half of whom were racial minority youth (Herdt and Boxer, 1993). The mean age of self-identification as lesbian or gay was 16.7 years for males and 16 years for females. Gay males were, on average, aware of same-sex attraction at about age 9; the average age for lesbians was 10. Based on the results of their study, the researchers concluded that sexual identity development should be viewed as an ongoing process rather than as a series of stages or phases.
Investigators who conducted early work on the development of sexual orientation identity argued that coming out or self-identifying as lesbian or gay during adolescence may be a developmental process seen only in contemporary LGB youth—one that may have unique consequences for later life-course development compared with lesbian and gay adults who did not come out during adolescence (Boxer and Cohler, 1989). Herdt and Boxer (1993) document the process of transition from a heterosexual to a gay identity in the context of LGB cultural supports (social institutions, a gay youth program, lesbian and gay adult role models). Boxer and Cohler (1989) observe that one of the major developmental tasks for lesbian and gay youth is the deconstruction of previously internalized heterosexual expectations and the construction of a new set of future expectations of the gay and lesbian life course.
A range of investigators have focused on “milestones” as indicators of sexual identity development among LGB adolescents. These include age of awareness of sexual attraction; age of self-labeling as lesbian, gay, or
bisexual; age of disclosure of same-sex orientation; and age of first sexual experience. Research subsequent to Herdt and Boxer’s early work found comparable ages of first awareness of sexual attraction (i.e., approximately age 10) (e.g., D’Augelli, 2006; D’Augelli and Hershberger, 1993; Rosario et al., 1996).
“Coming out” or self-identifying and subsequently sharing that identity with others is a process that occurs in a social and historical context. Earlier literature indicates that this experience may be especially challenging for young people who come out during adolescence, given the need to integrate an LGB identity with other aspects of identity development in the context of social stigma and discrimination. However, little current research is available to show how this process might differ for contemporary adolescents as a result of increased awareness, greater access to information, and changes in media representation of LGB people. More research is needed to understand the process of coming out for diverse populations of LGB youth.
Similarly, little research has focused on sexual identity development among ethnically diverse LGB adolescents. Development experiences may differ as adolescents negotiate both ethnic and sexual orientation identity. One community-based study of 145 white, black, and Latino LGB youth aged 14–21 found no differences in sexual identity, current sexual orientation, or comfort with and acceptance of sexual identity among the three racial groups (Rosario et al., 2004). However, black youth were involved in fewer gay-related social activities, were less comfortable with others knowing about their sexual identity, and disclosed their sexual orientation to fewer persons than their white peers. While Latino youth disclosed their LGB identity to fewer people than white or black youth, they were more comfortable with others knowing about their LGB identity than members of the other racial groups.
More recent research examined ethnic and sexual identity development during adolescence among 22 black and Latino gay youth aged 16–22 (Jamil et al., 2009). The researchers found that ethnic and sexual identity developed concurrently during adolescence, but the processes were different and not related. Ethnic identity development was shaped by growing awareness of the youth’s ethnic and cultural heritage and was supported by peers; family members; and cultural markers such as food, music, and holidays. Sexual identity development was supported by community-based organizations, peers, and information from the Internet. Sexual identity development was described as a private process, while ethnic identity development was viewed as a more public process.
The ongoing process of sexual development among adolescents presents challenges to the collection of data on the size of the population of LGB youth, although some studies using large samples of adolescents have examined the prevalence of same-sex attraction, same-sex sexual behavior,
and LGB identities. In the 1999 wave of the Growing Up Today Study (n = 10,685), a national survey of adolescents aged 12–17, approximately 1 percent of adolescents identified as homosexual or bisexual (n = 103), with 5 percent identifying as mostly heterosexual (n = 511) and 2 percent identifying as unsure (n = 226) (Austin et al., 2004a). In the first wave of the National Longitudinal Study of Adolescent Health, conducted among 7th- through 12th-grade adolescents (n = 11,940), 5 percent of females and about 7.3 percent of males reported same-sex romantic or sexual attractions (Russell and Joyner, 2001). DuRant and colleagues (1998), reporting on the prevalence of reported same-sex sexual behavior using the 1995 wave of the Vermont Youth Risk Behavior Survey (n = 3,886 sexually active 8th-through 12th-grade males), found that 8.7 percent of high school males reported having had at least one same-sex partner (DuRant et al., 1998).
Similar to sexual orientation identity, gender expression is not necessarily constant throughout childhood development. Gender variance, as it relates to expressing and exploring gender identity and gender roles, is a part of normal development. A relatively small percentage of gender-variant children develop an adult transgender identity (Green, 1987; Wallien and Cohen-Kettenis, 2008; Zucker and Bradley, 1995). However, research shows that the majority of adolescents with a gender-variant identity develop an adult transgender identity (Wallien and Cohen-Kettenis, 2008). Data on the prevalence of childhood gender-variant or transgender identities are severely limited, largely because there is no national database available to collect such data. A relatively small number of studies using nonprobability samples have attempted to assess the incidence of childhood gender-variant identities. One such study, discussed in Chapter 2, found that 1 percent of parents of boys aged 4–11 reported that their son wished to be of the other sex; for girls, the percentage was 3.5 percent (Zucker et al., 1997).
Other studies using small nonprobability samples have documented trends in referrals to gender identity clinics by gender and persistence of gender identity concerns into adolescence and adulthood. One study examining children aged 3–12 with gender identity issues in a Toronto clinic (n = 358) and a Utrecht clinic (n = 130) showed that boys were referred more often and at an earlier age than girls for such concerns (Cohen-Kettenis et al., 2003). In another small study (n = 77) examining psychosexual outcomes of gender-dysphoric children at age of referral and then at follow-up approximately 10 years later, 27 percent of those with childhood gender identity concerns were still gender dysphoric (Wallien and Cohen-Kettenis, 2008). (It should be noted that at follow-up, 30 percent of the sample failed to respond to recruitment letters or were not traceable.) Research with small clinical samples of gender-variant children has shown that, compared with controls, gender-variant children have more difficulties with peer relationships (Zucker et al., 1997); this is the case particularly for
boys compared with girls (Cohen-Kettenis et al., 2003). Poor peer relations was found to be the strongest predictor of behavior problems in both gender-variant boys and girls (Cohen-Kettenis et al., 2003). One small study showed that children with gender identity disorder (n = 25) may have a more anxious nature than gender-conforming children (n = 25) (Wallien et al., 2007).
Grossman and D’Augelli (2006) conducted focus groups with young self-identified transgender males and females aged 15–21 and explored factors related to physical and mental health. In this qualitative study, most of the youth reported experiences of family and peers reacting negatively toward their gender-atypical behaviors. Therapy or counseling that aims to change an individual’s sexual orientation, often based on the presumption that LGBT orientation/identity is abnormal or unhealthy, is known as conversion or reparative therapy (Just the Facts Coalition, 2008). The nation’s most prominent medical and mental health professional organizations, including the American Medical Association, the American Psychiatric Association, and the American Psychological Association, oppose the use of conversion therapy with both youth and adults (AMA, 2010; American Psychiatric Association, 2000a). The American Psychological Association formed a task force to review peer-reviewed studies on efforts to change sexual orientation. The task force concluded that evidence is lacking for the effectiveness of efforts to change sexual orientation and that conversion therapy may cause harm to LGBT individuals by increasing internalized stigma, distress, and depression (American Psychological Association, 2009). Instead, the task force expressed support for the use of affirmative, culturally competent therapy that helps those facing distress related to their sexual orientation cope with social and internalized stigma and strengthen their social support networks (American Psychological Association, 2009).
MENTAL HEALTH STATUS
As noted, most of the research conducted among LGBT youth has examined their mental health status. Although a small amount of the literature explores the process of sexual orientation and gender identity development among LGBT youth (see the preceding section), a greater portion of the literature focuses on sexual-minority youth’s risk for suicidality and depression; few studies examine the prevalence of mood, anxiety, or eating disorders in these populations. As discussed below, the lack of data in many areas of mental health demonstrates the need for further research on the mental health status of LGBT youth.
It is important to note that LGBT youth are typically well adjusted and mentally healthy. Research based on probability samples with LGB youth consistently indicates that the majority do not report mental health
problems (Mustanski et al., 2010b; Russell and Joyner, 2001). Regarding transgender youth, although no data from national probability samples are available, studies with sizable convenience samples indicate that many, if not most, of these youth do not report mental health problems (Clements-Nolle et al., 2001; Nuttbrock et al., 2010).
Mood and Anxiety Disorders
Most of the research that has been conducted on mental health disorders among LGBT youth has relied on symptom or distress scales rather than formal clinical diagnoses (Mustanski et al., 2010b). To the committee’s knowledge, only two published studies have assessed LGBT adolescents diagnostically. Fergusson and colleagues (1999) conducted a study in New Zealand on the risk of psychiatric disorder and suicidal behavior using data from a birth cohort. They found that, relative to youth who identified as heterosexual, youth who identified as lesbian, gay, or bisexual were between 1.8 and 2.9 times more likely to experience generalized anxiety disorder, major depression, and conduct disorder. It should be noted, however, that of the 1,007 youth surveyed, only 28 self-identified as LGB or described past relationships with same-sex partners (Fergusson et al., 1999).
More recently, Mustanski and colleagues (2010b) administered a structured diagnostic interview to a community sample of 246 LGBT youth. They found that, although the youth in the sample showed a higher prevalence of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses compared with national data, the prevalence was similar to that among another sample of urban, ethnically diverse youth from the same geographic area.
Depression and Suicidality
Over the past decade, an increasing number of studies based on large probability samples have consistently found that LGB youth and youth who report same-sex romantic attraction are at increased risk for suicidal ideation and attempts, as well as depressive symptoms, in comparison with their heterosexual counterparts. These include both school-based, state-based, and national studies (Almeida et al., 2009; Birkett et al., 2009; Bontempo and D’Augelli, 2002; Garofalo et al., 1999; Jiang et al., 2010; Russell and Joyner, 2001; Saewyc et al., 2007). The results of these studies suggest increased rates of suicidal ideation and attempts among LGB youth in comparison with heterosexual youth even after controlling for potentially confounding factors such as substance use and depression. These population-based studies followed more than two decades of community-based studies of LGB youth that showed elevated reported rates of suicidal
ideation and attempts and identified predictors of suicidality in these populations, although it should be noted that, much as with the larger population of young people, it is a small group of LGB youth who report suicidal behavior.
With few exceptions, the increased rate of suicidality among LGB youth in comparison with heterosexual youth is consistent across age groups (i.e., middle school, high school, and young adult populations), gender (i.e., male, female, transgender), race/ethnicity (e.g., white, black, Latino, Asian/ Pacific Islander, American Indian/Alaska Native), and differing definitions of sexual orientation (i.e., same-sex attraction, self-identification, and behavior) (Almeida et al., 2009; Birkett et al., 2009; Bontempo and D’Augelli, 2002; Faulkner and Cranston, 1998; Garofalo et al., 1998, 1999; Jiang et al., 2010; Saewyc et al., 2007). However, evidence from longitudinal studies on suicidality over time among LGB youth is lacking.
Some older evidence disputes the idea of increased rates of completed suicide among LGB youth. Two studies using postsuicide data found no association between suicide and sexual orientation (Rich et al., 1986; Shaffer et al., 1995). However, capturing information about sexual orientation is especially difficult postsuicide since adolescents who are highly conflicted about their sexual orientation may not share these concerns with others. Moreover, these studies examined completed suicides from more than 20 years ago, when it was more difficult to be openly gay during adolescence. In addition, results of two community-based studies suggest that some of the suicide attempts reported by LGB youth may not be life-threatening, but rather low-risk suicidal ideation or plans (Savin-Williams, 2001). These studies have been challenged for potentially drawing on relatively low-risk populations, however (Russell, 2003).
Many risk factors, both general and LGB-specific, have been implicated in the increased rates of suicidal behavior among LGB youth (see the detailed discussion of risk factors for the health of LGBT youth later in this chapter). General risk factors have been implicated in suicidal behavior in the larger population of youth and tend to be high among LGB youth. They include depression, substance use, early sexual initiation, not feeling safe at school, cigarette smoking, and inadequate social support. These factors may partially mediate the increased risk of suicidality for LGB youth, although results of studies on this association are mixed (Fergusson et al., 1999; Garofalo et al., 1999; Russell and Joyner, 2001). Specific factors related to sexual-minority status, including homophobic victimization and stress (Huebner et al., 2004; Safren and Heimberg, 1999; Savin-Williams and Ream, 2003), are associated with suicidal behavior. In a study of 528 self-identified LGB youth aged 15–19, D’Augelli and colleagues (2005) found that recognizing same-sex attraction, initiating same-sex sexual activity, or appearing gender nonconforming at earlier ages was associated
with reported suicide attempts in LGB youth; this association may be exacerbated by experiences of victimization and maltreatment (Corliss et al., 2009; Friedman et al., 2006).
Family rejection due to sexual orientation may also be associated with increased risk of suicidality. In the previously mentioned study of 528 LGB youth, greater childhood parental psychological abuse and parental efforts to discourage gender-atypical behavior were associated with increased risk of suicide attempts (D’Augelli et al., 2005). Similarly, a study of 224 self-identified LGB youth aged 21–25 found that higher rates of family rejection were associated with increased rates of reports of attempted suicide, high levels of depression, and risk behaviors (Ryan et al., 2009). Conversely, findings from a study of 245 Latino and non-Latino white self-identified LGBT youth (aged 21–25) suggest that family acceptance of and supportive reactions to an adolescent’s LGBT identity may be protective against depression and suicidal ideation and attempts (Ryan et al., 2010). Using data from the 2004 Minnesota Student Survey of 9th and 12th graders (n = 21,927), Eisenberg and Resnick (2006) found that family connectedness, adult caring, and school safety may also be protective against suicidal ideation and attempts.
Evidence from several large samples of middle and high school students suggests that the above LGB-specific factors, including victimization and perceived discrimination, largely mediate the association between sexual-minority status and both depressive symptoms and suicidal behavior (Almeida et al., 2009; Birkett et al., 2009; Bontempo and D’Augelli, 2002).
Because large data sets have not measured whether people are transgender, information on suicidal behavior and depressive symptoms among transgender youth is limited to relatively small convenience samples. In a nonprobability sample of 515 transgender people (n = 392 male-to-female and n = 123 female-to-male), Clements-Nolle and colleagues (2006) found that 47 percent of participants younger than 25 (n = 66) had a history of attempted suicide. Another study, of 55 transgender youth aged 15–21, found that 45 percent seriously thought about taking their lives, and 26 percent reported a history of life-threatening behavior (Grossman and D’Augelli, 2007). These studies suggest there is an elevated risk for depression and attempted suicide among transgender youth.
Limited cross-sectional research has explored mental health–related disparities among urban samples of transgender youth. Nuttbrock and colleagues (2010) examined the life course of 571 transgender females aged 19–59 (separated into two age groups: 19–39 and 40–59). The authors found that gender-related interpersonal abuse was a significant health problem in the sample. Among the younger group of transgender women, 15.6 percent reported an attempted suicide during adolescence. Among the older
group, 23.5 percent experienced major depression during adolescence. In addition, interpersonal abuse associated with gender atypicality, not infrequently at the hands of parents or other family members, was associated with both major depression and suicidality as defined by DSM-IV. These associations, particularly with depression, were extremely strong during adolescence, and tended to decline over time but remain significant over the life course.
Interventional approaches to prevent suicidality among LGBT youth have not been widely tested. The published literature includes suggestions to encourage greater awareness and appropriate treatment by health care providers (Kitts, 2005), psychotherapists (Hart, 2001), and school personnel (Bontempo and D’Augelli, 2002); to educate and counsel parents and families to decrease rejecting and increase supportive behaviors (Ryan et al., 2010); or to use specific media to reach isolated youth, such as Web-based social networks (Silenzio et al., 2009). To the committee’s knowledge, however, no specific interventions have been tested. In addition, little research has examined suicidality by race/ethnicity.
Eating Disorders/Body Image
A large cohort study provides some evidence that eating disorders follow gender-specific patterns among LGB youth. In data from the previously mentioned 1999 Growing Up Today Study (n = 10,583 youth), lesbian and bisexual girls, who were combined in the study (n = 59), were found to be more content with their bodies and less likely to report trying to look like images of women in the media than were heterosexual girls. On the other hand, the study found that gay and bisexual boys, also combined in the study (n = 38), were more likely than heterosexual boys to report trying to look like images of men in the media (Austin et al., 2004b). In another study, using the 1998–2005 waves of the Growing Up Today Study (n = 13,795), youth who described themselves as lesbian/gay, bisexual, and “mostly” heterosexual had higher rates of binge eating than their heterosexual peers, and all subgroups with the exception of lesbians had higher rates of purging (vomiting and/or using laxatives to control weight) throughout adolescence (Austin et al., 2009a). While these are provocative findings, they come from only two studies; more research is required to either confirm or refute them. Additionally, if these findings are accurate, more research is needed to understand the mechanisms that put these youth at increased risk for eating disorders.
Results of one study using data from the 1995 and 1997 waves of the Vermont (n = 14,623) and Massachusetts (n = 8,141) Youth Risk Behavior Surveys suggest that youth who reported having sex with both males and females were at greatest risk for a variety of problem behaviors, including
disordered eating. In Vermont, 25.6 percent of youth with sexual partners of both sexes reported using unhealthy weight control practices, compared with 12.3 percent of those with exclusively same-sex sexual partners and 7.1 percent of those with exclusively opposite-sex sexual partners. In Massachusetts these practices were reported by 37.4 percent of students with sexual partners of both sexes, compared with 15.3 percent of those with exclusively same-sex sexual partners and 7.0 percent of those with exclusively opposite-sex sexual partners. This study was based on sexual behavior, not identity (Robin et al., 2002).
The literature on eating disorders among LGBT youth is based on large data sets, unlike most of the literature on these populations, which often relies on small convenience samples. However, the research on eating disorders in these populations is still sparse.
Transgender-Specific Mental Health Status
DSM-IV includes diagnoses of gender identity disorder for children as well as for adolescents (and adults) (American Psychiatric Association, 2000b). The criteria for diagnosis of childhood gender identity disorder are listed in Box 4-1. This diagnosis has been controversial, particularly when applied to children. One objection raised is that including this phenomenon as a psychiatric diagnosis identifies gender-variant identity and expression as pathological, even though many gender-variant children do not report emotional distress; rather, distress may be related to the reaction of the social environment to the child’s gender variance. Also, as noted earlier in this chapter, most children with gender-variant expression do not develop an adolescent or adult transgender identity (Wallien and Cohen-Kettenis, 2008), and many adults with a transgender identity do not report symptoms of childhood gender identity disorder (Lawrence, 2010). More specifically, this diagnosis has been criticized for conflating gender-variant expression with gender-variant identity. At least four of the five criteria are required to qualify for the diagnosis, and only one of these explicitly refers to crossgender identification, allowing children with gender-variant expression but without a variant gender identity to qualify for the diagnosis (see also Bockting and Ehrbar, 2006).
The approach to treatment of gender identity disorder among children includes early therapeutic interventions with the child, and perhaps with the family, school, and/or community, to broaden the child’s gender role interests and behavior and/or provide a safe environment to allow gender identity to develop while preventing rejection, ridicule, and abuse from peers (Benestad, 2009; Brill and Pepper, 2008; Menvielle and Tuerk, 2002; Meyer-Bahlburg, 2002; Rosenberg, 2002; Zucker, 2008). The approach to treatment of gender identity disorder among adolescents includes
Criteria for Diagnosis of Childhood Gender Identity Disorder
In adolescents, it is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.
In adolescents, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.
SOURCE: DSM IV (American Psychiatric Association, 2000b).
therapeutic interventions to assist the adolescent and his or her family to explore and understand gender variance and cope with the related stress and social adjustment, which may include a gender role transition (Di Ceglie, 2009; Meyer et al., 2001). In addition, early medical intervention is avail-
able for carefully selected youth who have persistent gender dysphoria that has increased with the initial stages of puberty and who have support from their parents for such intervention (Cohen-Kettenis et al., 2008; Hembree et al., 2009; Meyer et al., 2001). The intervention consists of administering puberty-delaying hormones (such as gonadotropin-releasing hormone [GnRH] analogs) as early as Tanner Stage II of puberty (a development stage marked by certain physical milestones as opposed to age) and cross-sex hormones as early as age 16. The puberty-delaying hormones allow for more time to monitor the development of the youth’s gender identity while reducing the dysphoria associated with the pubertal development of incongruent sex characteristics, an approach that has been shown to be beneficial (Cohen-Kettenis and van Goozen, 1997; de Vries et al., 2010; Delemarrevan de Waal and Cohen-Kettenis, 2006; Smith et al., 2001, 2005).
PHYSICAL HEALTH STATUS
As noted earlier, for most people, including LGBT youth, childhood and adolescence are times of good physical health. It is not surprising, then, that few studies have examined the physical health of children and adolescents who are LGBT.
Teen Pregnancy/Reproductive Health
Very little research has been conducted on the relationship between teen pregnancy and sexual orientation, although there is some indication that lesbian and bisexual adolescents may have at least the same and possibly an increased likelihood of pregnancy compared with heterosexual adolescents. Saewyc and colleagues (1999) conducted a secondary analysis of a subsample of 12- to 19-year-old young women from the 1987 Minnesota Adolescent Health Survey (n = 3,816) and found that self-identified lesbians and bisexual females (samples combined for analysis, n = 182) were just as likely as their heterosexual counterparts (n = 1,881) to have heterosexual intercourse but much more likely to have gotten pregnant.
In 2008, Saewyc and colleagues (2008) performed secondary analyses on three different waves of the British Columbia Adolescent Health Survey (1992, 1998, and 2003 waves). Sexual orientation in 7th- to 12th-grade youth was measured by means of self-assessment in a paper-and-pencil survey. Gay and bisexual male students were more likely than heterosexual male students to have ever had sexual intercourse. They were also more likely to have been responsible for a pregnancy, to report having had two or more sexual partners, and to report first intercourse before age 14. Lesbian and bisexual female students were more likely than heterosexual female students to have ever had heterosexual intercourse, had higher odds
of having been pregnant, were more likely to have had heterosexual intercourse before age 14, and were more likely to have had two or more sexual partners.
A more recent study using a community-based convenience sample of young women who have sex with women (n = 137, ages 16–24) found that 20 percent had been pregnant (Herrick et al., 2010). Although this is only one study, it is worth noting that this pregnancy rate is comparable to that among all girls. Providers may assume that young women who have sex with women are less likely to get pregnant, but findings from several studies suggest that this may not be the case even for those who self-identify as lesbians.
Aside from the studies conducted by Saewyc and colleagues (1998, 2008), most studies in this area have not included males. Although LGBT youth have indicated an interest in parenting (D’Augelli et al., 2006/2007), a discussion of parenting options and parenting/reproductive issues is largely absent in the literature on LGBT youth.
Childhood obesity rates have risen dramatically in the United States in the past few decades (Ogden et al., 2010). As discussed in the following chapter, some research suggests a higher prevalence of obesity among lesbians than among heterosexual women. However, almost no research has examined weight-related patterns among LGBT youth. One study, drawing on data from the 1998–2005 waves of the Growing Up Today Study (n = 13,785, ages 12–23), found that self-identified sexual-minority adolescent females had elevated body mass indexes (BMIs) compared with their heterosexual peers (Austin et al., 2009b). The same study also found a relationship between sexual orientation and age among males, with heterosexual adolescents showing steeper increases in BMI from early to late adolescence than nonheterosexual adolescents. More research is needed to document whether these disparities are generalizable, to understand the interaction between sexual orientation/identity and body weight among adolescents, and to develop appropriate interventions.
HIV/AIDS and Other Sexually Transmitted Infections
In the United States, the burden of HIV infection among young people falls disproportionately on young men under age 25 who have sex with men, particularly those who belong to racial/ethnic minority groups. Young men who have sex with men account for almost 60 percent of HIV diagnoses among all young people and represent twice as many diagnoses as young women across all risk categories (CDC, 2009). The Young Men’s Survey,
administered by the Centers for Disease Control and Prevention (CDC) in seven urban areas (n = 3,492, ages 15–22), found that 7.2 percent of the young men who have sex with men who were surveyed were HIV-positive; among these youth, prevalence increased with age (from 5.6 percent among those aged 15–19 to 8.6 percent among those aged 20–22) (Valleroy et al., 2000). Waldo and colleagues (2000), using a subsample of the Young Men’s Survey from three counties in San Francisco (n = 719), found that while those aged 15–17 reported fewer overall sex partners in the past 6 months than those aged 18–22, they reported similar levels of other sexual risk behaviors. National surveillance data from CDC for 2001–2006 showed that young men who have sex with men were the only risk group with an increasing number of HIV/AIDS diagnoses; the increase was an alarming 93 percent among young black men (CDC, 2008). Compared with their white peers in the United States in 2006, more than twice as many black young men who have sex with men were diagnosed with HIV; black and Latino young men who have sex with men were more likely to become infected at younger ages (CDC, 2008).
Agronick and colleagues (2004) examined HIV risk behavior among 441 Latino young men and found differences in partnership characteristics between those who self-identified as bisexual and those who self-identified as gay. The bisexual young men were more likely to report more than 1 male sex partner in the past 3 months and were less likely to report being in an exclusive sexual relationship with a primary male partner. The authors also found differences in sexual risk behaviors. The bisexual young men were more likely to report having unprotected insertive anal intercourse during their last sexual encounter with a nonprimary male partner, as well as using drugs or alcohol during their last sexual encounter with either a primary or nonprimary male partner.
Few studies have examined the correlates that might explain the racial/ ethnic differences in HIV seroprevalence or HIV risk (Garofalo et al., 2010; Harawa et al., 2004). According to Peterson and Jones (2009), the racial/ ethnic disparities in HIV seroprevalence are likely due to the intersection of race, sexual orientation, and other social determinants. Millett and colleagues (2007) conducted a meta-analysis comparing black and white men who have sex with men and concluded that behavioral risks, such as unprotected anal intercourse, commercial sex work, sex with a known HIV-positive partner, or HIV testing history may not fully explain racial disparities. While results were generalized across all ages, studies of youth were included in the analysis. For Asian/Pacific Islander youth, very limited data are available (Choi et al., 2005; Do et al., 2005).
Almost no data on HIV risk for young women exist except for a few isolated studies from convenience samples of urban women who have sex with women regarding increased risks for HIV and other sexually
transmitted infections (STIs). One statewide survey using the 1995–2001 waves of the Massachusetts Youth Risk Behavior Survey examined the associations among self-identified sexual orientation (heterosexual, lesbian/ gay, bisexual, or not sure), sex of partners, and HIV-related risk behavior among sexually experienced 9th- to 12th-grade females (n = 3,973). Goodenow and colleagues (2008) found that respondents’ self-identification of their sexual orientation was frequently inconsistent with their reports of the sex of their sexual partners. They also found that self-identifying as lesbian, bisexual, or “not sure” or having any same-sex sexual experiences was associated with a greater probability of HIV-related risk behavior. There have been a few studies, using convenience samples, of HIV and STI prevalence and risk among transgender youth. Although these studies are quite limited (Garofalo et al., 2006; Wilson et al., 2009), they suggest that male-to-female transgender youth may face a risk for HIV similar to or even higher than that of young men who have sex with men.
Some studies of urban samples of young men who have sex with men have begun to look at the potential correlates or underlying mechanisms of HIV risk (Garofalo et al., 2007a, 2008; Koblin et al., 2006; Mustanski, 2007). There is an evolving literature on sexual contexts (for example, older partners and the Internet) as promoters of HIV risk (Mustanski, 2007; Mustanski et al., 2010a). One study involving a convenience sample (n = 120) found that among transgender women, the likelihood of HIV risk behaviors varied according to the nature of the relationship with their sexual partner (either main, casual, or commercial) (Wilson et al., 2010). It should be noted that, while much of the research has focused on sexual risk behaviors, there has been much less research on the actual acquisition of STIs other than HIV among young people. Exceptions are some research on hepatitis B (Diamond et al., 2003; MacKellar et al., 2001) and the work of Valleroy and colleagues (2000) based on the Young Men’s Survey.
Although a fair amount of research has been conducted on the association between sexual orientation and HIV and other STIs, particularly using epidemiological data, the data still have limitations. For example, few studies have examined epidemiological data on multisite or representative national samples (Guenther-Grey et al., 2005; Valleroy et al., 2000). Much of the representative, population-based data still comes from the 1995–1999 Massachusetts Youth Risk Behavior Surveillance System. The first study using these data to examine the association between sexual orientation and health risk behaviors was published in Pediatrics in 1998 (Garofalo et al., 1998).
Few longitudinal or natural history studies of high-risk groups such as young men who have sex with men or young transgender women have been conducted. Filling these gaps in the literature may elucidate underlying mechanisms of risk and ultimately help in designing much-needed interventions, an area in which perhaps the greatest gap in the literature exists.
Despite alarming epidemiological data on the HIV risk faced by young men who have sex with men, there has been no commensurate response in terms of designing and implementing interventions to reduce this risk. The vast majority of youth-specific HIV prevention programs in the published literature are focused on heterosexual young people (Johnson et al., 2003; Mullen et al., 2002; Pedlow and Carey, 2004; Robin et al., 2004). A recent meta-analysis of HIV behavioral interventions targeting men who have sex with men reported not a single randomized controlled trial in which the mean age was less than 23 (Herbst et al., 2005). Similarly, in a community-based HIV prevention program targeting young men who have sex with men (n = 300 men who have sex with men), the mean age was 23 (Herbst et al., 2005; Kegeles et al., 1996).
Transgender-Specific Physical Health Status
Although some literature addresses the process of gender identity development among transgender youth, little of this literature is supported by empirical evidence or longitudinal data. The lack of available cohort data on the relationship between developmental issues and general health status represents a distinct gap in the literature. In addition, although some small, largely European studies in children and adolescents have examined the effects and consequences of hormone administration and/or blocking of puberty with GnRH analogs, empirical data on how these medical interventions affect overall physical health and well-being remain extremely limited. While some preliminary animal studies have suggested that GnRH analog therapy can affect sex-specific brain development, no comparable research has been done in humans.
RISK AND PROTECTIVE FACTORS
The literature addresses a number of risk factors that affect the health of LGBT youth. Conversely, little research has been conducted on protective factors for these populations.
Risk factors affecting the health of LGBT youth examined in the literature include harassment, victimization, and violence; substance use; homelessness; and childhood abuse.
Harassment, Victimization, and Violence
Compared with heterosexual youth, LGBT youth report experiencing higher levels of harassment, victimization, and violence, including verbal,
physical, and sexual abuse. These experiences are related to increased substance use (see below), mental health problems, and sexual risk-taking behavior (Birkett et al., 2009).
School-based harassment, bullying, and peer victimization are the most common topics in the literature on LGB youth. This emphasis may be due to the role of schools in child and adolescent socialization and development and the increasing focus over the past 20 years on schools as a primary site of conflict, victimization, and activism for young people who are known or perceived to be LGBT.
School victimization based on known or perceived sexual orientation and gender identity has been documented consistently in studies of LGB and, more recently, transgender adolescents. A community-based study of LGB youth aged 21 or younger (n = 350) (D’Augelli et al., 2002) found that school-based victimization was widespread for LGB youth and that an association existed between this victimization and mental health and posttraumatic stress symptoms. The study results showed that earlier recognition of same-sex feelings, self-identification as LGB, and disclosure of sexual orientation were correlated with increased high school victimization. Similarly, youth who were open about their sexual orientation or exhibited gender-atypical behavior were targets for victimization. Likewise, a series of community school climate surveys conducted since 1999 has documented extensive verbal and physical harassment and discrimination among LGBT students in schools (Kosciw et al., 2007, 2008).
Population-based surveys of high school students have shown that those with same-sex sexual experience (DuRant et al., 1998; Faulkner and Cranston, 1998; Robin et al., 2002) and those who identify as LGB (Garofalo et al., 1998) are more likely than their heterosexual peers to be threatened or injured with a weapon at school and to skip school because they feel unsafe. (Few population-based studies have assessed risk factors affecting the health of LGBT youth beyond violence. Those that have [Garofalo et al., 1998; O’Shaughnessy et al., 2004] have found significantly higher rates of health problems among LGB youth compared with their heterosexual peers.)
Concerns about their safety have consequences for the academic achievement of LGBT youth. O’Shaughnessy and colleagues (2004) examined data from the 2002 California Healthy Kids Survey (n = 237,544) and the 2003 Preventing School Harassment Survey (n = 634) and found that, compared with other students, LGBT students and students perceived to be sexual minorities were more likely to report low grades, to miss school because they felt unsafe, and to report less support from teachers and other adults. Similarly, using data from the 1995 wave of the National Longitudinal Study of Adolescent Health, Russell and colleagues (2001) found that, compared with heterosexual girls, sexual-minority girls as identified
by same-sex attraction may hold less positive attitudes about school and may be more likely to have school problems. Both bisexual-attracted boys and girls appear to be significantly more likely to have school troubles and lower grade point averages. The study did not find significant differences in school outcomes or attitudes between heterosexual boys and boys reporting exclusively same-sex attraction.
Using data from waves 1 and 3 of the National Longitudinal Study of Adolescent Health, Himmelstein and Bruckner (2010) examined both school and criminal punishments received by LGB youth. They found that sexual-minority adolescents were 1.25 to 3 times more likely than their heterosexual peers to receive punishment from schools, police, or courts. The authors note that this greater likelihood of punishment is not explained by greater engagement in troublesome behaviors and suggest that LGB youth may be targeted for punishment or that mitigating factors such as self-defense may be overlooked.
Although less research has focused on nonschool settings, LGBT youth experience victimization and violence in their homes, communities, and other institutions. In a 1998 study of 105 LGB youth aged 14–21, family-based victimization, including verbal and physical abuse, was related to disclosure of and openness about sexual orientation (D’Augelli et al., 1998). In addition, results from a convenience sample of 521 LGB youth aged 13–22 suggest that LGB youth experience dating and intimate partner violence at rates that may be similar to those for heterosexual youth (Freedner et al., 2002).
Other than studies in small LGBT-specific journals, very little literature includes or focuses on transgender or gender-variant youth’s experience of victimization or violence (Garofalo et al., 2006; McGuire et al., 2010). This lack of attention may be due to limited access to data sets that include transgender youth. Nonetheless, gender-based harassment and victimization clearly are a reality for transgender and gender-variant youth and are directly related to physical and emotional health outcomes. For example, a recent study of school victimization of gender-variant LGBT youth showed that the association between adolescent gender nonconformity and psychosocial adjustment in young adults is impacted by victimization as a result of perceived or actual LGBT status (Toomey et al., 2010).
Disparities in rates of substance use exist between LGB and heterosexual youth, with sexual minority youth reporting increased substance use and initiation of use at younger ages (Corliss et al., 2010; Marshal et al., 2009). The trajectory of substance use also appears to increase more rapidly for LGB youth compared with those who self-identify as heterosexual.
A study using data from the 1994–1996 wave of the National Longitudinal Study of Adolescent Health (n = 12,603) found that sexual-minority adolescent males and females had a higher prevalence of smoking than heterosexual youth (Easton et al., 2008). In a large cohort study using data from the 1999 Growing Up Today Study (n = 10,685), lesbian and bisexual girls (n = 62) were 9.7 times more likely than heterosexual girls (n = 5,475) to have smoked at least weekly in the past year. While there was no significant difference in the likelihood of smoking between gay and bisexual boys (n = 41) and heterosexual boys (n = 3,821), gay and bisexual boys were less likely to have tobacco dependence. In this study, lesbian and bisexual girls were combined for analysis, as were gay and bisexual boys (Austin et al., 2004a).
Another study examining substance use among college students (n = 9,161) found that both self-identified and behaviorally bisexual women had significantly higher odds of cigarette smoking (McCabe et al., 2005). Eisenberg and Wechsler (2003a) examined substance use and sexual behavior in a national sample of sexually active college students (n = 10,301) and found that women with both-sex partners were significantly more likely to smoke than women with exclusively other-sex partners. A significantly increased risk for smoking was not found among women and men with same-sex partners only or men with both-sex partners.
In addition to smoking, LGB youth may be at greater risk than their heterosexual peers for alcohol consumption. Almost a quarter of a community-based sample of young men who have sex with men aged 18–24 (n = 526) reported binge drinking (Wong et al., 2008). Three national studies using data from the National Longitudinal Study of Adolescent Health, the Growing Up Today Study, and the 1999 College Alcohol Study showed that adolescent males and females who indicated they had “both-sex” attractions were more likely to drink alcohol than their heterosexual counterparts (Russell et al., 2002; Ziyadeh et al., 2007). In the previously mentioned study by McCabe and colleagues (2005), no difference in heavy episodic drinking was found between self-identified bisexual and heterosexual females, but there were significantly higher rates of heavy episodic drinking among behaviorally bisexual than behaviorally heterosexual females. In contrast, self-identified and behaviorally bisexual males were significantly less likely than heterosexual males to engage in heavy episodic drinking (McCabe et al., 2005).
Differences in drug use and abuse based on sex may exist among LGB youth. In the previously mentioned study by Ford and Jasinski (2006), bisexual females were more likely than either heterosexual or homosexual students to have used marijuana and other illicit drugs. Other studies support this finding, with self-identified and behaviorally bisexual students, especially females, being more likely than any other group (e.g., lesbian, gay,
heterosexual) to report drug use (Eisenberg and Wechsler, 2003a; Russell et al., 2002). On the other hand, McCabe and colleagues (2005) did not find a significant difference in rates of illicit drug use among homosexual, bisexual, and heterosexual college males.
In a community-based sample of 310 young men who have sex with men aged 16–24, methamphetamine use was identified as correlated with high-risk sexual behavior as well as with specific sexualized social contexts (for example, the Internet, bathhouses) (Garofalo et al., 2007b).
The literature highlights a number of potential mediators of substance use in LGB youth. In a study of 156 LGB youth aged 14–21, receiving a rejecting reaction to disclosure of sexual orientation was associated with use and abuse of alcohol, cigarettes, and marijuana (Rosario et al., 2009). Tucker and colleagues (2008) examined other psychosocial factors that may predict substance use among young women. Results of a longitudinal survey of approximately 1,600 young women based on self-reported sexual orientation as either bisexual or heterosexual (participants identifying as lesbian were not included in the analysis) suggest that as adolescents, bisexual women were more likely to have been substance users. Self-identified bisexual participants were also more likely than self-identified heterosexual participants to report holding beliefs in support of drugs, greater perceived parental approval of substance use, increased exposure to peers who used substances, and poorer mental health. By age 23, bisexual women in the study had higher rates of current substance use, greater quantity and frequency of use, and more problematic use (Tucker et al., 2008).
Almost no research has examined substance use among transgender youth. In one study, using a convenience sample of male-to-female transgender youth (n = 51) aged 16–24 from racial and ethnic minority communities, 65 percent reported alcohol use in the last year (Garofalo et al., 2006).
Although self-identified LGB youth engage in greater substance use and earlier initiation of use than heterosexual youth, sufficient evidence does not exist in the literature to determine whether this trend levels out with age. The committee was unable to locate longitudinal or natural history studies examining issues of substance use in these populations. Such studies would be helpful in discerning how patterns of use change over time and whether greater use relative to heterosexual youth levels off as these young people age into adulthood. There also has been little research on interventions specifically targeting substance use in LGBT youth.
Lesbian, gay, and bisexual youth are disproportionately represented among the homeless youth population. Studies of homelessness using a
variety of samples have reported that 22–35 percent of their samples comprise sexual-minority youth (Cochran et al., 2002; Rew et al., 2002; Van Leeuwen et al., 2006). Studies specific to sexual minorities suggest that LGB youth are at increased risk of homelessness (Cochran et al., 2002; Gwadz et al., 2004; Milburn et al., 2006; Rew et al., 2002; Whitbeck et al., 2004). Furthermore, Gwadz and colleagues (2004) report that, in their sample of 569 young men who have sex with men, the probability of becoming homeless increased with age. Additionally, compared with young men who have sex with men who self-identified as homosexual or gay, the likelihood of homelessness was four times greater for those young men who have sex with men who identified as heterosexual, three times greater for those who identified as bisexual, and twice as likely for those who identified as transgender. The literature tends to define sexual orientation by behavior rather than by identity or attractions, thereby failing to account for the unique challenges faced by youth who engage in same-sex survival sex (sex for money, food, etc.) or the complex impact sexual identity may have on risk factors. Therefore, these findings are especially useful in helping to identify how sexual identity (as opposed to sexual behavior) may impact risk.
A review by Coker and colleagues (2010) highlights that the general risks associated with homelessness are exacerbated for LGB youth. In studies examining both sexual-minority and heterosexual homeless youth, the sexual-minority youth were shown to be at significantly greater risk for mental health issues (Cochran et al., 2002; Gangamma et al., 2008; Noell and Ochs, 2001; Whitbeck et al., 2004), including suicidal ideation and/or suicide attempts (Leslie et al., 2002; Noell and Ochs, 2001; Van Leeuwen et al., 2006).
In a study examining homeless adolescents (n = 227), LGB youth (n = 37) were significantly more likely than heterosexual youth to report discrimination due to being homeless (Milburn et al., 2006) and to have been sexually and/or physically victimized while homeless (Cochran et al., 2002; Whitbeck et al., 2004). Likewise, although homeless or street-involved LGB youth appear to be more likely than homeless heterosexual youth to be tested for HIV and other STIs (Rew et al., 2005; Solorio et al., 2006; Van Leeuwen et al., 2006), they also appear to engage in more sexual risk behaviors (Kipke et al., 2007), making them more likely to contract such infections (Gangamma et al., 2008; Marshall et al., 2010). And various studies have found that young men who have sex with men are significantly more likely than young heterosexual men to engage in survival sex after becoming homeless (Gangamma et al., 2008; Marshall et al., 2010; Russell et al., 2001; Van Leeuwen et al., 2006; Whitbeck et al., 2004). The literature also suggests that homeless young men who have sex with men are more likely than nonhomeless young men who have sex with men to use controlled substances (Clatts et al., 2005) and to have a lifetime
history of substance use (Clatts et al., 2005). Therefore, it is apparent from the literature not only that LGB youth are at greater risk for homelessness than their heterosexual peers, but also that once homeless, LGB youth are more likely to experience multiple risk factors and significantly more negative outcomes.
Research on LGB homelessness has utilized both cross-sectional and longitudinal designs, and most studies have occurred in large, urban settings. The majority of samples have been recruited through venue-based convenience sampling and with the assistance of social service agencies. To the best of the committee’s knowledge, there has been no published research on interventions directed at decreasing homelessness or alleviating negative outcomes among homeless LGB youth.
More problematic is that there has been very little research focused directly on the specific needs of homeless youth who are LGBT. Given the magnitude of the risks to which sexual- and gender-minority homeless youth are exposed, the scholarship on this particular issue lacks the depth needed to fully assess the problem or to inform the development of interventions. For example, the majority of studies provide comparisons of homeless LGB and heterosexual youth, outlining the basic risks without examining the mechanisms of those risks in depth. Understanding the mechanisms of risks is critically important, as highlighted by the case study of HIV in Chapter 2. In the case of HIV, the failure to examine mechanisms of risk among LGBT youth, specifically young men who have sex with men and young transgender women, has hindered the development of interventions for these high-risk groups.
There is almost no literature examining the risks of homelessness faced by transgender youth. The limited research that has been done on transgender females using small convenience samples suggests that they are at significant risk for homelessness (Garofalo et al., 2006; Wilson et al., 2009). There are hardly any data on homelessness among transgender males.
Most of the literature on childhood abuse is based on adults reporting retrospectively about their childhood and/or adolescence. Chapters 5 and 6 present some of that literature. However, in secondary analyses of data from seven population-based high school health surveys in the United States and Canada, Saewyc and colleagues (2006) found that the prevalence of sexual and physical abuse was significantly higher for sexual minorities than for their heterosexual peers in nearly all of the surveys. In a survey of 391 young women aged 18–24, Austin and colleagues (2008) found that, compared with heterosexual females, “mostly heterosexual females” reported higher rates of childhood sexual abuse. More research is needed
to determine what impact childhood emotional, physical, and sexual abuse has on LGBT youth, including how disclosure or nondisclosure of sexual identity relates to this abuse; when the abuse is taking place; and what interventions might be appropriate.
While some may view the absence of risk factors as protective, there is, as noted earlier, a paucity of data on specific protective factors that affect the health of LGBT youth. When examining protective factors, it is important to focus on multiple levels: the individual level, interactional levels (e.g., family, school, or peers), and the broader systems level. The few studies that have examined protective factors for LGBT youth have considered individual and interactional factors, such as self-esteem (Savin-Williams, 1989a,b), school support, and family relatedness (Eisenberg and Resnick, 2006). Saewyc and colleagues (2009), using data from six large-scale school-based surveys, compared family connectedness, school connectedness, and religious involvement among bisexual adolescents with the same protective factors among heterosexual, mostly heterosexual, and homosexual adolescents. The results showed that in almost all of the cohorts, bisexual adolescent boys and girls tended to report lower levels of family and school connectedness compared with heterosexual adolescents. Similarly, Sheets and Mohr (2009) examined the relationship between social support and psychosocial functioning in 210 self-identified bisexual college students aged 18–25 and found that the level of support of both family and friends predicted depression, life satisfaction, and internalized negative feelings about bisexuality. Using data from the previously mentioned 2004 Minnesota Student Survey (n = 21,927), Eisenberg and Resnick (2006) studied four protective factors (family connectedness, teacher caring, other adult caring, and school safety) and their association with suicidal ideation and attempts among high school students with same-sex sexual experience. Based on their sex partners, the students were classified as LGB or non-LGB, and data on the LGB students were analyzed as a whole. The researchers found that family connectedness, adult caring, and school safety were significantly protective against suicidal ideation and attempts.
The systemic exposure to stigma that LGBT children and adolescents experience from early ages calls for studying protective factors that are unique to LGBT youth in addition to those that can be found among heterosexual youth (Russell, 2005). While little research has focused on protective factors unique to LGB youth, several studies may provide insight. For example, an association was found between high self-esteem among young gay men (n = 214) and their being open about their gay identity with their mothers (Savin-Williams, 1989a), as well as holding positive attitudes
about homosexuality (Savin-Williams, 1989b). These findings may warrant further research. Another potential protective factor may be disclosure of sexual identity. In one study of 156 LGB youth participating in an HIV prevention program, youth who disclosed their sexual identity to more people in their support networks were less likely to have high levels of distress related to their sexual identity, which has been associated with mental health problems in LGB youth (Wright and Perry, 2006). However, disclosure of identity is a multifaceted issue, and as noted in the above discussion of risk factors, may also lead to harassment and victimization (D’Augelli, 2002). Ryan and colleagues (2010) found protective effects related to specific accepting family reactions to adolescents’ LGBT identity—such as advocating for the youth when they were discriminated against or welcoming their LGBT friends and partners to family events and activities. In their community sample of LGBT young adults (n = 245), those who experienced high levels of family acceptance reported significantly lower rates of depression, substance abuse, and suicidal ideation and attempts compared with those who reported no or low levels of family acceptance. Unique protective factors for LGBT youth warrant further study, particularly to inform services and approaches to caring for LGBT adolescents.
A small body of research has begun to evaluate the impact of school policies and procedures on the experiences of LGB students (Szalacha, 2003). Blake and colleagues (2001), using data (n = 4,159) from the 1995 Massachusetts Youth Risk Behavior Survey, found an association between LGB students who attended schools with gay-sensitive HIV instruction and less sexual risk taking than their LGB peers in other schools. Goodenow and colleagues (2006) analyzed data from the 1999 Massachusetts Youth Risk Behavior Survey and a 1998 state survey of high school principals to examine the relationship among school supports, victimization, and suicidality among LGB youth. They found that LGB students (n = 202) who attended schools with supportive staff, antibullying policies, and gay–straight alliance clubs were less likely to report being victimized, skipping school because of fear of victimization, or attempting suicide compared with those in other schools. They also found that sexual-minority youth in larger schools with more low-income and ethnically diverse students experienced lower rates of victimization and suicidality. In the previously mentioned study by O’Shaughnessy and colleagues (2004), results showed that students at schools with antiharassment policies reported feeling safer and less likely to be harassed. Similarly, students were less likely to report being harassed or feeling unsafe at schools with gay–straight alliance clubs and teachers who intervened to stop harassment. Another study comparing sexual minorities at colleges with and without LGB resources found that sexual-minority women were less likely to smoke at colleges with LGB resources, but sexual-minority
men were more likely to binge drink at these same colleges (Eisenberg and Wechsler, 2003b). These conflicting findings indicate the need for further study to understand protective factors.
In addition to addressing specific needs related to sexual orientation and gender identity, primary care for LGBT adolescents, as for all adolescents, should be sensitive, comprehensive, and high-quality. Preventive health and health maintenance visits should include periodic, private, and confidential discussions of a range of health and health-related issues, including sexuality and sex (Frankowski and American Academy of Pediatrics Committee on Adolescence, 2004). These discussions should address identity-related feelings and concerns, as well as behaviors and experiences that can affect health and development.
Access and Utilization
With the recent implementation of health care reform, access to health services has increased for many youth since they can now be covered under their parents’ insurance until age 26. However, this increased access may be less relevant for those LGBT youth who are not cared for by their families.
In some U.S. cities, specialized health care centers are available to provide comprehensive care to LGB youth. In addition to primary care services, these centers provide other services, such as case management, counseling, and support groups. Organizations such as the Gay and Lesbian Medical Association have websites that offer listings of health care professionals who are able to provide appropriate care to LGB patients. However, not all LGB youth have access to such centers or health care professionals; most receive health care from providers in their own community who also provide care to non-LGB youth. Nationally, family physicians are the primary care providers for the majority of youth aged 15–24, and overall they are insufficiently trained to provide care to LGBT youth (IOM, 2009).
In a study of the experiences of transgender youth with physical and mental health services (n = 26), the youth reported a lack of access to health care for the prevention and treatment of STIs, transition-related health services, and mental health services; they attributed this lack of access to discrimination by providers (Grossman and D’Augelli, 2006). As with LGB youth, while centers exist that specialize in providing care to transgender patients, not all transgender youth have access to these centers.
Quality of Care
Studies utilizing convenience samples of LGBT youth show that they value the same health provider characteristics as other youth. Specifically, they wish to receive private and confidential services, to be treated with respect and honesty, and to be seen by providers who are well trained and have good listening and communication skills (Ginsburg et al., 2002; Hoffman et al., 2009).
Whether LGB or straight, adolescents often are uncomfortable with initiating discussions about sex (including sexual orientation) with their providers; thus, it is incumbent on those who provide health services to youth to initiate such discussions. Studies of LGB youth (using small convenience samples) show that substantial percentages have not disclosed their sexual orientation to their physician; these include youth who describe themselves as being out to almost everyone in their lives (Allen et al., 1998; Meckler et al., 2006). In a sample of 60 pediatricians and adolescent medicine specialists responding to a mailed survey, more than half reported that they do not usually include sexual orientation in their sexual histories, and a large majority had some reservations about broaching the issue with patients (East and El Rayess, 1998). In a more recent self-administered survey, most physicians reported that they did not discuss sexual orientation, sexual attraction, or gender identity with their adolescent patients. A majority of respondents indicated they would not address sexual orientation even if their patient were depressed, had suicidal thoughts, or had attempted suicide. Physicians reported that they did not feel they could adequately address sexual orientation issues with their patients (Kitts, 2010). In a similar study, 70 percent of physicians reported that they did not discuss sexual orientation with their adolescent patients. Many of those physicians reported a fear of offending patients and a lack of knowledge about the treatment needs of sexual-minority patients (Lena et al., 2002). Furthermore, data from a variety of samples suggest that many clinicians may have negative attitudes toward LGBT individuals. These attitudes may affect clinicians’ ability to provide appropriate care to these populations (Kaiser Family Foundation, 2002; Klamen et al., 1999; Sanchez et al., 2006; Smith and Mathews, 2007).
The health of LGBT children and adolescents is shaped by contextual influences such as sociodemographic and familial factors. Limited research exploring these factors has been conducted.
Few recent population-based studies have published substantive sociodemographic findings on LGBT youth. However, studies with smaller samples suggest that sociodemographic factors play a role in the lives of LGBT youth. For example, in a community-based sample of 145 sexual-minority youth aged 14–21, Rosario and colleagues (2004) found racial and ethnic differences in the timing of the coming out process. Similarly, a recent retrospective study of a community-based sample of 245 LGBT young adults on family acceptance during their adolescence found an association between family acceptance and parental job status, with highly accepting families having higher parental job status (Ryan et al., 2010). The same study also explored religion as a factor in family acceptance and found that participants who reported a religious affiliation in childhood also reported lower family acceptance compared with participants with no childhood religious affiliation (Ryan et al., 2010).
Drawing on population-based data obtained from students in 7th through 12th grades in British Columbia, Poon and Saewyc (2009) compared adolescents from rural and urban areas. They found differences between the groups on some health outcomes (for example, rural sexual-minority youth were more likely than their urban peers to binge drink) and further noted that the interaction between gender and location produced different outcomes. Rural boys were more likely to have considered or attempted suicide in the past year than rural girls or urban boys, and rural girls were more likely than urban girls or rural boys to have been physically assaulted at school.
More community-based and population-based research on the lives of LGBT adolescents is needed to document the role of sociodemographic factors and their impact on health. Community-based research can help inform the questions in this area for population-based surveys.
Although connections to family have been shown to be protective against major health risk behaviors, the literature on LGB youth and families has been very limited in scope and quantity, and has focused mainly on negative aspects of the relationships between LGB youth and their parents. Little research has examined the family experiences of transgender youth. Exceptions include research conducted by Grossman and colleagues (Grossman and D’Augelli, 2006; Grossman et al., 2005) as part of a larger study of LGBT youth using a convenience sample and Ryan and colleagues’ (2010) research on LGBT adolescents, young adults, and families.
Family-related research has been based on reports of LGBT youth themselves and rarely on reports of parents or other family members, especially among ethnically diverse groups. Research has continued to document fear of coming out to parents (D’Augelli et al., 1998), which remains a persistent concern for LGB youth (D’Augelli et al., 2010) despite considerable social changes over the past two decades.
Other research has measured parental rejection and support among LGBT adolescents and young adults in several ways. Rosario and colleagues (2009) examined substance use among LGB youth (n = 156) and asked the youth whether they perceived reactions to their LGB identity from a range of people (including family members, coaches, teachers, and friends) to be accepting, neutral, or rejecting. The number of perceived rejecting reactions was found to predict substance use. Although accepting reactions did not directly reduce substance use, such reactions buffered the link between rejecting reactions and alcohol use.
Needham and Austin (2010) assessed the relationship between LGB young adults’ perceived family support (e.g., general closeness, warmth, and enjoying time together) and depression, substance use, and suicidality using data on young adults from wave 3 of the National Longitudinal Study of Adolescent Health (n = 11,153). They found that parental support either partially or fully mediated associations related to suicidal thoughts, recent drug use, and depressive symptomatology.
Ryan and colleagues (2009) measured specific parental rejecting behaviors in a sample of 224 LGB young adults, recruited from community organizations, who were open about their LGB identity to at least one parent or caregiver during adolescence. They found associations between parental rejection and use of illegal drugs, depression, attempted suicide, and sexual health risk. A subsequent study of specific parental and caregiver supportive behaviors during adolescence found that family acceptance during adolescence predicted increased self-esteem, social support, and general health status, and also protected against depression, substance abuse, and suicidal ideation and behaviors among LGB young adults (Ryan et al., 2010).
Results of the above studies provide evidence to inform family interventions aimed at reducing risk and promoting well-being among LGBT children and adolescents, thereby reducing health disparities and affecting outcomes across the life course.
Little research has focused on LGBT youth in custodial care—foster care or juvenile justice—although reports from providers have noted a high proportion of LGBT youth in these systems over many years. Researchers and providers have documented the experiences of LGBT individuals involved in these systems in a series of listening forums across the United States (Child Welfare League of America, 2006). In addition, experts have developed model standards for care of LGBT youth in foster
care and juvenile justice settings that are informed by research (Wilbur et al., 2006).
SUMMARY OF KEY FINDINGS AND RESEARCH OPPORTUNITIES
Although the data on LGBT youth are scarce, the available research offers a number of important findings about the health status of these populations. Key findings are presented below.
Development of Sexual Orientation and Gender Identity
As a result of the ongoing process of sexual development and awareness among adolescents, self-identification of sexual orientation and the sex of sexual partners may change over time and may not necessarily be congruent.
Some research examining sexual identity development among ethnically diverse sexual-minority adolescents suggests that the process may differ as adolescents negotiate both ethnic and sexual orientation identity.
A relatively small percentage of gender-variant children may develop an adult transgender identity.
Gender-variant children may have more difficulties with peer relationships and behavioral problems than non-gender-variant children.
Mental Health Status
LGB youth are at increased risk for suicidal ideation, attempted suicide, and depression. This increased risk appears to be consistent across age group, gender, race, and self-identified orientation. A few studies with small nonprobability samples suggest the same is true for transgender youth.
Potential risk factors for increased rates of suicidal ideation and suicide attempts specific to LGB youth include sexual-minority status, homophobic victimization and stress, and family rejection.
A few studies show that LGB youth may demonstrate higher rates of disordered eating than heterosexual youth.
Physical Health Status
Pregnancy rates may be the same or possibly even higher for lesbian and bisexual girls than for heterosexual girls.
Self-identified sexual-minority females may have elevated BMIs relative to their heterosexual peers.
While GnRH analogs may be used to alleviate gender dysphoria among adolescents, a paucity of empirical data exists concerning how these medical interventions affect overall physical health and well-being.
The burden of HIV infection falls disproportionately on young men who have sex with men, particularly young black men who have sex with men. These racial disparities are likely due to the intersection of race, sexual orientation, and other social determinants. Additionally, interventions are lacking for this group of LGBT youth.
Limited studies suggest that male-to-female transgender youth may face a risk for HIV similar to or even higher than that faced by young men who have sex with men.
Risk and Protective Factors
LGBT youth report experiencing elevated levels of harassment, victimization, and violence. School-based victimization due to known or perceived identity has been documented, although very little literature exists on violence experienced by young lesbians, bisexual women, or transgender people.
Compared with other students, sexual-minority youth may be more likely to report feeling unsafe at school, being offered weaker support by school staff, and receiving lower grades.
Rates of substance use, including smoking and alcohol consumption, may be higher among LGB than heterosexual youth. Almost no research has examined substance use among transgender youth. Few interventions have been developed to address these disparities.
The homeless youth population comprises a disproportionate number of LGB youth. Some research suggests that young transgender women are also at significant risk for homelessness. There are almost no data on homelessness among young transgender men. Interventions designed to decrease homelessness are lacking, and limited research on the specific health needs of homeless LGBT youth has been conducted.
The prevalence of childhood abuse may be higher among sexual-minority youth compared with their heterosexual peers.
The few studies that have examined protective factors for LGBT youth suggest that family connectedness and school safety are two possible areas for intervention research.
Limited studies evaluating the impact of school polices on the experiences of LGB students indicate that students attending schools with antiharassment policies report that they feel safer and are less likely to be harassed.
Family acceptance among LGBT youth may be a protective factor against depression, substance use, and suicidal ideation and attempts.
LGBT youth may lack access to health care professionals who are able to provide appropriate care to LGBT patients.
Small studies suggest that many LGB youth have not disclosed their sexual orientation to their physician. Similarly, there appears to be some unease among physicians about addressing sexual orientation with their adolescent patients.
Population-level data on sociodemographic factors that affect LGBT youth are lacking. Studies with small samples suggest that sociodemographic factors, including race, ethnicity, geography, religion, and socioeconomic status, play a role in the lives of LGBT youth.
While research on families suggests that family support may be protective, most research has focused on negative interactions with families. Results of this research suggest that family rejection may be associated with negative mental health outcomes.
Research on all adolescents, regardless of their sexual orientation or gender identity, is limited. However, research on the health status of LGBT youth is particularly challenging. Other than small studies based on convenience samples, the committee found no studies addressing health and health care for subgroups of LGBT youth, such as racial and ethnic minorities, or health and health care for transgender youth. While a few studies on LGBT health have included bisexual youth, research examining health and health care for this group specifically is quite limited. Both cross-sectional and longitudinal research is especially needed to explore the demographic realities of LGBT youth in an intersectional and social ecology framework, and to illuminate the mechanisms of both risk and resilience so that appropriate interventions for LGBT youth can be developed. These parameters could be brought to bear in research in the following areas:
Demographic and descriptive information, including the percentage of adolescents who are LGBT and how that percentage varies by demographic characteristics such as race, ethnicity, socioeconomic status, geography, and religion; also, the general experiences and health status of LGBT adolescents and how these vary by demographic characteristics.
Family and interpersonal relations, including the family life of LGBT youth from diverse backgrounds (e.g., race/ethnicity, socioeconomic status) and school and social life concomitants of LGBT identity and attraction, with special attention to protective factors at the individual, interactional (family, school, peers), and systems levels; also patterns and experiences of homelessness among LGBT youth, as well as intrafamily and domestic violence (e.g., sexual abuse, abuse by parents, intimate partner violence) and anti-LGBT victimization.
Health services, including barriers to access (particularly related to identity disclosure and interactions with providers), utilization rates, and quality of care received.
Mental health, including the diagnosis of disorders among LGBT youth, their rates of suicidal behavior and suicidality, identity-related issues and experiences of stigma and discrimination, and eating disorders.
Physical health, including obesity and substance use (including smoking and alcohol use).
Sexual and reproductive health, including sexual development, sexual health, reproductive health, risk behaviors, pregnancy, STIs, and HIV rates and interventions (with a focus on natural history studies of high-risk groups).
Transgender-specific health care, including the effects, benefits, and risks of puberty-delaying hormone therapy.
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