Mental Health and Victimization Among <scp>LGBTQ</scp>+ Youth: Future Directions for Support in Schools

The impact of the SARS-CoV-2 (COVID-19) pandemic on the United States (U.S.) education system coupled with the proliferation of anti-lesbian, gay, bisexual, transgender, and queer (LGBTQ+) bills, discrimination and racism has been significant and far-reaching—further exacerbating existing mental health disparities and inequities that marginalized youth experience.1-9 Discrimination and racial bias, intersecting with gender bias, can begin as early as preschool and continue to college admissions (as seen by the recent reversal of collegiate Affirmative Action programs by the U.S. Supreme Court).4, 5 In addition, 520 anti-LGBTQ+ bills have been introduced across the U.S. in 2023 alone, which is a new record.1 Many of these bills specifically target bans or restrictions to gender-affirming health care for youth, resources and opportunities for trans students (eg, sports participation, updating gender marker and name in school records, use of pronouns, and undermining the privacy of trans status disclosure to parents), book bans, and restrictions on curriculum regarding LGBTQ+ black and Indigenous histories, to name a few.1, 10, 11 The discussion and enforcement of these anti-LGBTQ+ bills have been shown to negatively impact mental health for LGBTQ+ youth (eg, giving them fear, stress and/or anxiety), and LGBTQ+ youth have reported online bullying and harassment victimization due to the discussion and enforcement of these bills.12 The impact is felt by millions of youth, as approximately 1 in 4 high school students identified as LGBTQ+ in 2021 according to data collected by the Centers for Disease Control and Prevention.13 As the current sociopolitical environments continue to shift, it is essential for schools to address the mental health disparities and victimization rates that LGBTQ+ students are experiencing. The impact of these syndemic factors (ie, the interwoven consequence and interactions of the COVID-19 pandemic with the social and structural/political factors like anti-LGBTQ+ bills and racism) on the physical and mental health outcomes of LGBTQ+ students need to be closely monitored and addressed. It is essential for schools to foster an environment that is safe for LGBTQ+ students since adolescents spend most of their time in school when outside of the home, and they may not feel safe inside the home. In fact, only 1 in 3 LGBTQ+ youth reported their home life to be affirming to their gender or sexual identity in 2021.14 LGBTQ+ youth also report higher levels of childhood adverse experiences and physical abuse perpetuated by parents/guardians compared to their cisgender heterosexual peers.15, 16 With LGBTQ+ youth disproportionately impacted by childhood adverse experiences and abuse, this could lead to further inequitable health outcomes as childhood adverse experiences and abuse are highly connected to worse long-term physical and mental health outcomes into adulthood.17 Furthermore, it is well-documented that LGBTQ+ youth experience higher victimization rates from an early age (eg, bullying, dating violence, sexual violence, and rape) in addition to mental health inequities.18-24 In 2021, 81.8% of LGBTQ+ students reported feeling unsafe in school, with 83.1% of LGBTQ+ students experiencing harassment or assault while attending school in-person during the academic year.25 According to the Trevor Project's 2023 U.S. National Survey, 41% of LGBTQ+ youth reported considering attempting suicide, and youth identifying as transgender, nonbinary, and youth of color reported these thoughts disproportionately more.8 Recent research by Gill and McQuillan in Dane County, Wisconsin compared pre-pandemic reports of peer victimization and suicide attempts to reports during the pandemic.26 These results could suggest that school disruptions may have alleviated LGBTQ+ students from school environments that were harmful to their physical and mental health, with rates of peer victimization and suicide attempts higher in 2018 (pre-pandemic reports) compared to 2021 (reports during the pandemic).26 However, it is important to note that while students had less access to peers during the pandemic with schools closures and perhaps less exposure to peer victimization, many LGBTQ+ youth were isolated from other LGBTQ+ peers while at home in an unsupportive environment, which was also harmful.27-29 A school's environment has a large impact on mental health, especially when not equipped with the resources LGBTQ+ need. Results from a national survey in 2021 showed that 48% of LGBTQ+ youth reported that they were unable to seek counseling from a mental health professional.14 Barriers to accessing mental health services include fear of disclosing sexual and gender identity, risks of homophobia, biphobia, and transphobia, and being under parental insurance, among others. Furthermore, fear of being “outed” has shown to be a concern for transgender and nonbinary youth seeking support.9, 30, 31 In addition, the COVID-19 pandemic should be noted in the context of these findings, as the pandemic disrupted many mental health care services and, in general, further exacerbated mental health for many people across the world.32 Schools need to ensure that they can adequately address victimization and mental health disparities for LGBTQ+ students. Providing LGBTQ+ friendly and free school-based health services provide a protective role by mitigating stigma-related and economic barriers of access to care and may reach youth who are generally less likely to access care.33 School-based health centers (SBHCs) deliver physical and mental health services to youth on or near school campuses and have been shown to help mental health outcomes among sexual minority youth.34 Providing these services within school settings may potentially address health care challenges related to lack of family support. Additional research is needed to better characterize this association for trans and gender diverse youth in addition to LGBTQ+ youth with intersecting diverse racial and ethnic identities. While SBHCs are important for responding to physical and mental health concerns among youth, another school-based service, such as comprehensive sexual health education, is theorized to be a strategy for preventing violence victimization for youth.35, 36 However, LGBTQ+ youth with diverse racial and ethnic identities have reported experiencing barriers for sexual health education in school due to feeling unrepresented and unsupported.37 Schools should address these barriers by providing information that specifically addresses the sexual health of LGBTQ+ youth of color to represent diverse experiences.37 In addition to providing health services, a significant body of research, primarily from the U.S. and Canada, demonstrates the importance of improving school climate to promote the mental health and well-being of LGBTQ+ students, including the presence of supportive or LGBTQ+ staff, LGBTQ+ support groups, inclusive education curricula, and anti-discrimination school policies.38, 39 An evaluation of anti-HBT (homophobic, biphobic, and transphobic) bullying initiatives in the United Kingdom (UK) schools found a “whole-school” approach to be effective and involves moving away from individual-level approaches to address the problem (eg, punishing perpetrators of bullying) to multi-level approaches, such as creating more inclusive curricula and positive LGBTQ+ representations.40 The “whole-school” approach aims to challenge multiple factors in the school environment that upholds cis-normative culture (eg, heterosexuality norms and viewing gender as binary).38 While this UK evaluation of the “whole-school” intervention did not assess mental health impacts, this “whole-school” intervention could be introduced in the U.S. and improved with LGBTQ+ protective policies in schools (eg, anti-discrimination policies, legal gender marker and name change, use of pronouns). However, early intervention services for LGBTQ+ youth mental health must also address multiple discriminations that LGBTQ+ youth face from intersectional identities, including race, ethnicity, socioeconomic status, religion, and disability.41 Future research could investigate an approach that combines a “whole-school” intervention with anti-racism school curriculum to determine if a synergistic approach could address disparities experienced by LGBTQ+ youth with intersectional identities. One example of a classroom initiative that can help address LGBTQ+ youth with intersectional identities is to talk to students about concept maps that depict their own intersecting identities, or discuss the intersectionality wheel of privilege, to start the conversation with students.42, 43 Additional resources have been developed to help teach about intersectionality and critical race praxis in K-12 education.44, 45 As an example, Learning for Justice has developed a toolkit called “Teaching at the Intersections” that can be used for K-12 students, with different tools for different age groups.46 In some states, efforts to identify effective future interventions among LGBTQ+ youth in schools are ongoing. For instance, Washington State (WA) youth have voiced the need for LGBTQ+ competency training for school staff in addition to LGBTQ+-competent mental health support.47 The American School Counselor Association states that K-12 school counselors have the ethical responsibility to understand and advocate for all students regardless of their gender identity or sexual orientation to ensure that they are free from discrimination and bullying.48 K-12 school counselors throughout the U.S. should be required to complete annual trainings on how to best support LGBTQ+ students at different grade levels. K-12 schools should take a more proactive approach by sharing their awareness and dedication to addressing the various factors that influence LGBTQ+ students in K-12 schools. Potential approaches include adopting non-discrimination policies, specifying protections against bullying LGBTQ+ students, consistently monitoring school climate, and ensuring that school staff members have ongoing trainings on creating inclusive learning environments. An example of a proactive approach includes the California Department of Education website containing a statement regarding their school counselors being cognizant and aware of the difficulties that LGBTQ+ youth face and the challenges that can hinder their academic achievements.49 Furthermore, school districts that include inclusive policies are associated with increased perceptions of a more supportive school environment.50 Research on LGBTQ+ visibility in K-12 curriculum, spaces, and materials shows positive impacts on LGBTQ+ students' sense of belongingness, academic achievement, and emotional and mental health.51-53 One recommendation for K-12 schools is to increase visibility, safety, acceptance, and celebration of LGBTQ+ students by creating a mission statement and displaying it on their school website. By establishing and displaying a mission statement, schools can foster a more welcoming and safer environment for LGBTQ+ students and create the foundation for more spaces (eg, Gender-Sexuality Alliance student clubs [GSAs], events celebrating LGBTQ+ people and histories, and self-expression) for them to thrive.54 GSAs aim to provide a safe and supportive school environment for LGBTQ+ youth.55 GSAs are associated with lower mental health concerns and increased empowerment among LGBTQ+ youth.56 However, it is imperative that K-12 schools that are predominantly students of color also establish visibility, belongingness, and safety because LGBTQ+ students of color endure multiple levels of discrimination, harassment, and bullying that leave them especially susceptible to poor mental health outcomes. For example, about half of black LGBTQ+ students report having a GSA organization at their school, with those attending a predominantly black school less likely to report having a GSA compared to those attending a predominantly white school.57 The Gay, Lesbian and Straight Education Network have developed best practices for GSAs in schools, including how GSAs can be more inclusive for students of color and students who identify as transgender or non-binary.55 At the structural/policy level, education policies are an impactful defense against homophobia and transphobia for K-12 students.53 For example, in 2023, WA passed Senate Bill (SB) 5462 which will require school board official to create policies that require K-12 public schools to teach inclusive curricula that is age-appropriate about the perspectives of marginalized and underrepresented groups (including LGBTQ+ people).58 SB 5462 recognizes that including LGBTQ+ curricula will improve attendance, student achievement, and other factors of success for students. SB 5462 is a step in the right direction; however, this advocacy can be further extended to include required trainings for all K-12 educators and staff members to ensure that they are aware of how best to support their LGBTQ+ students. LGBTQ+ trainings and non-discrimination policies are associated with school staff intervening at higher levels when witnessing LGBTQ+ students being bullied or discriminated.50 Therefore, there is value in requiring frequent education for all members of school communities. Furthermore, research has found that shared identities between mental health therapists and LGBTQ+ individuals makes therapy a more positive experience, with LGBTQ+ individuals feeling “seen” by the therapist.59 Therefore, additional efforts should be made to hire LGBTQ+ counselors, especially those with intersecting identities that mirror the population of schools. Current data on the unique experiences for LGBTQ+ youth with diverse racial and ethnic identities is limited and needs to be explored to understand how schools can not only support LGBTQ+ students, but support LGBTQ+ students with intersecting identities. Researchers also need to investigate the experiences of LGBTQ+ students with intersecting identities with school-based services to address potential gaps and help schools re-build systems to address the health disparities LGBTQ+ students are facing, further exacerbated by COVID-19. With the current sociopolitical climate, it is imperative we prioritize this work to achieve health equity for youth with diverse gender, sexual, racial, and ethnic identities. Given that violence victimization and mental health are highly prevalent and connected for LGBTQ+ youth, both need to be adequately addressed to prevent further health consequences such as suicide ideation and death by suicide.60 Schools have the opportunity to address and prevent these outcomes through school health services, programs and curricula, and policies. It is essential for schools to implement additional programming for LGBTQ+ youth, as suggested in this commentary, and swiftly address the ways the COVID-19 pandemic has inequitably impacted the health of LGBTQ+ youth. The authors declare no conflict of interest.

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