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Introduction

BACKGROUND

To better understand the inequalities facing lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth and the promising interventions being used to address these inequalities, the National Academies of Sciences, Engineering, and Medicine’s Board on Children, Youth, and Families hosted a virtual public workshop titled Reducing Inequalities Between LGBTQ Adolescents and Cisgender, Heterosexual Adolescents, which convened on August 25–27, 2021. The workshop was developed by a planning committee composed of experts from the fields of sociology, medicine, public health, psychology, social work, policy, and direct-service provision. This Proceedings of a Workshop summarizes the presentations and discussions from that workshop.

On day one of the workshop, speakers explored key concepts and frameworks necessary to understand inequalities facing LGBTQ youth and reviewed the policy and research landscapes around LGBTQ youth well-being (see Appendix A for complete agenda). Exploring interventions that address differences among sexual-minority youth across the intersecting social identities of race, ethnicity, cultural background, gender, and gender identity was a primary aim of the workshop. Day one concluded with a panel highlighting the lived experience of LGBTQ youth of color and a panel focused on the state of knowledge regarding outcomes and interventions for LGBTQ youth of color. Speakers on workshop days two and three detailed promising interventions being used to reduce inequalities in the domains of health, education, family, and community, as well as in systems of care and juvenile justice.

ORGANIZATION OF THE PROCEEDINGS

This proceedings describes the workshop panel presentations and the discussion that followed each panel. The chapters are organized around the key topics of the workshop, with some chapters including summaries of related content from multiple panels. Chapter 1 highlights key concepts and definitions, including an overview of sexual and gender diversity and inequalities. This chapter applies an intersectional lens to LGBTQ youth well-being, and reviews the research and policy landscape. Chapter 2 focuses broadly on outcomes and interventions for LGBTQ youth of color, and includes a summary of the workshop’s lived experience panel. Chapters 3 through 6 offer insights into key inequalities facing LGBTQ youth in various domains, and these chapters highlight promising interventions for addressing inequalities in these areas. Chapter 3 focuses on personal, carceral, and care systems; Chapter 4 focuses on family and community; Chapter 5 addresses mental, emotional, and physical health; and Chapter 6 addresses education. Finally, Chapter 7 summarizes reflections shared in the workshop’s closing sessions.

The full meeting agenda and biographical sketches of planning committee members and workshop presenters appear in the appendices. A full recording of the workshop and the speakers’ presentations have been archived online.¹

This proceedings has been prepared by the workshop rapporteur as a factual summary of what occurred at the workshop. The views contained in the proceedings are those of the individual workshop participants and do not necessarily represent the views of other workshop participants, the workshop planning committee, or the National Academies.

OPENING REMARKS

Stephen Russell (University of Texas at Austin), chair of the workshop planning committee, welcomed workshop participants and called attention to two reports from the National Academies that are relevant to the topic at hand. In 2019, The Promise of Adolescence was published; this consensus report explored how changes in brain structure, function, and connectivity create a period of opportunity and possibility during adolescence (NASEM, 2019). Russell noted that, for the purposes of this workshop, the planning committee adopted the definition of adolescence from the 2019 report. Rather than a specific age range, adolescence is a period of complex social changes that begin in late childhood and last through multiple social transitions into adulthood, he said. In 2020, the National Academies published

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¹ For more information, see: https://www.nationalacademies.org/event/08-25-2021/reducing-inequalities-between-lgbtq-adolescents-and-cisgender-heterosexual-adolescents-a-workshop.

Understanding the WellBeing of LGBTQI+ Populations, which was motivated by the growing prevalence and visibility of sexual- and gender-diverse (SGD) people in the U.S. and around the world, and the need for greater understanding of the ways that laws, systems, and programs affect their well-being (NASEM, 2020).

Over the last decade, said Russell, it has become evident that disparities related to sexual orientation and gender identity are going in the wrong direction, particularly for subgroups of SGD youth, such as youth of color and youth with plurisexual identities. These same subgroups have historically been excluded from research on LGBTQ youth, meaning that the most marginalized and disadvantaged populations are also the least understood. The present workshop, said Russell, aims to explore three questions posed in the Statement of Task (see Box 1-1).

The planning committee set several priorities for the workshop. First, the committee prioritized inviting speakers with diverse experiences in terms of identities, disciplines, and institutions, and also included the perspectives of young people themselves. Second, the workshop was designed to focus on solutions and promising interventions, rather than on simply identifying known inequalities in the well-being of LGBTQ youth. Third,

the committee asked speakers to recognize connections between areas of inequality; Russell noted that systems such as education, juvenile justice, and child welfare are intertwined. Finally, said Russell, it is critical to acknowledge the diversity of identities among LGBTQ young people, and to recognize that experiences may differ dramatically from person to person. Relatedly, he said, the language used to refer to these communities is ever evolving and does not always capture the diverse understanding that young people have of who they are. Russell said that the committee aimed for the use of affirming language that recognizes the multidimensional nature of identity, and that he looked forward to learning from workshop speakers about how to do this better.

KEY CONCEPTS AND DEFINITIONS

To introduce and frame the topics of the workshop, the first panel described the current state of sexual and gender diversity in the U.S., and gave an overview of the research and policy landscape in this area. Russell Toomey (University of Arizona) began by noting that sexual- and gender-diverse (SGD) youth are aware of and disclosing their identities at younger ages than did prior generations. For example, the Generations Study² found that the youngest cohort were aware of their same-sex attractions at age 11, compared to age 13 for the oldest cohort (Bishop et al., 2020). The youngest cohort disclosed their sexual identities at around age 16, whereas the oldest cohort reported disclosure around age 26 (Bishop et al., 2020). Similar trends are seen in gender-diverse populations, with younger generations disclosing their genders earlier and beginning social and medical transitions at younger ages (Puckett et al., 2021). These shifts, said Toomey, are likely due to the increased visibility of sexual and gender diversity in everyday life, as well as shifting attitudes that have become more positive toward SGD populations. Related to these earlier ages of identity development, the percentage of youth who identify as something other than cisgender or heterosexual is also larger than it was in prior generations (Conron, 2020). A 2020 poll found that while only 5 percent of the overall U.S. population identifies as lesbian, gay, bisexual, or transgender, this rises to 16 percent for those born between 1997 and 2002, and 10 percent for those born between 1981 and 1996 (Jones, 2021). These numbers, said Toomey, are consistent with other research showing that about 10 percent of youth aged 13–17 identify as LGBTQ (Conron, 2020). A survey of an incoming class at the University of Arizona, where Toomey teaches, found that 25 percent of students do not identify as heterosexual, and 12 percent identify outside the gender binary. In addition to the increasing numbers of LGBTQ youth,

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² See http://www.generations-study.com.

the language they use to describe themselves is expanding and becoming more nuanced, said Toomey. For example, LGBTQ youth may identify themselves as plurisexual, bisexual, pansexual, queer, asexual, nonbinary, and/or transgender (Puckett et al., 2021; The Trevor Project, 2021b).

There is a considerable racial and ethnic diversity within the population of LGBTQ youth, said Allen Mallory (Ohio State University). Data from the Centers for Disease Control and Prevention Youth Risk Behavior Survey (CDC, 2021) show that, within each racial and ethnic group, 17–31 percent of youth identify as lesbian, gay, bisexual, or unsure about their sexual identities, or report sexual behavior with same-sex partners (Figure 1-1).

RESEARCH LANDSCAPE

Despite the growing and changing face of LGBTQ youth, research has not kept pace with the collective understanding of sexuality and gender, said Toomey. A 2014 study found that 86 percent of National Institutes of Health (NIH)-funded studies that examined LGBTQ health issues focused specifically on sexual-minority men, with only 13 percent focused on sexual-minority women and less than 7 percent on transgender populations (Coulter et al., 2014). Less than 10 percent of these studies focused on LGBTQ youth (Coulter et al., 2014). The health outcomes measured in NIH-funded studies were narrow, with 80 percent focused on HIV and AIDS, 30 percent on drug use, 23 percent on mental health, 16 percent on

sexual health, and 12.9 percent on alcohol use (Coulter et al., 2014). While many NIH-funded studies examined health disparities, said Toomey, less than 5 percent focused on malleable, systemic drivers of disparities or areas of leverage; such research is necessary to translate evidence into practice, policy, and intervention, he said.

In addition to these research gaps, even less is known about the unique experiences of diverse populations within the LGBTQ community, such as Black, Indigenous, people of color (BIPOC), plurisexual, and nonbinary individuals. These populations are underrepresented in research, despite evidence that large health disparities exist within these populations, said Toomey. Further, he said, research on sexual- and gender-diverse BIPOC populations tends to reify “racist notions of Black and Latinx youth as highly sexual beings and fails to acknowledge their holistic humanity.” Research on well-being among asexual, intersex, and similar youth is “nearly nonexistent,” said Toomey. The labels used within and among diverse LGBTQ populations are just beginning to be examined with empirical research, as are the intersections between sexuality and gender and characteristics such as race, ethnicity, immigration status, and disability.

The lack of inclusive questions about sexual and gender identity in large population-based surveys continues to create a barrier to understanding youth sexuality and gender development, as well as to identifying potential areas for intervention and prevention, said Toomey. Most of the research on these populations has been conducted by scientists who occupy privileged positions in society, said Toomey, including positions of educational privilege, socioeconomic privilege, and often racial and ethnic privilege. Historically, LGBTQ youth themselves have not been included in the production of knowledge in this area. Issues of representation and exclusion in research are not new, said Toomey, but they are systemic issues that will take systemic solutions to redirect, resolve, and repair. As a result of gaps and exclusions in research, said Toomey, the evidence base on LGBTQ youth is inconsistent and limited in areas. There is robust or growing evidence in areas such as gender-affirmative practices, school policies and practices, and some sexual health interventions (Abreu et al., 2021; Craig et al., 2019), but limited empirical literature in areas including mental health interventions, family-based interventions, and multilevel interventions (Bochicchio et al., 2020; Coulter et al., 2019; Newcomb et al., 2019; Hobaica et al., 2018).

The evidence base on LGBTQ youth is also limited due to a lack of research that incorporates an intersectional perspective, said Mallory. Every individual has multiple overlapping and interacting identities; these identities include characteristics such as race, ethnicity, gender, sexual orientation, religion, and abilities. These characteristics are tied to social systems that structure society and empower certain identities as privileged and others as

disadvantaged, and that also impact a person’s day-to-day experiences of advantage, privilege, and power. When research focuses on individual identities (e.g., sexual orientation), the emphasis is put on attributes of groups of people, rather than on the systemic inequality, stigma, and discrimination that can lead to disparities in health and well-being, said Mallory. An intersectional perspective, on the other hand, goes beyond categories of identity to examine how macro- and micro-systems shape individual and community experiences. There are myriad ways in which these systems may interact, said Mallory, and there are three hypotheses currently being explored: the multiplicative, additive, and inuring hypotheses (Mallory and Russell, 2021; Else-Quest and Hyde, 2016a, 2016b; Thoma and Huebner, 2013; Raver and Nishii, 2010). Mallory used the relationship between discrimination and mental health to demonstrate each hypothesis (Figure 1-2). The multiplicative hypothesis proposes that, for each additional form of discrimination a person experiences, mental health would multiplicatively worsen (i.e., two forms of discrimination worsen mental health twice as much as one form of discrimination). The additive hypothesis suggests that mental health incrementally worsens for each additional form of discrimination experienced. The inuring hypothesis suggests that, after experiencing one form of discrimination, additional forms of discrimination do not worsen mental health. Mallory noted that while his examples focused on

discrimination, the same hypotheses could be applicable for examining protective factors (e.g., engagement with multiple communities) in the lives of SGD youth.

There is ongoing debate among scholars and researchers about how to best integrate or represent intersectionality in research with SGD youth, said Mallory. One critical characteristic, however, is that intersectional research explicitly addresses intersectional power, inequality, privilege, and/or disadvantage. Research that does not address intersectional power, inequality, privilege and/or disadvantage does not fully align with intersectionality theory, and research that does not align with intersectionality theory, he said, has clear limitations for understanding the experiences of SGD youth. Researchers could improve their work by asking themselves who they have missed or failed to include, and who has been actively excluded from their research. Further, Mallory said that researchers should consider whether they are asking the questions that matter to SGD youth, and whether the questions truly reflect the intersections of their experiences and identities. Mallory emphasized the importance of research that can identify positive intersectional experiences, as well as negative ones. For example, two recent daily diary studies found that participants (Black and Muslim SGD youth) reported more positive than negative experiences (e.g., seeing their particular intersectional identities represented in the media) (Jackson et al., 2021). These types of positive intersectional experiences are largely nonexistent in the current literature, he said. While research is acknowledging and finding ways to incorporate the intersecting identities and experiences of SGD youth into research, there is more work to be done.

POLICY LANDSCAPE

In reviewing the policy landscape facing LGBTQ youth, Naomi Goldberg (Movement Advancement Project) emphasized the importance of recognizing the incredible gender diversity, sexual diversity, and racial and ethnic diversity in this population. It is critical to consider which youths may be disproportionately impacted by anti-LGBTQ policies and which are particularly privileged by LGBTQ-affirming policies, she said. Goldberg also highlighted the fact that youths are engaged in multiple systems, including schools, faith communities, the child welfare system, and the healthcare system, and the policies that govern these systems shape the experiences of the young people involved. Policy is a broad term, encompassing federal laws; state laws; local, city, county, and district ordinances and policies; agency regulations; and funding decisions.

Goldberg summarized the key laws and policies that impact LGBTQ youth, starting with laws and policies that explicitly and directly implicate sexual orientation and gender identity. In the school environment, these

policies may cover issues including nondiscrimination, bullying, curriculum, and participation and access (e.g., to sports or certain facilities). In the healthcare arena, policies that directly impact LGBTQ youth include insurance coverage determinations, nondiscrimination, whether providers may refuse service, and permitting or prohibiting certain procedures or approaches (e.g., conversion therapy, gender-affirming care). Government policies may include anti-discrimination rules, the availability of religious exemptions, and more. There are many laws and policies that directly impact LGBTQ youth, and there has been considerable movement in this area in recent years, said Goldberg. For example, many states have passed laws banning the use of conversion therapy.³ Currently, half of the states in the U.S. either ban conversion therapy outright or have restrictions in place on its use, and many cities and counties have also banned this therapy. At the same time, she said, hundreds of bills have been introduced in state legislatures to place restrictions on transgender youth, including bans on participation in sports, limited access to bathrooms that match gender identity, and reduced access to affirming medical care. In the past year, eight states have passed laws restricting trans youth’s ability to play sports, and Arkansas banned affirming medical care. Looking across many areas of LGBTQ youth-related laws and policies, Goldberg also noted trends in state policies across the country, which vary significantly by region (Figure 1-3). States in the South and Midwest tend to have more anti-LGBTQ policies than affirming or supportive policies, while states in the West, Northeast, and upper Midwest have more affirming policies than anti-LGBTQ policies, said Goldberg.

Goldberg emphasized the importance of remembering that policies impact individual people, and that they may not impact all LGBTQ youth in the same way. Both the academic literature and the experiences of young people, she said, show that there is a direct connection between the policy landscape and the experiences of LGBTQ youth. For example, in places with enumerated school nondiscrimination and anti-bullying policies, students report feeling safer, hearing fewer homophobic remarks, experiencing less victimization based on their sexual orientation or gender identity, and having higher self-esteem. They are also less likely to be absent from school (Meyer et al., 2019; Kosciw et al., 2018; Berger et al., 2017; Hall, 2017; Greytak et al., 2016; Kull et al., 2016; Hatzenbuehler et al., 2014; Hatzenbuehler and Keyes, 2013; Kosciw et al., 2013; Wheeler Black et al., 2012; Hatzenbuehler, 2011; Russell et al., 2010; Horn and Szalacha, 2009; Goodenow et al., 2006). Schools with supportive environments—including inclusive curricula, suicide-prevention programming, and affirming staff—

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³ Conversion therapy is any attempt to change a person’s sexual orientation, gender identity, or gender expression (GLAAD, n.d.).

also improve students’ mental health (The Trevor Project, 2021a). On the other hand, policies that negatively target LGBTQ youth have a negative impact on their mental health and well-being (GLSEN, 2018), said Goldberg. Even when anti-LGBTQ proposals do not become law, the discussion of LGBTQ lives in the public sphere can have negative effects; for example, on calls with staff from The Trevor Project and Trans Lifeline, Goldberg heard reports of spikes in calls to crisis lines when media stories negatively focus on trans youth playing sports (see also Levesque, 2021).

In addition to laws that explicitly implicate LGBTQ youth, there are many more policies that are critical to the health, safety, and development of these young people, said Goldberg. For example, LGBTQ youth, particularly youth of color, are overrepresented in the child welfare system and the juvenile justice system. Thus, laws and policies about policing, law enforcement, child welfare, community safety, families, and education are critically important to LGBTQ youth. Moving forward, said Goldberg, it is vitally important to meaningfully include youth voices at the table and to empower LGBTQ youth to be a part of crafting the policies that impact their lives. She noted that this could include establishing youth advisory councils, identifying youth advisors, engaging in problem-solving exercises with young people, and using funding strategies that involve young people in the development of policies and programs.

REFLECTIONS

Following the speaker presentations, Russell led participants in a discussion to reflect on the presentations and the broader workshop aims. He asked participants to identify one takeaway they hoped would emerge from the workshop. These ideas included:

• Ensuring the inclusion of LGBTQ people in policymaking at the highest levels (Goldberg);
• Finding ways to be inclusive of the diversity of SGD youth experiences and identities (Mallory);
• Considering the ways that nonLGBTQ-specific policies shape the intersectional experiences of LGBTQ youth (Toomey);
• Reducing and minimizing the power structures that are present in research science, and actively including young people in the knowledge-production process from day one (Toomey);
• Recognizing that many of the laws and policies that impact LGBTQ youth are built on the same white supremacist framework as other laws and policies, and reconsidering how to define concepts such as safety, security, and well-being (Goldberg).

A workshop participant asked the speakers to comment on funding priorities for LGBTQ health equity, research, and practice. Goldberg responded that there are many innovative and groundbreaking programs happening around the country; for example, a program in Michigan brings together LGBTQ youth advocates, state officials, and child welfare professionals to help families understand gender diversity in small children. Funding is needed, she said, to share, adapt, and scale up these programs for use in other parts of the country. Mallory concurred and stressed the importance of developing models to help SGD youth, such as the Stories and Numbers project.⁴ There are well-funded efforts that push for anti-LGBTQ school policies, said Toomey, and there is a need for funding and for a national strategy to counter these efforts and to advocate for evidence-based policies and practices in schools.

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⁴ See https://storiesandnumbers.org.

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