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Pediatric Collections: LGBTQ+: Support and Care Part 1: Combatting Stigma and Discrimination

By American Academy of Pediatrics

Part 1 of this first-of-its-kind 3-part series can help show how to break down the cycles of ignorance, shame, and toxic stress that harm children who identify as LGBTQ+ and improve their chances of leading happy, healthy adult lives.


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      Address correspondence to Laura Baams, PhD, Pedagogy and Educational Sciences, University of Groningen, Grote Rozenstraat 38, 9712 TJ Groningen, Netherlands. E-mail: l.baams@rug.nl

      OBJECTIVES To identify patterns of childhood adversity in a sample of adolescents and assess disparities in these experiences for lesbian, gay, bisexual, transgender, and questioning adolescents and by level of gender nonconformity.

      METHOD By using the cross-sectional, statewide, anonymous 2016 Minnesota Student Survey, 81 885 students were included in the current study (50.59% male; mean age = 15.51). Participants were enrolled in grades 9 and 11 in a total of 348 schools.

      RESULTS Four patterns of childhood adversity were identified with sex-stratified latent class analyses (entropy = 0.833 males; 0.833 females), ranging from relatively low levels of abuse (85.3% males; 80.1% females) to polyvictimization (0.84% males; 1.98% females). A regression analysis showed that compared with heterosexual adolescents, gay, lesbian, bisexual, and questioning adolescents were more likely to be classified into profiles characterized by polyvictimization (odds ratio [OR] 1.81–7.53) and psychological and/ or physical abuse (OR 1.29–3.12), than no or low adversity. Similarly, compared with nontransgender adolescents, transgender adolescents were more likely to be classified into profiles characterized by patterns of polyvictimization (OR 1.49–2.91) and psychological and/or physical abuse (OR 1.23–1.96). A higher level of gender nonconformity predicted a higher likelihood of being classified into each adversity profile compared with the no or low adversity profile (OR 1.14–1.45).

      CONCLUSIONS Sexual minority adolescents and adolescents with high levels of gender nonconformity are vulnerable to experience adversity. The disparities for lesbian, gay, bisexual, transgender, and questioning adolescents and adolescents with high gender nonconformity highlight the variation in patterns of childhood adversity that these youth are at risk of experiencing. The findings reveal the need for further research on the benefits and harm of screening for childhood adversity by physicians and pediatricians.

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      Address correspondence to Michael Goodman, MD, MPH, Department of Epidemiology, Emory University School of Public Health, 1518 Clifton Rd, NE, CNR 3021, Atlanta, GA 30322. E-mail: mgoodm2@emory.edu

      BACKGROUND Understanding the magnitude of mental health problems, particularly life-threatening ones, experienced by transgender and/or gender nonconforming (TGNC) youth can lead to improved management of these conditions.

      METHODS Electronic medical records were used to identify a cohort of 588 transfeminine and 745 transmasculine children (3–9 years old) and adolescents (10–17 years old) enrolled in integrated health care systems in California and Georgia. Ten male and 10 female referent cisgender enrollees were matched to each TGNC individual on year of birth, race and/ or ethnicity, study site, and membership year of the index date (first evidence of gender nonconforming status). Prevalence ratios were calculated by dividing the proportion of TGNC individuals with a specific mental health diagnosis or diagnostic category by the corresponding proportion in each reference group by transfeminine and/or transmasculine status, age group, and time period before the index date.

      RESULTS Common diagnoses for children and adolescents were attention deficit disorders (transfeminine 15%; transmasculine 16%) and depressive disorders (transfeminine 49%; transmasculine 62%), respectively. For all diagnostic categories, prevalence was severalfold higher among TGNC youth than in matched reference groups. Prevalence ratios (95% confidence intervals [CIs]) for history of self-inflicted injury in adolescents 6 months before the index date ranged from 18 (95% CI 4.4–82) to 144 (95% CI 36–1248). The corresponding range for suicidal ideation was 25 (95% CI 14–45) to 54 (95% CI 18–218).

      CONCLUSIONS TGNC youth may present with mental health conditions requiring immediate evaluation and implementation of clinical, social, and educational gender identity support measures.

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      Address correspondence to Robert W.S. Coulter, PhD, MPH, Graduate School of Public Health, University of Pittsburgh, 6129 Public Health Building, 130 De Soto St, Pittsburgh, PA 15261. E-mail: robert.ws.coulter@pitt.edu

      CONTEXT Compared with cisgender (nontransgender), heterosexual youth, sexual and gender minority youth (SGMY) experience great inequities in substance use, mental health problems, and violence victimization, thereby making them a priority population for interventions.

      OBJECTIVE To systematically review interventions and their effectiveness in preventing or reducing substance use, mental health problems, and violence victimization among SGMY.

      DATA SOURCES PubMed, PsycINFO, and Education Resources Information Center.

      STUDY SELECTION Selected studies were published from January 2000 to 2019, included randomized and nonrandomized designs with pretest and posttest data, and assessed substance use, mental health problems, or violence victimization outcomes among SGMY.

      DATA EXTRACTION Data extracted were intervention descriptions, sample details, measurements, results, and methodologic rigor.

      RESULTS With this review, we identified 9 interventions for mental health, 2 for substance use, and 1 for violence victimization. One SGMY-inclusive intervention examined coordinated mental health services. Five sexual minority–specific interventions included multiple state-level policy interventions, a therapist-administered family-based intervention, a computer-based intervention, and an online intervention. Three gender minority–specific interventions included transition-related gender-affirming care interventions. All interventions improved mental health outcomes, 2 reduced substance use, and 1 reduced bullying victimization. One study had strong methodologic quality, but the remaining studies’ results must be interpreted cautiously because of suboptimal methodologic quality.

      LIMITATIONS There exists a small collection of diverse interventions for reducing substance use, mental health problems, and violence victimization among SGMY.

      CONCLUSIONS The dearth of interventions identified in this review is likely insufficient to mitigate the substantial inequities in substance use, mental health problems, and violence among SGMY.

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      Address correspondence to Mark L. Hatzenbuehler, PhD, Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, 722 W 168th St, Room 549D, New York, NY 10032. E-mail: mlh2101@cumc.columbia.edu

      BACKGROUND Bias-based bullying is associated with negative outcomes for youth, but its contextual predictors are largely unknown. Voter referenda that target lesbian, gay, bisexual, and transgender groups may be 1 contextual factor contributing to homophobic bullying.

      METHODS Data come from 14 consecutive waves (2001–2014) of cross-sectional surveys of students participating in the California Healthy Kids Survey (N = 4 977 557). Student responses were aggregated to the school level (n = 5121). Using a quasi-experimental design, we compared rates of homophobic bullying before and after Proposition 8, a voter referendum that restricted marriage to heterosexuals in November 2008.

      RESULTS Interrupted time series analyses confirmed that the academic year 2008–2009, during which Proposition 8 was passed, served as a turning point in homophobic bullying. The rate of homophobic bullying increased (blinear = 1.15; P , .001) and accelerated (bquadratic = 0.08; P , .001) in the period before Proposition 8. After Proposition 8, homophobic bullying gradually decreased (blinear = 20.28; P , .05). Specificity analyses showed that these trends were not observed among students who reported that they were bullied because of their race and/or ethnicity, religion, or gender but not because of their sexual orientation. Furthermore, the presence of a protective factor specific to school contexts among lesbian, gay, bisexual, and transgender youth (gay-straight alliances) was associated with a smaller increase in homophobic bullying pre–Proposition 8.

      CONCLUSIONS This research provides some of the first empirical evidence that public campaigns that promote stigma may confer risk for bias-based bullying among youth.

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      Address correspondence to Valerie A. Earnshaw, PhD, Division of General Pediatrics, Boston Children’s Hospital, 130 Enders Building, 300 Longwood Ave, Boston, MA 02115. E-mail: valerie.earnshaw@gmail.com

      Lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth experience significant bullying that undermines their mental and physical health. National health organizations have called for the development of innovative strategies to address LGBTQ bullying. Pediatricians and other clinicians, medical and public health students, interdisciplinary researchers, government officials, school leaders, community members, parents, and youth from around the country came together at a national symposium entitled “LGBTQ Bullying: Translating Research to Action to Improve the Health of All Youth” in May 2016 to generate strategies to prevent LGBTQ bullying and meet the needs of LGBTQ youth experiencing bullying. This article describes key scientific findings on bullying, LGBTQ stigma, and LGBTQ bullying interventions that were shared at the symposium and provides recommendations for pediatricians to address LGBTQ bullying via clinical care, research, interventions, and policy. Symposium participants recommended that pediatricians engage in efforts to foster inclusive and affirming health care environments wherein LGBTQ youth feel comfortable discussing their identities and experiences, identify youth experiencing LGBTQ bullying, and prevent the negative health consequences of bullying among youth. Moreover, pediatricians can attend to how multiple identities (eg, sexual orientation, gender identity, race and/or ethnicity, disability, and others) shape youth experiences of bullying and expand intervention efforts to address LGBTQ bullying in health care settings. Pediatricians can further advocate for evidence-based, antibullying policies prohibiting bullying on the basis of sexual orientation and gender identity. Collaboration between pediatricians and diverse stakeholders can contribute to the development and implementation of lasting change in all forms of bullying, including LGBTQ bullying.

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      Address correspondence to Gabriel R. Murchison, MPH, Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115. E-mail: gmurchison@g.harvard.edu

      BACKGROUND Transgender and gender nonbinary adolescents experience high rates of peer victimization, but the prevalence of sexual assault in this population has not been established. Some schools restrict transgender and nonbinary students from using restrooms and locker rooms that match their gender identity, with unknown effects on sexual assault risk. We tested whether these restrictions were associated with the 12-month prevalence of sexual assault victimization.

      METHODS Survey responses were analyzed from 3673 transgender and nonbinary US adolescents in grades 7 through 12 who participated in the cross-sectional 2017 LGBTQ Teen Study. We estimated the association between school restroom and locker room restrictions and sexual assault, adjusting for potential social and behavioral confounders, using logistic regression. We also tested potential mediators.

      RESULTS The 12-month prevalence of sexual assault was 26.5% among transgender boys, 27.0% among nonbinary youth assigned female at birth, 18.5% among transgender girls, and 17.6% among nonbinary youth assigned male at birth. Youth whose restroom and locker room use was restricted were more likely to experience sexual assault compared with those without restrictions, with risk ratios of 1.26 (95% confidence interval [CI]: 1.02–1.52) in transgender boys, 1.42 (95% CI: 1.10–1.78) in nonbinary youth assigned female at birth, and 2.49 (95% CI: 1.11–4.28) in transgender girls. Restrictions were not associated with sexual assault among nonbinary youth assigned male at birth.

      CONCLUSIONS Pediatricians should be aware that sexual assault is highly prevalent in transgender and nonbinary youth and that restrictive school restroom and locker room policies may be associated with risk.

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      Address correspondence to Ellen C. Perrin, MD, Division of Developmental-Behavioral Pediatrics, Floating Hospital for Children, Tufts Medical Center, 800 Washington St, Boston, MA 02111. E-mail: eperrin@tuftsmedicalcenter.org

      BACKGROUND Gay men have become fathers in the context of a heterosexual relationship, by adoption, by donating sperm to 1 or 2 lesbian women and subsequently sharing parenting responsibilities, and/or by engaging the services of a surrogate pregnancy carrier. Despite legal, medical, and social advances, gay fathers and their children continue to experience stigma and avoid situations because of fear of stigma. Increasing evidence reveals that stigma is associated with reduced well-being of children and adults, including psychiatric symptoms and suicidality.

      METHODS Men throughout the United States who identified as gay and fathers completed an online survey. Dissemination of the survey was enhanced via a “snowball” method, yielding 732 complete responses from 47 states. The survey asked how the respondent had become a father, whether he had encountered barriers, and whether he and his child(ren) had experienced stigma in various social contexts.

      RESULTS Gay men are increasingly becoming fathers via adoption and with assistance of an unrelated pregnancy carrier. Their pathways to fatherhood vary with socioeconomic class and the extent of legal protections in their state. Respondents reported barriers to becoming a father and stigma associated with fatherhood in multiple social contexts, most often in religious institutions. Fewer barriers and less stigma were experienced by fathers living in states with more legal protections.

      CONCLUSIONS Despite growing acceptance of parenting by same-gender adults, barriers and stigma persist. States’ legal and social protections for lesbian and gay individuals and families appear to be effective in reducing experiences of stigma for gay fathers.

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