Child and Adolescent
An increasing number of youths identify as LGBTQ. Estimates vary but are as high as 27% in a 2017 survey of California teenagers (William’s Institute, 2017). It is increasingly important for child and adolescent clinicians to understand the unique characteristics and needs of gender and sexual minority youth.
LGBTQ youths, like adults, display notable health disparities compared to their heterosexual and cisgender counterparts. Numerous studies have documented increased rates of suicidal thoughts, suicide attempts, and depressive symptoms among sexual minority youth. Transgender youth populations have not been studied to the same degree, though existing data also suggest significant disparities in negative mental health outcomes.
In one large study, investigators found that teenagers who identified as sexual minorities experienced more than two times the odds of suicidal ideation and suicide attempts compared to heterosexual peers (Zhao et al., 2010). In the most recent Youth Risk Behavior Survey (YRBS), a survey conducted annually among 9th to 12th grade students by the Centers for Disease Control and Prevention (CDC), LGB youths reported high rates of suicidal thoughts (40%), and 60% of LGB youths surveyed reported feeling sad or hopeless enough to stop doing some of their usual activities (Kann et al., 2016). The overall prevalence of suicide attempts resulting in contact with a medical professional was 9.4% for LGB students, versus 2.0% for heterosexual students (Kann et al., 2016). Though fewer studies exist on transgender youth, national survey data are very alarming: a stunning 40% of adult respondents in the 2015 US Transgender Survey (USTS) reported at least one lifetime suicide attempt – 9 times the rate of the general US population – with 92% reporting that the attempt(s) occurred prior to age 25 (James et al., 2016). Community studies reflect similar mental health outcomes for transgender youth (see, for example, Reisner et al., 2015).
It is no surprise that LGBTQ youths experience elevated rates of depression and suicidality given the well-documented adversity they face, including high rates of emotional, physical, and sexual trauma (Kosciw et al., 2012; Friedman et al., 2011). Almost 18% of LGB student responders in the YRBS reported at least one incident of being physically forced to have non-consensual sexual intercourse, and a similar number reported physical violence within the last year (Kann et al., 2016). Of note, students who identified as “questioning,” or unsure of their sexuality, also reported higher rates of rape and physical violence than heterosexual peers (Kann et al., 2016). A well-known Institute of Medicine report also noted that gender non-conforming youth experienced elevated levels of violence, victimization, and harassment, as well as high levels of discrimination (Institute of Medicine, 2011).
LGBTQ youths also face much higher rates of homelessness and substance use. A study by the Williams Institute revealed that 40% of homeless youth served in national agencies identified as LGBTQ (Durso, 2012). These youth most frequently lost their homes due to family rejection of their sexual orientation and/or gender identity (Durso, 2012). Though accurate statistics are difficult to determine due to the overall lack of data, LGBTQ youths have typically reported higher rates of alcohol, tobacco, and other substance use, especially among urban youth (Broderick and Clark, 2013).
The marked disparities in mental health outcomes seen in LGBTQ populations are often explained in academic literature by the minority stress theory, which asserts that they are the result of chronic stress related to experiences of stigma and discrimination on the basis of identity (Cochran, 2001). The minority stress framework stems from social stress theory and reflects earlier research on psychological outcomes associated with discrimination and stigma (e.g., Markowitz, 1998). Numerous well-known studies also examine the impact of childhood traumatic stress more broadly, showing clear associations between early adverse events and worse mental and physical health outcomes in adulthood (e.g., Felitti et al., 1998).
There is great interest among mental health clinicians in mitigating stressors to improve mental health outcomes. However, specific treatment protocols around gender-related care for youths presenting with gender-related stressors and/or mental health symptoms are limited. Numerous reputable medical societies, including the American Psychiatric Association, the American Academy of Pediatrics, and the American Psychological Association, recommend nondiscriminatory, supportive interventions that recognize variations in gender identity and sexuality as natural outcomes in human development. No credible scientific evidence has demonstrated that individuals with diverse sexual and gender identities have an inherent predisposition for psychopathology (Bailey, Vasey, Diamond, & Breedlove, 2016).
Child and adolescent clinicians play an increasing role in guiding families through gender exploration and identity consolidation. Psychoeducation about gender and sexuality development across human life stages can help families better understand a youth’s feelings and behaviors. Very young children generally do not have the cognitive ability to understand gender, but they still pick up cues from their parents and environment that may shape their later understanding about gender. It is generally accepted that around ages 3-4 children begin to better understand gender identity (Kuhn, Nash, & Brucken, 1978; Martin, Ruble, & Szkrybalo, 2004; Halim & Ruble, 2010). Reasoning at this age usually remains quite rigid and rule-bound. According to psychologist Lawrence Kohlberg, who generally based his theories of cognitive development upon the earlier work of Jean Piaget, children develop “gender constancy” through a series of stages. Preschool children can “gender label,” or identify a gender based on concrete attributes. Children then achieve “gender stability,” where they begin to understand that gender is stable over time. Around ages 5-6 years old (school age), most children achieve “gender consistency,” the ability to understand that gender identity is fixed despite changes in appearance or activities (American Psychological Association). Rigidity about gender typically declines in later childhood and, especially, in adolescence.
Parents’ responses to youths’ gender identities and sexualities vary widely, with some highly accepting, some highly rejecting, and many expressing ambivalence (Ryan, 2004; Ryan & Chen-Hayes, 2013). Clinicians can help family members identify their beliefs about gender and sexuality and develop insight into how they influence their thinking about the youth’s identity. In working with families, it is also helpful to teach parents and caregivers ways to express acceptance for their child as they are. Numerous studies have shown that family rejection is a significant risk factor for adverse mental health outcomes in LGBTQ youth, including depression, suicidality, substance use, and other risk behaviors (Ryan, Huebner, Diaz, & Sanchez, 2009). On the other hand, family support has been shown to be protective against suicidal behaviors in LGBTQ youth (Eisenberg & Resnick, 2006; Mustanski & Liu, 2013; Ryan et al., 2010). As a clinician, it is important to understand that most families are motivated to provide care and support to their child. Some families are not deliberately rejecting but rather do not understand gender diversity or how to communicate about this topic. Research has shown that even rejecting families can become less rejecting over time and that providing resources and accurate information can help families better support their children (Mustanki, 2013; Ryan et al., 2010).
It is worth noting that conversion therapy — a treatment aimed at changing LGBTQ individuals’ gender identity and/or sexuality — is still legal in most states across the US and continues to be practiced. The Williams Institute estimates that almost 700,000 US adults have received conversion therapy, with half of them receiving it before age 18 (Mallory, Brown, and Conron, 2018). Currently, 20 states and the District of Columbia have laws banning conversion therapy for minors (Movement Advancement Project, 2020). There is no credible or mainstream medical or mental health association that supports the use of conversion therapy. Conversion therapy has been repeatedly associated with poor mental health outcomes, including suicidality (Flentje et al, 2013; Weiss et al., 2010; Shidlo & Schroeder, 2002; James et al., 2016). Numerous mental health associations, representing thousands of providers, oppose the use of conversion therapy; these include the American Psychological Association (2009), the American Psychiatric Association (2018), the American Academy of Child and Adolescent Psychiatry (2018), and the LGBT Committee of the Group for Advancement of Psychiatry (Drescher, 2016).
CME Question: Which of the following is not a risk factor for suicide among LGBTQ youth?
(a) family rejection
(b) identification as transgender or gender non-conforming
(c) traumatic experiences
(d) exploration of gender at a young age
Answer: D