Behavioral Health and LGBT Youth

Behavioral health is an umbrella term that includes issues and services related to both mental health and substance use. This article synthesizes information relevant to these two areas.

Mental Health and Suicide

As the Institute of Medicine (IOM) has noted, lesbian, gay, bisexual, and trans (LGBT) youth are typically well adjusted and mentally healthy.¹ However, they experience higher rates of mental health challenges and increased health complications arising from these challenges compared to their heterosexual peers.^2,3

Research on transgender youth outcomes as separate from lesbian, gay, and bisexual youth outcomes is more limited, though growing. Some recent nonrandom surveys of self-identified transgender people indicate that up to one third reported attempting suicide at least once, with higher rates for youth and young adults than for older adults.⁴ Moreover, suicide is the third leading cause of death among youth ages 15 to 24, and LGBT youth are more likely to attempt suicide than their peers.⁵ This does not mean, however, that LGBT identity itself is the cause of these challenges. Rather, these higher rates may be due to bias, discrimination, family rejection, and other stressors associated with how they are treated because of their sexual identity or gender identity/expression.^4,6,7 These challenges, which researchers refer to as microaggressions,⁸ can contribute to anxiety, depression, and other mental health challenges, as well as to suicide and self-harming behavior.

Research has found that lesbian, gay, and bisexual youth have much higher levels of suicidal ideation than their heterosexual peers.⁹ Also, recent population-based studies suggest that the reported rates of suicide attempts for high school students who identify as LGBT are 2–7 times higher than rates among high school students who describe themselves as heterosexual.⁴ LGBT youth are also twice as likely to have thoughts about suicide.⁴ The 2017 Youth Risk Behavior Surveillance System found the following during the 12 months before the survey was administered, across the sites evaluated:

• The percentage of students who reported having felt sad or hopeless ranged from 26.4 percent to 32.9 percent among heterosexual students, and from 60.4 percent to 62.7 percent of gay, lesbian, and bisexual students.
• The percentage of students who seriously considered attempting suicide ranged from 11.9 percent to 19.7 percent for heterosexual students, but from 39.6 percent to 44.5 percent among lesbian, gay, or bisexual students.
• The percentage of students who attempted suicide one or more times ranged from 2.0 percent to 9.7 percent among heterosexual students, but from 9.4 percent to 29.4 percent of gay, lesbian, and bisexual students.¹⁰

Strategies to improve mental health and prevent self-harming behavior and suicide include

• Providing safe and supportive environments, particularly through affirming relationships with family and peers¹¹
• Enacting legislation to protect the safety of LGBT youth
• Reevaluating institutional practices that undermine positive child and youth development
• Building community awareness and capacity to understand and address stressors that LGBT youth may experience¹²

Substance Use

LGBT youth may be more likely to use substances to cope with bias and stress and may be more likely to experience increased rates of depression and anxiety than their non-LGBT peers.¹³ Challenges such as family rejection of, or anticipated reaction to, one's LGBT identity are also associated with substance use. For example, one study found that youth who experienced a moderate level of family rejection were 1.5 times more likely to use illegal substances than those who experienced little to no rejection; youth experiencing high levels of family rejection were 3.5 times more likely to use these substances.¹⁴ Also, youth who have run away from home have higher rates of alcohol and illicit drug use.¹⁵

Additionally, an analysis of more than 18 studies between 1994 and 2006 examining the use of tobacco, alcohol, and illicit drugs (e.g. methamphetamines, marijuana) found that lesbian, gay, and bisexual youth had higher rates of usage for all these substances than their heterosexual peers.¹³ Lesbian and bisexual girls were 9.7 times more likely than heterosexual girls to smoke cigarettes,¹⁶ and a quarter of young gay men reported regular binge drinking.¹⁷

Transgender youth have a high risk for developing substance-dependency issues. Transgender people have higher rates of usage for some drugs and may have higher rates of methamphetamine, injectable drug, and tobacco usage.¹⁸ Additionally, transgender youth face more barriers to accessing behavioral health care. These barriers include experiencing physical/verbal abuse by other clients and staff; being required to wear clothing based on their sex rather than their identified gender; and being required to shower/sleep in areas based on their sex rather than their identified gender.¹⁹ Providers with culturally and linguistically competent practices can help improve the quality of care for transgender youth and address these barriers.

Reducing the rates of bias, discrimination, and victimization that LGBT youth experience can help reduce substance use. A related strategy includes creating safe spaces for LGBT youth in drug-free environments such as community centers. Also, accepting/positive family behaviors toward LGBT youth during adolescence can protect against not only suicide and depression but also substance use.¹⁴

Resources

Centers for Disease Control and Prevention: Lesbian, Gay, Bisexual, and Transgender Health
This website from the Centers for Disease Control and Prevention (CDC) contains specific health topics for the LGBT community, with specific resources for gay and bisexual men, youth, lesbian and bisexual women, and transgender persons.
Link opens in a new windowhttps://www.cdc.gov/lgbthealth/index.htm

CDC Lesbian, Gay, Bisexual, and Transgender Health: Youth
This website from the CDC focuses on information for LGBT youth. The site highlights the experiences that LGBT youth face and provides information for schools and parents related to responding to violence for LGBT students.
Link opens in a new windowhttps://www.cdc.gov/lgbthealth/youth.htm

A Guide for Understanding, Supporting, and Affirming LGBTQI2-S Children, Youth, and Families (PDF, 8 pages)
This guide, written by members of the U.S. Department of Health and Human Services' (DHHS's) Substance Abuse and Mental Health Services Administration's (SAMHSA's) National Workgroup to Address the Needs of Children and Youth Who Are LGBTQI2-S and Their Families, provides information for service providers, educators, allies, and community members who seek to support the health and wellbeing of children and youth who are lesbian, gay, bisexual, transgender, questioning, intersex, or two-spirit (LGBTQI2-S) and their families. This guide can support efforts to promote full and affirming inclusion of LGBTQI2-S youth and families in communities and provider settings (e.g. child welfare, juvenile justice, mental health, schools). The guide's last page includes a place for organizations to add their endorsement electronically. Both the National Association of School Psychologists (NASP) and the National Association of Social Workers (NASW) have endorsed the guide. You can access the guide with the NASP and NASW endorsements through the guide link below.
Link opens in a new windowhttps://www.air.org/sites/default/files/A_Guide_for_Understanding_Supporting_and_Affirming_LGBTQI2-S_Children_Youth_and_Families.pdf

The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding
This comprehensive IOM report on LGBT people, commissioned by the National Institutes of Health (NIH), concludes that future research and data collection must address LGBT people, because the lack of research yields an incomplete picture of the health status and needs of LGBT people.
Link opens in a new windowhttps://www.ncbi.nlm.nih.gov/pubmed/22013611

Healthy People 2020 Topics & Objectives: Lesbian, Gay, Bisexual, and Transgender Health
The Healthy People 2020 website has a specific focus to improve the health, safety, and wellbeing of LGBT individuals. It provides resources and subtopics to address specific health challenges that the LGBT community faces. Moreover, a new Healthy People 2020 LGBT Workgroup was formed recently to help advance efforts to identify LGBT health care disparities, needs, and potential ways these needs can be addressed.
Link opens in a new windowhttps://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health

Medline Plus: Gay, Lesbian, and Transgender Health
This website, managed by the U.S. National Library of Medicine, the DHHS, and the NIH, provides resources and information for the specific health issues related to gay, lesbian, bisexual, and transgender individuals.
Link opens in a new windowhttps://medlineplus.gov/gaylesbianbisexualandtransgenderhealth.html

The Movement Advancement Project (PDF, 4 pages)
The Movement Advancement Project offers key recommendations for talking about suicide in safe and accurate ways with LGBT youth.²⁰ Learn more about how the mental health system can support LGBT youth by reading Link opens in a new windowendever*'s story.
Link opens in a new windowhttp://www.lgbtmap.org/file/talking-about-suicide-and-lgbt-populations.pdf

Practice Brief 1: Providing Services and Supports for Youth Who Are Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex, or Two-Spirit (PDF, 8 pages)
This practice brief, commissioned by the Council on Coordination and Collaboration of the Child, Adolescent and Family Branch (CAFB), Center for Mental Health Services (CMHS), SAMHSA, outlines key information for working with and providing culturally and linguistically competent services to LGBTQI2-S youth.
Link opens in a new windowhttps://nccc.georgetown.edu/documents/lgbtqi2s.pdf

A Provider's Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals
This manual, prepared for the SAMHSA Center for Substance Abuse Treatment (CSAT), seeks to inform administrators and clinicians about appropriate diagnosis and treatment approaches that will help ensure the development or enhancement of effective LGBT-sensitive programs. SAMHSA has also funded the development of a 22-module training curriculum to accompany this publication.
Link opens in a new windowhttps://store.samhsa.gov/product/A-Provider-s-Introduction-to-Substance-Abuse-Treatment-for-Lesbian-Gay-Bisexual-and-Transgender-Individuals/SMA12-4104

Recommended Actions to Improve the Health and Wellbeing of Lesbian, Gay, Bisexual, and Transgender Communities
This statement by the Secretary of the DHHS addresses the work the DHHS has engaged in and future recommended actions to address and improve the health and wellbeing of the lesbian, gay, bisexual, and transgender communities.
Link opens in a new windowhttps://www.hhs.gov/programs/topic-sites/lgbt/enhanced-resources/reports/health-objectives-2011/index.html

SAMHSA Office of Behavioral Health Equity
SAMHSA's website for the Office of Behavioral Health Equity provides a variety of LGBT-focused data and resources on substance abuse and mental health.
Link opens in a new windowhttps://www.samhsa.gov/behavioral-health-equity

Suicide and Bullying: Issue Brief (PDF, 8 pages)
The Suicide Prevention Resource Center, supported by SAMHSA, includes recommendations for bullying and suicide prevention and targeted facts related to LGBT people's experiences with bullying and risk of suicide.
Link opens in a new windowhttp://www.sprc.org/sites/default/files/migrate/library/Suicide_Bullying_Issue_Brief.pdf

Suicide Risk and Prevention for Lesbian, Gay, Bisexual, and Transgender Youth (PDF, 63 pages)
This report, prepared for the SAMHSA CMHS, highlights the higher risk of suicidal behavior among LGBT youth and provides recommendations for youth services (e.g. schools, health practices, suicide prevention programs) and funders to promote the health, safety, and inclusion of LGBT youth.
Link opens in a new windowhttp://www.sprc.org/sites/default/files/migrate/library/SPRC_LGBT_Youth.pdf

National Workgroup to Address the Needs of Children and Youth Who Are LGBTQI2-S and Their Families
The CAFB, Center for Mental Health Services, supported by SAMHSA, initiated the National Workgroup to Address the Needs of Children and Youth Who Are LGBTQI2-S and Their Families to support and enhance services for children and youth who are LGBTQI2-S. The workgroup helps guide CAFB efforts to develop policies, programs, materials, and other products that help address the needs of children and youth who are LGBTQI2-S. The workgroup has developed a system-of-care toolkit of more than 150 resources from various organizations and has delivered learning events at conferences/meetings and in communities to build capacity to improve services and outcomes for LGBT youth and their families.
Link opens in a new windowhttp://www.lgbtqi2stoolkit.net

The Trevor Project
The Trevor Project is the leading national organization focused on crisis and suicide prevention services to LGBT and questioning young people ages 13 to 24. It operates the only accredited, nationwide, around-the-clock crisis and suicide prevention helpline for youth who are LGBTQ at 866-4-U-TREVOR (866-488-7386). The Trevor Project also facilitates TrevorSpace (Link opens in a new windowhttps://www.trevorspace.org), a peer social networking site for LGBTQ youth and their allies; Link opens in a new windowTrevor Support Center, an online FAQ answering common questions about sexuality and gender issues; TrevorChat, an online messaging service that allows youth in crisis to live chat with volunteers who can provide support; TrevorText, a free, confidential messaging service; the Lifeguard Workshop Program, which educates participants through a structured curriculum about recognizing and responding to the warning signs of depression and suicide; and additional valuable resources for youth, families, and educators.
Link opens in a new windowhttps://www.thetrevorproject.org

References

1. Institute of Medicine (IOM). (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Bethesda, MD: National Institutes of Health (NIH). Retrieved September 17, 2019, from https://www.ncbi.nlm.nih.gov
2. American Psychological Association (APA) Office on Sexual Orientation and Gender Diversity. (2011). Lesbian, gay, bisexual and transgender health. Retrieved September 17, 2019, from http://www.apa.org
3. National Alliance on Mental Illness (NAMI). (2011). LGBTQ. Retrieved September 17, 2019, from https://www.nami.org
4. Haas, A.P., Eliason, M., Mays, V.M., Mathy, R.M., Cochran, S.D., D'Augelli, A.R., et al. (2011, January). Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. Journal of Homosexuality, 58(1), 10–51.
5. Hatzenbuehler, M.L. (2011, May). The social environment and suicide attempts in lesbian, gay, and bisexual youth. Pediatrics, 127(5), 896–903. doi: 10.1542/peds.2010-3020
6. Almeida, J., Johnson, R.M., Corliss, H.L., Molnar, B.E., & Azrael, D. (2009, August). Emotional distress among LGBT youth: The influence of perceived discrimination based on sexual orientation. Journal of Youth and Adolescence, 38(7), 1001–1014. doi: 10.1007/s10964-009-9397-9
7. U.S. Department of Health and Human Services. (n.d.). Health & wellbeing for lesbian, gay, bisexual and transgender Americans. Retrieved September 17, 2019, from https://www.hhs.gov
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9. Suicide Prevention Resource Center. (2008). Suicide risk and prevention for lesbian, gay, bisexual, and transgender youth. Retrieved September 17, 2019, from http://www.sprc.org
10. Kann, L., Olsen, E.O., McManus, T., Harris, W.A., Shanklin, S.L., Flint, K.H., et al. (2016, August 12). Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9-12 – United States and selected sites, 2015. Morbidity and Mortality Weekly Report (MMWR) Surveillance Summaries, 65(9), 1–202.
11. Mustanski, B., Newcomb, M., & Garofalo, R. (2011, January 1). Mental health of lesbian, gay, and bisexual youth: A developmental resiliency perspective. Journal of Gay & Lesbian Social Services, 23(2), 204–225.
12. Horvath, K.J., Remafedi, G., Fisher, S.K., & Walrath, C.M. (2012). Addressing suicide and self-harmbehaviors among LGBT youth in systems of care. In S. Fisher, G.M. Blau, & J. Poirier (Eds.), Improving emotional and behavioral outcomes for LGBT youth. Baltimore: Brookes.
13. Marshal, M.P., Friedman, M.S., Stall, R., King, K.M., Miles, J., Gold, M.A., et al. (2008, April). Sexual orientation and adolescent substance use: A meta-analysis and methodological review. Addiction, 103(4), 546–556. doi: 10.1111/j.1360-0443.2008.02149.x
14. Ryan, T.G. (2009, November 18). Inclusive attitudes: A pre‐service analysis. Journal of Research in Special Educational Needs, 9(3), 180–187. doi: 10.1111/j.1471-3802.2009.01134.x
15. Tyler, K.A., Kort-Butler, L.A., & Swendener, A. (2014). The effect of victimization, mental health, and protective factors on crime and illicit drug use among homeless young adults. Violence and Victims, 29(2), 348–362.
16. Austin, S.B., Ziyadeh, N., Fisher, L.B., Kahn, J.A., Colditz, G.A., & Frazier, A.L. (2004, April). Sexual orientation and tobacco use in a cohort study of US adolescent girls and boys. Archives of Pediatrics and Adolescent Medicine, 158(4), 317–322. doi:10.1001/archpedi.158.4.317
17. McDavitt, B., Iverson, E., Kubicek, K., Weiss, G., Wong, C.F., & Kipke, M.D. (2008, October 1). Strategies used by gay and bisexual young men to cope with heterosexism. Journal of Gay & Lesbian Social Services, 20(4), 354–380.
18. Xavier, J., Honnold, J., & Bradford, J. (2007). The health, health-related needs, and lifecourse experiences of transgender Virginians. Richmond, VA: Virginia HIV Community Planning Committee & Virginia Department of Health. Retrieved September 17, 2019, from http://www.vdh.virginia.gov
19. Lombardi, E.L., & van Servellen, G. (2000, October). Building culturally sensitive substance use prevention and treatment programs for transgendered populations. Journal of Substance Abuse Treatment, 19(3), 291–296.
20. Movement Advancement Project. (2011). National LGBT movement report. Retrieved September 17, 2019, from http://www.lgbtmap.org