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 few studies that have examined protective factors for LGBT youth have considered individual and interactional factors, such as self-esteem Savin-Williams, a , b , school support, and family relatedness Eisenberg and Resnick, Saewyc and colleagues , 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 examined the relationship between social support and psychosocial functioning in 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.
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, While little research has focused on protective factors unique to LGB youth, several studies may provide insight.
These findings may warrant further research. Another potential protective factor may be disclosure of sexual identity. In one study of 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, 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, Ryan and colleagues 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.
A small body of research has begun to evaluate the impact of school policies and procedures on the experiences of LGB students Szalacha, Goodenow and colleagues analyzed data from the Massachusetts Youth Risk Behavior Survey and a state survey of high school principals to examine the relationship among school supports, victimization, and suicidality among LGB youth.
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 , 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, b.
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, These discussions should address identity-related feelings and concerns, as well as behaviors and experiences that can affect health and development.
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 However, this increased access may be less relevant for those LGBT youth who are not cared for by their families. In some U. 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, As with LGB youth, while centers exist that specialize in providing care to transgender patients, not all transgender youth have access to these centers.
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. 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. 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, 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, 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.
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, ; Klamen et al. 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 sexual-minority youth aged 14—21, Rosario and colleagues found racial and ethnic differences in the timing of the coming out process. Similarly, a recent retrospective study of a community-based sample of 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.
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. Drawing on population-based data obtained from students in 7th through 12th grades in British Columbia, Poon and Saewyc 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, ; Grossman et al. 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. Other research has measured parental rejection and support among LGBT adolescents and young adults in several ways. 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 assessed the relationship between LGB young adults' perceived family support e. They found that parental support either partially or fully mediated associations related to suicidal thoughts, recent drug use, and depressive symptomatology. Ryan and colleagues measured specific parental rejecting behaviors in a sample of 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. 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, 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. 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. 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:. Turn recording back on. National Center for Biotechnology Information , U. Search term. 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.
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.
Obesity Childhood obesity rates have risen dramatically in the United States in the past few decades Ogden et al. 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. Risk Factors 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.
Substance Use 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. Homelessness Lesbian , gay, and bisexual youth are disproportionately represented among the homeless youth population.
Protective Factors 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. 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 Quality of Care Studies utilizing convenience samples of LGBT youth show that they value the same health provider characteristics as other youth.
Sociodemographic Factors Few recent population-based studies have published substantive sociodemographic findings on LGBT youth. Familial Factors 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. 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.
DEVELOPMENT OF SEXUAL ORIENTATION AND GENDER IDENTITY
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.
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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.