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 Running Head: LGBT Youth Mental Health

Mental Health Among LGBT Youth

Sophia Choukas-Bradley1 & Brian C. Thoma2

1University of Pittsburgh, Department of Psychology
210 S. Bouquet St., Pittsburgh, USA 15206
2University of Pittsburgh School of Medicine, Department of Psychiatry
3811 O’Hara St., Pittsburgh, USA 15213

Note from Sophia Choukas-Bradley on April 8, 2020:

This is a draft of a book chapter that has been accepted for publication by Springer in the
forthcoming book listed below, due for publication in 2020. This document is not the copy of
record and may not exactly replicate the authoritative chapter published by Springer. Please do
not copy or cite this version without permission of the first author (Sophia Choukas-Bradley;
schoukas@gmail.com).

Citation:

Choukas-Bradley, S. & Thoma, B. C. (in press). Mental health among LGBT youth. In W. I.
Wong & D. VanderLaan (Eds.), Gender and Sexuality Development: Contemporary Theory and
Research. New York: Springer.
LGBT YOUTH MENTAL HEALTH 2

Abstract
Lesbian, gay, bisexual, and transgender (LGBT) youth report disproportionately high

rates of mental health problems when compared to their heterosexual and cisgender peers,

including suicidality, depression, and substance use. These mental health disparities likely result

from experiences of minority stress, such as bullying and victimization, discrimination, and

internalized homo/transnegativity. Many of these stressors are modifiable, as are the protective

factors and coping strategies that provide most LGBT youth with resilience in the face of

minority stress. A comprehensive review of the literature on LGBT youth mental health is

beyond the scope of this brief chapter, and we do not provide a systematic review here. Rather,

our goal is to provide an overview of the state of this emerging literature. Specifically, we will

provide an overview of minority stress theory as it relates to the experiences of LGBT youth,

review current knowledge of mental health disparities among LGBT adolescents, describe how

minority stress experiences are related to the mental health of LGBT youth, and summarize our

current understanding of resilience and protective factors within this population.

Key Words: LGBT youth; adolescence; mental health disparities; sexual minority; gender
minority; depression; suicidality; NSSI; substance use
LGBT YOUTH MENTAL HEALTH 3

Introduction

Lesbian, gay, and bisexual (LGB) youth report disproportionately high rates of mental

health problems when compared to their heterosexual peers, including suicidality, depression,

and substance use (Institute of Medicine, 2011; Marshal et al., 2011; Marshal et al., 2008).

Current estimates indicate that while only around 4% of U.S. adults identify as LGB (Gallup,

2017), approximately 15% of adolescents identify as LGB or questioning (Kann et al., 2018). It

is possible that these prevalence rates underestimate the number of sexual minority adolescents,

given that contemporary sexual minority youth use a variety of labels beyond “lesbian, gay, and

bisexual,” such as “pansexual” and “mostly heterosexual”; furthermore, some youth who identify

as “heterosexual” report same-sex attraction and/or behavior (e.g., Stewart, Spivey, Widman,

Choukas-Bradley, & Prinstein, 2019). Health disparities research has documented higher rates of

mental health problems among youth who identify as LGB, among youth who report sexual or

romantic attraction to individuals of the same sex, and also among youth who engage in same-

sex sexual behavior (Marshal et al., 2011). While the mental health of transgender adolescents

(adolescents who identify with a gender identity that diverges from their gender assigned at

birth) has been examined less frequently, initial evidence indicates that transgender adolescents

experience very high rates of suicidality and depressive symptoms (Connolly, Zervos, Barone,

Johnson, & Joseph, 2016; Thoma et al., 2019; Toomey, Syvertsen, & Shramko, 2018).

Prevalence rates for transgender youth are difficult to estimate, as the number of adolescents

seeking treatment at gender care clinics has increased in recent years (Handler et al., 2019), but

recent estimates suggest that 1.8% of U.S. adolescents identify as transgender, with higher

endorsement of transgender identities among adolescents assigned female at birth (Johns et al.,

2019; Zucker, 2017). Mental health disparities among lesbian, gay, bisexual, and transgender
LGBT YOUTH MENTAL HEALTH 4

(LGBT) adolescents likely result from their experiences of minority stress in the form of

discrimination and stigmatization. This chapter will provide an overview of minority stress

theory as it relates to the experiences of LGBT adolescents, review current knowledge of mental

health disparities among LGBT adolescents, describe how minority stress experiences are related

to the mental health of LGBT youth, and summarize our current understanding of resilience and

protective factors within this population.

Minority Stress Experiences of LGBT Adolescents

Researchers theorize that experiences of minority stress underlie health disparities

between LGB and heterosexual individuals (Meyer, 1995, 2003). LGB individuals encounter

stress within their social environments in the form of discrimination based upon known or

perceived sexual orientation, and LGB people also internalize negative societal and cultural

messages about their minority group (Meyer, 1995, 2003). Meyer (2003) theorized minority

stressors fall into two distinct categories: distal stressors and proximal stressors. Distal stressors

include experiences and perceptions of anti-gay discrimination within a person’s social

environment (Meyer, 2003). Discrimination can include verbal harassment, physical violence,

property crimes, housing or employment discrimination, and sexual assault (Katz-Wise & Hyde,

2012). LGB adolescents report more frequent experiences of bullying and victimization by peers

than heterosexual adolescents (Berlan, Corliss, Field, Goodman, & Austin, 2010; Fedewa & Ahn,

2011; Friedman et al., 2011; Zaza, Kann, & Barrios, 2016). In recent nationally representative data

from adolescents in the United States, 34% of LGB adolescents reported being bullied at school

during the past year compared with 19% of heterosexual adolescents (Zaza et al., 2016).

Victimization disparities based on sexual orientation have been detected in children as young as

8- and 9-years-old (Martin-Storey & Fish, 2019).

LGBT YOUTH MENTAL HEALTH 5

Proximal minority stressors are internal processes that can be harmful for LGB

individuals, including internalized homonegativity, expectations of rejection within social

interactions, and concealment of sexual orientation from others (Meyer, 2003). LGB individuals

with higher levels of internalized homonegativity report more negative attitudes about

themselves because they are LGB (DiPlacido, 1998; Meyer, 2003; Shidlo, 1994). Furthermore,

LGB individuals may experience anxiety or fear that they will experience rejection by others

because of their sexual orientation (Meyer, 2003; Pachankis, Goldfried, & Ramrattan, 2008).

Because sexual orientation is a concealable stigmatized identity and LGB individuals’ minority

status might not be readily apparent in many social interactions (Pachankis, 2007; Quinn &

Chaudoir, 2009), LGB individuals must decide when to conceal and disclose their sexual

orientation to others and may have to repeatedly disclose their minority status, causing additional

stress (Meyer, 2003; Pachankis, 2007). Many studies indicate that bisexual youth are at even

higher risk for mental health issues than lesbian and gay youth (Marshal et al., 2011; Marshal et

al., 2008), with minority stress theories highlighting the role of stressors related to “double

discrimination” (i.e., rejection from both the heterosexual and LGBT communities) and

invalidation of one’s identity as “just a phase” (Dyar, Feinstein, & Davila, 2019; Dyar &

London, 2018).

While minority stress has been directly linked to mental health (Meyer, 2003),

researchers have also established a psychological mediation framework to describe mechanisms

through which minority stress affects mental health among LGB individuals (Hatzenbuehler,

2009). Hatzenbuehler (2009) theorized that stressful experiences negatively affect the health of

LGB individuals by causing emotion dysregulation and creating interpersonal and social

problems that can impoverish social support. In addition, LGB individuals who experience
LGBT YOUTH MENTAL HEALTH 6

minority stress are more likely to report feelings of hopelessness and low self-esteem, and these

cognitions and beliefs may leave LGB people more susceptible to negative outcomes in the face

of stress (Hatzenbuehler, 2009). Other factors, such as more liberal social norms about substance

use in the LGB community, may also contribute to health disparities (Hatzenbuehler, 2009).

While minority stress theory is a useful lens through which to understand the experiences

of LGB individuals, Meyer (2003) did not explicitly address the developmentally-specific

experiences and social contexts of adolescents (Goldbach & Gibbs, 2017). Adolescence is a

developmental period during which individuals are highly attuned to feedback from peers, and

peer rejection and victimization can cause great distress (Choukas-Bradley & Prinstein, 2014).

LGB youth often first disclose their sexual orientation during adolescence (Katz-Wise et al.,

2017), and others’ reactions to their disclosure can cause further stress. LGB adolescents who

report negative reactions to their sexual orientation disclosures have higher rates of mental health

problems (Heatherington & Lavner, 2008). Adolescence is a unique developmental period in

that, although peer relationships and peer feedback reach paramount importance, parents also

remain important for adolescents’ basic needs and psychological well-being. Parental rejection of

sexual orientation is common among LGB adolescents, and parental rejection during adolescence

has been linked with increased risk for suicidality and depression during young adulthood among

LGB individuals (Ryan, Huebner, Diaz, & Sanchez, 2009). Furthermore, some evidence indicates

LGB adolescent mental health is related to broad societal attitudes related to sexual orientation.

For example, LGB adolescents who live in counties in the United States where there is a positive

environment for sexual minority individuals (including a higher proportion of same-sex couples

and more schools with anti-bullying policies and gay-straight alliances) report lower levels of

victimization, suicidality, and depressive symptoms as compared to LGB adolescents in less

LGBT YOUTH MENTAL HEALTH 7

supportive counties (Hatzenbuehler, 2011).

It is also important to consider that minority stress theory as described by Meyer (2003)

applies specifically to the experiences of LGB individuals, and minority stress experiences of

transgender individuals likely differ in important ways (Hendricks & Testa, 2012). Like LGB

adolescents, transgender adolescents experience higher rates of peer victimization than their non-

transgender peers (Perez-Brumer, Day, Russell, & Hatzenbuehler, 2017; Sterzing, Ratliff,

Gartner, McGeough, & Johnson, 2017). Victimization is a common experience for transgender

adolescents, and 69% of transgender adolescents report they have been harassed because of their

gender identity during the past year (Veale, Peter, Travers, & Saewyc, 2017). More research is

needed regarding the role of victimization in transgender adolescents’ suicidality, but in one

online sample of U.S. transgender and gender-nonconforming young people ages 14-to-30 years,

gender-related and sexual orientation-related victimization were found to be associated with

higher likelihood of past-year suicide attempt (Kuper, Adams, & Mustanski, 2018). However,

less is understood about transgender individuals’ proximal experiences of minority stress

(Hendricks & Testa, 2012). In particular, having one’s gender identity perceived accurately by

others within social contexts, or passing as one’s true gender identity, is an important

interpersonal construct that is related to distress and mental health among transgender individuals

(Bockting, Miner, Romine, Hamilton, & Coleman, 2013; Dubois, 2012). Transgender individuals

often initiate a social gender transition during adolescence, including disclosing their gender

identity to parents and peers, asking others to refer to them by a chosen name, using different

pronouns that align with their true gender identity, and changing their hairstyle and/or clothing to

express their gender in a way that accords with their true gender identity (Connolly et al., 2016;

Grossman & D'augelli, 2007; Russell, Pollitt, Li, & Grossman, 2018). Many questions remain
LGBT YOUTH MENTAL HEALTH 8

regarding whether and how progression through these transition steps is related to transgender

adolescents’ mental health. Further research is required to understand how the minority stress

experiences of transgender adolescents differ from the experiences of LGB individuals.

Mental Health Disparities among LGBT Adolescents

In this section, we provide an overview of the empirical literature regarding mental health

disparities related to adolescents’ sexual and gender minority identities. A comprehensive review

of the literature on LGBT youth mental health is beyond the scope of this brief chapter, and we

do not provide a systematic review here. Rather, our goal is to provide an overview of the state

of this emerging literature.

Suicidality

Suicide is the second leading cause of death among adolescents (Kochanek, Murphy, Xu, &

Tejada-Vera, 2016), and LGB adolescents are at high risk for suicidality. Compared with

heterosexual adolescents, LGB adolescents have two-times the odds of suicidal ideation (Marshal et

al., 2011). Disparities are even larger when examining more severe forms of suicidality, as LGB

adolescents have much higher odds of suicide attempts (OR = 3.18) and suicide attempts requiring

medical attention (OR = 4.17) than their heterosexual peers (Marshal et al., 2011). Recent nationally

representative adolescent health data from the 2015 Youth Risk Behavior Surveillance System

(YRBSS) indicate 43% of U.S. LGB adolescents have seriously considered suicide in the past year,

38% have made a suicide plan, 29% have attempted suicide in the past year, and 9% have made an

attempt requiring medical attention (Zaza et al., 2016). Data from the same survey revealed

especially high levels of suicidality among bisexual girls, with 35% attempting suicide in the past

year and 12% making a suicide attempt requiring medical attention (Taliaferro, Gloppen,

Muehlenkamp, & Eisenberg, 2017). Comparatively, only 6% of heterosexual adolescents within the
LGBT YOUTH MENTAL HEALTH 9

same sample reported attempting suicide during the past year (Zaza et al., 2016). LGB adolescents

also report higher levels of non-suicidal self-injury (self-harm behaviors, such as cutting oneself,

without intent to end one’s life) when compared to their heterosexual peers (Almeida, Johnson,

Corliss, Molnar, & Azrael, 2009).

Researchers have linked experiences of minority stress to higher levels of suicidality

among LGB adolescents, and peer victimization is the most commonly examined stressor. Peer

victimization is typically operationalized as experiencing verbal or physical aggression from

peers. LGB adolescents who report more frequent experiences of peer victimization report higher

rates of suicidality (Espelage, Merrin, & Hatchel, 2018), including suicidal ideation (Birkett,

Espelage, & Koenig, 2009; Espelage, Aragon, Birkett, & Koenig, 2008), suicide attempts

(Bontempo & D'Augelli, 2002; Fedewa & Ahn, 2011), and non-suicidal self-injury (Almeida et

al., 2009; Liu & Mustanski, 2012). Researchers have also examined whether peer victimization

accounts for differences in suicidality outcomes between LGB and heterosexual adolescents.

Bontempo and colleagues (2002) found that victimization experiences mediated the association

between LGB-status and suicidality among adolescents. Within this study, LGB adolescents who

reported high levels of victimization reported more suicide attempts during the past year when

compared with heterosexual adolescents who experienced high levels of victimization

(Bontempo & D'Augelli, 2002), indicating that victimization experiences have an especially

deleterious effect among LGB adolescents. Similarly, peer victimization predicted higher levels

of suicidality among LGB adolescents over the next six months in a longitudinal study, and

victimization mediated the association between LGB-status and suicidality (Burton, Marshal,

Chisolm, Sucato, & Friedman, 2013). Finally, victimization was found to predict increases in

both future suicidality and self-harm behavior within a sample of LGBT youth ages 16-to-20
LGBT YOUTH MENTAL HEALTH 10

years (Liu & Mustanski, 2012).

Suicidality has been examined less frequently among transgender adolescents, but initial

results indicate transgender adolescents experience high rates of suicidal ideation and attempts

when compared to their cisgender peers (Becerra-Culqui et al., 2018; Connolly et al., 2016;

Eisenberg et al., 2017; Perez-Brumer et al., 2017; Peterson, Matthews, Copps‐Smith, & Conard,

2017; Toomey et al., 2018; Veale, Watson, Peter, & Saewyc, 2017). Sixty-one percent of

transgender adolescents report a lifetime history of suicidal ideation, and 31% report attempting

suicide during their lifetime (Eisenberg et al., 2017). In one recent study, rates of suicidality were

higher among transgender adolescents than both their cisgender heterosexual and cisgender

sexual minority peers (Fox, Choukas-Bradley, Salk, Marshal, & Thoma, 2020). Recent work

indicates that rates of suicidal behavior may be even higher among some subgroups of

transgender adolescents, with 51% of female-to-male adolescents reporting a lifetime history of

suicide attempts (Toomey et al., 2018). However, inadequate measurement of gender assigned at

birth and current gender identity has hampered empirical efforts to estimate rates of suicidality

among transgender adolescents, and additional research that uses comprehensive measures of

gender identity within nationally representative adolescent health datasets is required.

Additional research examining psychosocial factors related to suicidality among

transgender adolescents is needed as well. Initial evidence indicates transgender adolescents who

experience higher levels of victimization report higher rates of suicidal ideation, suicidal

behavior, and non-suicidal self-injury (Clements-Nolle, Marx, & Katz, 2006; Hatchel, Valido,

De Pedro, Huang, & Espelage, 2019; Perez-Brumer et al., 2017; Veale, Peter, et al., 2017; Veale,

Watson, et al., 2017). Additional psychosocial factors could protect against or confer risk for

suicidal behavior among transgender adolescents. Initial evidence from one cross-sectional study
LGBT YOUTH MENTAL HEALTH 11

indicates that completing social transition steps within multiple social contexts (i.e., using a

chosen name at home, at school, and at work) is associated with fewer mental health problems,

including suicidal ideation and behavior (Russell et al., 2018). Further research is required to

understand how progressing through gender transition milestones is related to the severity of

suicidality during adolescence among transgender youth.

Finally, several studies of LGBT youth have provided evidence consistent with the

interpersonal-psychological theory of suicidal behavior (Joiner, 2005). According to this theory,

the desire for suicide is developed through a combination of perceived burdensomeness and low

belongingness. In several studies, perceived burdensomeness has been found to mediate the

association between several minority stressors and depressive symptoms among LGBT

adolescents in the U.S. and the Netherlands, including sexual orientation victimization,

internalized homonegativity, and coming-out stress (Baams, Dubas, Russell, Buikema, & van

Aken, 2018; Baams, Grossman, & Russell, 2015). Regarding low belongingness—in other

words, social alienation—several of the studies regarding interpersonal stressors above (e.g.,

victimization) may provide indirect support for this part of the theory.

Depression and Other Internalizing Symptoms

In addition to the disparities discussed above related to suicidality, LGBT adolescents are

significantly more likely than their cisgender heterosexual peers to report depressive symptoms.

A meta-analysis found an overall weighted effect size for the association between sexual

orientation and depression of d = 0.33 (Marshal et al., 2011). In one study, 15% of LGBT youth

met diagnostic criteria for Major Depressive Disorder (Mustanski, Garofalo, & Emerson, 2010).

Higher levels of depressive symptoms during adolescence could negatively influence the long-

term mental health of LGB individuals, as longitudinal studies indicate that depressive symptoms
LGBT YOUTH MENTAL HEALTH 12

among LGB individuals persist from adolescence into adulthood (Marshal et al., 2013;

Needham, 2012). Disparities also likely begin prior to adolescence, as higher levels of depressive

symptoms were detected by age 11 among sexual minority girls in one Dutch study (la Roi,

Kretschmer, Dijkstra, Veenstra, & Oldehinkel, 2016). Several studies indicate that transgender

youth also experience high levels of depressive symptoms (see Connolly et al., 2016).

As with studies focused on suicidality, research suggests that minority stressors mediate

the association between sexual minority identity and depressive symptoms. A recent systematic

review found that key risk factors for LGB youth depression include internalized sexual

orientation-related oppression, stress from hiding and managing one’s identity, parental

rejection, and victimization (Hall, 2018). With regard to distal stressors, many studies have

highlighted the roles of victimization, parental rejection, and discrimination in LGBT youth

depressive symptoms. In a previously mentioned longitudinal study, sexual minority-specific

victimization mediated the association between sexual minority identity and both depressive

symptoms and suicidality (Burton et al., 2013). Other studies have also found both victimization

and parental rejection to partially mediate the association between sexual minority identity and

depressive symptoms (la Roi et al., 2016; Martin-Storey & Crosnoe, 2012; Mittleman, 2019;

Robinson, Espelage, & Rivers, 2013; Toomey, Ryan, Diaz, Card, & Russell, 2010). Results from

a school-based study indicate that perceived discrimination accounted for the higher levels of

depressive symptoms among LGBT youth (Almeida et al., 2009). Other studies suggest that the

discrimination experiences that lead to depressive symptoms may be subtle, such as in the form

of microaggressions (Kaufman, Baams, & Dubas, 2017).

Proximal minority stressors have also been linked to depression and other internalizing

symptoms. For example, internalized homonegativity has been found to be associated with
LGBT YOUTH MENTAL HEALTH 13

higher levels of anxiety and depressive symptoms in samples of youth across several countries,

including the U.S., Belgium, and Israel (Cox, Vanden Berghe, Dewaele, & Vincke, 2010; Page,

Lindahl, & Malik, 2013; Shilo & Savaya, 2012). Additionally, in a sample of transgender

adolescents seeking care at a U.S. gender clinic, those with higher levels of internalized

transnegativity were more likely to meet diagnostic criteria for both major depressive disorder

and generalized anxiety disorder (Chodzen, Hidalgo, Chen, & Garofalo, 2019). Other studies

have found that internalized homonegativity mediates the association between environmental

stressors and internalizing symptoms. For example, in a community sample of U.S. sexual

minority youth, religious stress related to sexual orientation and other sexual orientation-related

stressors were associated with symptoms of depression and anxiety, and these associations were

mediated by homonegativity (Page et al., 2013).

Substance Use

LGB adolescents use substances at high rates, with a meta-analysis suggesting these rates

are almost three times that of their heterosexual peers (Marshal et al., 2008). A recent study

using state-representative data from California found that substance use was 2.5-4 times higher

among transgender youth compared to cisgender peers (Day, Fish, Perez-Brumer, Hatzenbuehler,

& Russell, 2017). Examining data from the National Longitudinal Study of Adolescent to Adult

Health (Add Health), Dermody and colleagues (2014) found disparities between sexual minority

and heterosexual individuals over time in hazardous drinking, from adolescence through

participants’ late 20s and early 30s; disparities increased as participants reached young

adulthood. LGB youth have higher rates of cigarette, alcohol, marijuana, cocaine, and injection

drug use when compared to heterosexual peers (Marshal et al., 2008), and recent evidence

indicates LGB adolescents have higher rates of vaping as well (Coulter, Bersamin, Russell, &
LGBT YOUTH MENTAL HEALTH 14

Mair, 2018). The vast majority of studies have used brief measures to assess substance use

among LGB youth and their peers (Marshal et al., 2008), and more research is required to

examine disparities in substance use disorder diagnoses between LGB and heterosexual youth.

As with suicidality and internalizing problems, a growing body of research highlights the

important role of minority stressors in LGBT adolescents’ substance use. A meta-analysis found

that victimization, negative reactions to adolescents’ coming out, and sexual orientation-related

stress were each associated with higher levels of adolescents’ substance use (Goldbach, Tanner-

Smith, Bagwell, & Dunlap, 2014). Although the data are now more than two decades old, a study

using 1995 YRBSS data found that the combination of LGB status and high levels of at-school

victimization predicted the highest levels of substance use, as well as suicidality and sexual risk

behavior; importantly, at low levels of victimization, LGB youths’ substance use, suicidality, and

sexual risk behaviors were similar to those of their heterosexual peers (Bontempo & D’Augelli,

2002). Updated data from the 2015 YRBSS revealed that bisexual adolescents specifically were

higher in alcohol use and binge drinking than their heterosexual peers, and bullying mediated the

association between sexual minority identity and alcohol use only among bisexual girls (Phillips

et al., 2017). Furthermore, a longitudinal study using a community sample of adolescents

recruited from adolescent health clinics found support for the mediating role of victimization in

the longitudinal association between LGB status and substance use (Dermody, Marshal, Burton,

& Chisolm, 2016). Fewer studies have examined substance use disparities among transgender

youth. However, both the California-wide study discussed above (Day et al., 2017) and a large-

scale national U.S. study (Reisner, Greytak, Parsons, & Ybarra, 2015) also revealed that

victimization mediated the association between transgender identity and substance use.

Protective Factors, Coping, and Prevention

LGBT YOUTH MENTAL HEALTH 15

It is critically important to note that many LGBT youth do not experience mental health

problems. Protective factors and coping strategies have been identified that may help mitigate

against the risks posed by minority stressors. In this section, we provide a brief overview of some

of the protective factors and coping strategies that have received research attention and that may

aid the development of prevention and intervention programs.

Several studies highlight the importance of social support from friends and the LGBT

community in promoting positive identity development (Bruce, Harper, & Bauermeister, 2015).

For example, a large-scale study of schools in Wisconsin found that LGBT youth in schools with

Gay-Straight Alliances (GSAs) reported lower levels of truancy, substance use, suicide attempts,

and risky sexual behaviors, as compared to youth in schools without GSAs (Poteat, Sinclair,

DiGiovanni, Koenig, & Russell, 2013). Additionally, in qualitative interviews, sexual minority

adolescents highlighted the importance of having LGBT centers and organizations for support, as

well as the protective effects of having close relationships with other individuals who identify as

LGBT (Goldbach & Gibbs, 2015). Furthermore, across many studies, support from parents and

peers has been found to be important in protecting against substance use, depression, and

psychological distress (Goldbach et al., 2014; Hall, 2018; McConnell, Birkett, & Mustanski,

2015, 2016; Mustanski, Newcomb, & Garofalo, 2011).

With regard to transgender youth, more well-designed longitudinal research studies are

needed, but the work of Olson and colleagues suggests that children and adolescents who are

socially transitioned have similar levels of depression, and marginally higher anxiety, when

compared to their siblings, age- and gender-matched-controls, and nationally representative

samples (Durwood, McLaughlin, & Olson, 2017; Olson, Durwood, DeMeules, & McLaughlin,

2016). Socially transitioned children’s psychosocial well-being also appears to be similar to that
LGBT YOUTH MENTAL HEALTH 16

of age- and gender-matched cisgender gender-nonconforming children (Wong, van der Miesen,

Li, MacMullin, & VanderLaan, 2019). Another cross-sectional study found that youth who used

their chosen name in more contexts (i.e., a proxy for gender affirmation) reported lower levels of

depressive symptoms, suicidal thoughts, and suicidal behavior (Russell et al., 2018). Thus,

engaging in a social gender transition within supportive social contexts might have the potential

to ameliorate mental health disparities among transgender youth, but more research on this topic

is required.

Throughout this chapter, we have highlighted the important role of victimization in

helping to explain why LGBT youth have higher levels of suicidality, depression, and substance

use than their peers. It is heartening to note that, overall, experiences of victimization may

decrease over time for LGBT youth, both with regard to historical trends and developmental

trajectories. First, a study of 11 YRBSS cohorts from 1995 to 2015 revealed that rates of school-

based victimization decreased among all students, and especially steep declines were revealed

among LGBT youth (Olsen, Vivolo-Kantor, Kann, & Milligan, 2017). Additionally, a

community study of adolescents and young adults using an accelerated longitudinal study design

found that while experiences of victimization predicted increases in psychological distress over

time, overall, both victimization and distress decreased over time (Birkett, Newcomb, &

Mustanski, 2015).

Limitations, Future Directions, and Conclusions

In this chapter, we provided an overview of the state of the literature on mental health

among LGBT youth. Tremendous advances have been made in recent years in our understanding

of both mental health disparities and the minority stressors that may underlie them. That said, the

research literature has been characterized by several substantial limitations that must be
LGBT YOUTH MENTAL HEALTH 17

addressed in future work. First, the majority of studies on sexual minority youth use cross-

sectional study designs and focus on older adolescents and young adults, with fewer studies

following youth longitudinally over the course of adolescence, and a strikingly limited number of

studies focused on pre-adolescent children (although see this chapter’s Spotlight Feature for a

description of recent research on pre-adolescent children). With youth coming out at younger

ages (Dunlap, 2016), it may be more feasible for future studies to recruit samples of children and

younger adolescents who identify as LGBT and to follow their developmental outcomes over

time.

Another challenge of research on LGBT youth mental health involves disentangling

developmental effects and historical change, as has been discussed by Mustanski (2015). Within

the U.S. specifically, support for LGBT individuals and couples has increased dramatically, both

with regard to personal attitudes and public policies (Pew Research Center, 2017). That said,

there is substantial variability in support and protections across geographical regions and based

on religious, political, and other identities (GLAAD, 2018; Pew Research Center, 2017).

Furthermore, at the time of our writing this chapter, several protections for sexual and gender

minority individuals are at risk of being weakened or removed (e.g., Goodnough, Green, &

Sanger-Katz, 2019). Youths’ experiences of minority stressors and mental health sequelae may

vary based on such structural and cultural shifts. Questions related to the sociocultural context of

LGBT youth development remain critically important avenues for future research.

Another emerging area of scholarship in this field that warrants further study concerns

intersectionality. Although many studies included in this chapter included racially and ethnically

diverse samples and some directly addressed issues related to intersectionality, a thorough

discussion of intersectionality was beyond the scope of the current chapter. According to
LGBT YOUTH MENTAL HEALTH 18

minority stress theories, belonging to multiple minority groups may be associated with unique

stressors and experiences of discrimination (Cole, 2009; Else-Quest & Hyde, 2016). Based on

these theories, we would expect that LGBT youth who also identify as racial/ethnic minorities

may experience more minority stressors (e.g., higher levels of discrimination) and may be more

at risk for mental health issues. However, research is mixed regarding whether such intersecting

identities confer greater risk, and it is possible that racial/ethnic minority LGBT youth may be

better equipped to cope with minority stress related to their LGBT identity, which emerges

during later childhood and adolescence, because they have previously developed effective

strategies to cope with racist discrimination and stigmatization earlier in development (c.f., Fox

et al., 2020; Thoma & Huebner, 2013; Velez, Moradi, & Deblaere, 2015). Future research with

LGBT youth should prioritize collecting sufficiently large and diverse samples of youth,

allowing us to build a stronger understanding of how mental health and minority stress

experiences differ across racial/ethnic subgroups of LGBT youth. Finally, the vast majority of

existing research examining health disparities between LGBT adolescents and their peers has

been conducted with samples collected in North America, Europe, and Australia (Marshal et al.,

2008). Given cultural differences in acceptance of and attitudes toward diverse sexual and gender

identities across the globe (Kite, Togans, & Case, 2018; Smith, Son, & Kim, 2014), as well as

limited legal protections for LGBT individuals in many countries, we cannot generalize using

existing evidence of LGBT youth mental health derived largely from Western societies.

Additional international research on the health and well-being of LGBT youth across the globe is

required.

This chapter aimed to provide a concise overview of research on mental health among

LGBT youth, with an emphasis on internalizing symptoms, substance misuse, and suicidality.
LGBT YOUTH MENTAL HEALTH 19

This chapter did not address mental health disparities related to autism spectrum disorder (but

see the Spotlight Feature in this chapter by Anna van der Miesen), eating disorders, externalizing

problems and health risk behaviors beyond substance use, or severe psychopathology such as

bipolar disorder or schizophrenia. Connolly and colleagues (2016) provide a review of the

mental health of transgender youth, but in this evolving field, many new studies have since

emerged.

A critically important area for future work involves the development of evidence-based

prevention and intervention efforts. Many researchers have called for mental health interventions

tailored to the unique minority stress experiences of LGBT youth. Mustanski (2015) outlined the

need for the development of interventions that “promote and build on natural resiliencies in the

face of chronic [sexual minority] stressors” (p. 212) and that emphasize prevention and health

promotion. A special challenge concerns how to reach young LGBT adolescents during the

processes of identity development during which vulnerability may be high (Mustanski, 2015).

Online recruitment and interventions may help with this effort (Mustanski, 2015). Finally,

successful interventions will likely need to address the complex sociocultural and interpersonal

systems in which adolescents are embedded, and interventions delivered online, including

family-based interventions (e.g., Huebner, Rullo, Thoma, McGarrity, & Mackenzie, 2013), may

provide fruitful avenues for these important efforts.

Conclusion

In conclusion, recent advances in basic research on LGBT youth mental health highlight

disparities between LGBT youth and their non-LGBT peers, and identify minority stressors that

may contribute to those disparities. Many of these stressors are modifiable, as are the protective

factors and coping strategies that provide most LGBT youth with resilience in the face of
LGBT YOUTH MENTAL HEALTH 20

minority stress. It is now vital for the field to develop, test, and disseminate prevention and

intervention programs to further mitigate these risks and allow LGBT youth to thrive.
LGBT YOUTH MENTAL HEALTH 21

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