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This guide is an entry point for research on LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Intersex, Asexual, Aromantic, and adjacent experiences) people, stories, and concerns. This is a constantly expanding field that is often highly affected by contemporary politics. As a result, such a guide will never be comprehensive and the terminology will vary widely. Resources are provided here for the purposes of research and should not be used to invalidate anyone's lived experiences or expressions.

For example- these dictionaries and terminology guides may support general learning, however language use and understanding may not be consistent on an individual level.

• An Ally's Guide to Terminology: Talking About LGBT People & Equality (GLAAD and MAP)
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LGBTQI+ Youth and Mental Health: A Systematic Review of Qualitative Research

• Systematic Review
• Open access
• Published: 21 May 2019
• Volume 5 , pages 187–211, ( 2020 )

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• Clare Wilson 1 &
• Laura A. Cariola 1  

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Due to increased levels of stigma, discrimination and victimization Lesbian, Gay, Bisexual, Transgender, Queer, Questioning or Intersex (LGBTQI+) youth face particular challenges in society. With the intention of better understanding the challenges and issues that LGBTQI+ youth are experiencing, this systematic review explored qualitative studies with a focus on mental health services and the requisite social support service policies and programs for LGBTQI+ youth. Qualitative research systematically examines the expressed thoughts and feelings of the research participants, and through reflective analysis of the themes and links discussed, can provide rich and nuanced understanding. A synthesis of the included studies identified five core themes: (1) Isolation, rejection, phobia, need for support; (2) Marginalization; (3) Depression, self-harm and suicidality; (4) Policy and environment; and (5) Connectedness. Key results suggest that community, school, and family resources to support resilience will optimize LGBTQI+ mental health. This systematic review of qualitative research provides a source of rich information to inform the provision of services and policies that will address the disparity into mental health statistics for the LGBTQI+ population.

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Introduction

Young people experience many challenges in adolescence. Anxiety, depression and suicide are reported as causes of youth morbidity and mortality across the world (Adelson et al. 2016 ). Empirical studies suggest that youth who identify as Lesbian, Gay, Bisexual, Transgender, Queer, Questioning or Intersex (LGBTQI+) can find themselves faced with greater challenges, compared to youth of heterosexual orientation, as they navigate the heteronormative educational and societal institutions where children and youth spend much of their early lives (Almeida et al. 2009 ; Fergusson et al. 1999 ; Hafeez et al. 2017 ; Russell and Fish 2016 ). Online and community services, such as RainbowYOUTH (RainbowYOUTH 2018 ) and InsideOUT (InsideOUT 2018 ) in New Zealand and their international equivalents, are available to youth, but the provision of a positive school climate where LGBTQI+ youth can feel physically, emotionally and socially safe is vital for them to thrive during their adolescence and early adulthood. Research into mental health disparities and challenges for LGBTQI+ youth to date has a predominantly quantitative focus, and several systematic reviews provide an overview of quantitative data available on issues faced by Sexual and Gender Minority Youth (SGMY) (e.g. Brown et al. 2016 ; McDonald 2018 ). Surprisingly, there are fewer qualitative studies that contribute to an in-depth understanding of the challenges and issues that LGBTQI+ youth are facing by exploring the views and opinions of those affected. This systematic review aims to identify and obtain a comprehensive overview of qualitative studies by appraising, critically reviewing and synthesizing qualitatively derived evidence-based results and main emergent themes sourced from current literature. Special attention is given to the provision of mental health services and the requisite social support service policies and programs for LGBTQI+ youth.

LGBTQI+ Mental Health

LGBTQI+ youth are one of the most vulnerable groups in society due to their increased risk of mental health problems. Statistics for the LGBTQI+ population estimate that New Zealand has 8% non-heterosexual youth (Clark et al. 2013 ), the U.S. has 7-8% LGB youth (lesbian, gay or bisexual) (Wilson et al. 2014 ), and the U.K. has 4.1% of LGB young people aged 16–24 (Office for National Statistics 2016 ). Although LGBTQI+ represents only a small proportion of the total youth population, they are at increased risk, compared to heterosexual youth, of experiencing hostile environments at home and in wider society, and are subject to direct and indirect discrimination, harassment, disadvantage and inequality with detrimental consequences for mental health (Hudson-Sharp and Metcalf 2016 ).

In fact, the 2012 survey completed as part of the Youth 2000 Survey Series, Young People Attracted to the Same Sex or Both Sexes Report (Lucassen et al. 2014 ), stated that sexual and gender minority youth were more than three times as likely to express symptoms of depression and more than twice as likely to have self-harmed than their heterosexual peers. One in five had attempted suicide, with almost half of the respondents having thought about a suicide attempt. 41% of sexual and gender minority youth had been to see a professional for emotional support in the last 12 months, compared to 16.6% of their non-LGBTQI+ peers. The Youth 2000 Survey (Lucassen et al. 2014 ) also identifies a greater risk of alcohol or drug use in LGBTQI+ youth. During the same period, in Scotland, 40% of LGBT youth considered themselves to have a mental health condition in comparison to 25% of non-sexual and gender minority youth, and bullying was identified as a key factor in distress among respondents (Mental Health Foundation 2016 ).

In particular, evidence suggests that sexual and gender minority youth have different risk factors and markers (Silenzio et al. 2007 ) and that these unique risks combined with general life stressors have the phenomenological outcome of higher levels of self-harm, suicidality and impulsivity (Liu and Mustanski 2012 ). These risk factors extend over the lifespan, with four times greater risk of suicide for SGM men, and both men and women being 1.5 times more likely to suffer from anxiety, depression and substance misuse (King et al. 2008 ). Evidence from Mental health of the non - heterosexual population of England, a 2011 study (Chakraborty et al. 2011 ) concludes that gay men and lesbian women have higher levels of psychological distress than heterosexuals and that discrimination may be a significant factor affecting mental health for the LGBTQI+ population.

Minority stress theory (Meyer 2003 ) suggests that the increased prevalence of mental health issues experienced by LGBTQI+ youth is due to the increased level of social stress, including stigma, discrimination, prejudice and victimization. Adolescence is a critical neurological development stage, with heightened effects of stress on mental health, important memory system development and a time of increased sensitivity to drug use (Fuhrmann et al. 2015 ). At this crucial time, feeling discriminated against by educational, medical or religious institutions, or internalizing feelings of victimization due to homophobia, transphobia or biphobia can result in significant psychological challenges for sexual and gender minority youth (Russell and Fish 2016 ). Evidence has consistently identified that issues such as marginalization, isolation, exclusion and bullying create social stress for sexual and gender minority youth (Grossman et al. 2009 ; Hafeez et al. 2017 ). Additionally, lack of access to understanding adults, safe places and change room facilities creates a psychological burden. However, as Bryan and Maycock ( 2017 ) point out, this can create a pathologizing phenomenon, which paradoxically may stigmatize well-adjusted and happy LGBTQI+ youth who are managing their lives in psychological comfort.

Particularly, stigma and shame create personal barriers for at-risk youth, preventing those affected from accessing services (Brown et al. 2016 ). McDermott ( 2015 ) suggests that embarrassment, shame and fear of stigmatization are reasons for sexual and gender minority youth to avoid seeking support from mental health services. Young LGBTQI+ people who are homeless, rural, or who are substance-users face additional barriers to seeking help (Brown et al. 2016 ). If support from adults or professionals is inaccessible, an alternative is for LGBTQI+ youth to find peer support and information on internet-based forums (McDermott et al. 2015 ; McDermott et al. 2008 ).

Family acceptance also has been identified as a salient influence on the mental health of sexual and gender minority youth (Sitkin and Murota 2017 ). Parental attachment, as described by Mohr and Fassinger ( 2003 ), is characterized by sensitivity and responsiveness to a young person’s needs. If sexual and gender minority youth feel accepted and valued as individuals, there is an increased likelihood to disclose non-heteronormative status to family, and “come out,” or “be out,” the colloquial terms for being able to openly express LGBTQI+ orientation (Ryan et al. 2010 ). However, there is a disproportionate number of homeless LGBTQI+ youth, signifying that familial rejection is a significant factor for compromised mental health (Russell and Fish 2016 ). Durso and Gates ( 2012 , p. 4) published results of a national USA online survey and found that “nearly seven in ten (68%) of their LGBT homeless clients have experienced family rejection and more than half of clients (54%) had experienced abuse in their family.”

Adolescence is a developmental time frame within which youth explore their sexuality and for LGBTQI+ youth it will often be the time when they develop understanding of their own sexual and gender orientation. Within the realm of early family relational psychology, Bowlby ( 1962 /1982) discusses changing attachments during the time of adolescence, with a subsequent shift in attachment to peers and social groups other than the family, and to institutions such as school, universities, religious or political groups. Acceptance by these alternative attachment groups is a strong protective factor for sexual and gender minority youth (Higa et al. 2014 ). The wider ecology of LGBTQI+ youth has a significant effect on their mental health and well-being and feelings of social connectedness to adults gives sexual and gender minority youth resilience in the face of adversity, particularly at the vulnerable developmental stage when they are establishing their sense of personal identity (Difulvio 2011 ).

Key Themes in Quantitative Research

The vast majority of quantitative literature on LGBTQI+ focuses on the impact of isolation, marginalization and discrimination against sexual and gender minority youth in relation to mental health outcomes, and the identification of risk and protective factors. For example, there is a robust pattern of results that demonstrated sexual and gender minority youth experience significantly higher levels of suicidality, depression, and substance misuse than heterosexual youth, which highlights the severity and prevalence of differences between sexual and gender minority youth and heterosexual youth (King et al. 2008 ; Lucassen et al. 2017 ). These results also identified higher rates of violence and victimization associated with higher levels of hopelessness and attempted suicide in sexual and gender minority youth, and also a greater potential for psychosocial problems (e.g. drug and alcohol use or abuse, risky sexual behaviors, eating disorders, and mood disorders) than reported by their heterosexual or cisgender peers. The relationship between peer victimization and sexual orientation, gender identity or expression associated with poor mental health outcomes (e.g. depression, traumatic stress, and suicidality, as well as alcohol and substance abuse) and educational outcomes (e.g. diminished school belonging, disruptions in educational trajectories) has been also confirmed in another systematic review (Collier et al. 2013 ). In particular, bisexual individuals have been shown to experience more psychological distress, compared to homosexual and heterosexual peers due to experiences of victimization, peer judgments and family rejection (King et al. 2008 ; Pompili et al. 2014 ).

Quantitative research has also focused on identifying risk and protective factors for mental health in LGBTQI+ youth, which has resulted in setting directions for prevention, intervention and treatment, as well as influencing laws and policies, and making advances in fostering improved mental health (Russell and Fish 2016 ). For example, the role of family acceptance as a protective factor in LGBTQI+ youth and young adults has been shown to be a predictor for positive mental health outcomes (e.g. greater self-esteem, social support, general health) and a protector against depression, substance abuse and suicidality (Bouris et al. 2010 ; Ryan et al. 2010 ). As such, family programs that motivate and empower parents, caregivers and other family members, have been recognized as a promising framework for community interventions that emphasize a strengths-based approach concentrating on the effects of positive parent–child relationships, rather than focusing on negative parent–child relationships and influences where a child’s sexual orientation and gender identity may be seen as a “deficit.” Further supporting these findings are those of a recent systematic review of literature (McDonald 2018 ), who identified that higher levels of social support were associated with positive self-esteem whereas lack of social support was associated with higher levels of depression, anxiety, shame and self-esteem, alcohol and drug misuse, as well as risky sexual behavior. In particular family or significant adults providing support for young LGBTQI+ is a protective factor. Family and caregiver acceptance and a sense of belonging to a peer group were identified as moderators of resilience, and thus, suggests McDonald, can be utilized in communities to support mental health outcomes.

In relation to accessing and engaging with mental health care, Brown and colleagues’ systematic review ( 2016 ) identified barriers and facilitators among youth from different minority groups, including but not exclusively LGBTQI+ , who had distinct needs that must be recognized by mental health services in order to improve their experiences with mental health care. In particular, findings demonstrated that barriers to access are more often identified (e.g. lack of awareness of services, stigma and shame around seeking help, issues around confidentiality, trust and anonymity), however, facilitators to support engagement with providers (e.g. community and educational programs to increase awareness of services and attitudes toward mental health services) have remained widely underexplored, and thus require further attention in future research. With regards to educational programs aimed at increasing LGBTQI+ wellbeing, safe school interventions and supportive environments such as “gay-straight alliances,” sometimes referred to as the “gender and sexuality alliances,” (GSAs) have been shown to have a positive effect in reduction of stigma in schools, with significantly better psychological outcomes (e.g. improvement in academic performance, feeling more comfortable in their sexual identity and empowerment), social outcomes (e.g. positive sexual diversity climates, greater sense of connectedness to their school), and also physical outcomes (e.g. lower levels of youths’ self-reports of homophobic victimization, fear of safety, and hearing homophobic remarks) (Black et al. 2012 ; Marx and Kettrey 2016 ). This study also showed that the empowering of youth to be activists and to form their own peer supports may mediate the negative effects of marginalization and the poor mental health outcomes, including depression and suicidality.

The Current Study

The existing quantitative studies provide a rich picture of trends based on statistical indications of sexual and gender minority youth who experience adverse outcomes in a heteronormative society. In contrast to quantitative studies, qualitative approaches to the analysis of data represent an important perspective for advancing the literature by obtaining an in-depth awareness of LGBTQI+ youth and their experiences of engaging in mental health and social support services and programs. As such, qualitative research provides insight into the thoughts and feelings of the research participants, and through reflective analysis by the researcher of the themes and links discussed, can provide meaning and understanding (Sutton and Austin 2015 ). One of the reasons participants may voluntarily engage in this type of research is the implicit chance that the evidence will inform change by giving them a voice, hence both personal and political empowerment (Clark 2010 ). The key aim is to provide a comprehensive understanding of nuances of human experience through analysis and interpretation of texts and images (McLeod 2010 ).

Qualitative research has also been traditionally excluded from systematic reviews but it has been recognized that qualitative research provides valuable insight to inform policies and practice (Thomas and Harden 2008 ). In particular, with the current focus on public and individual opportunity to be involved in the development and provision of LGBT services (Gillespie et al. 2002 ; Ministry of Youth Development 2015 ; Stonewall Scotland 2018 ), there is international recognition of the importance of client-centered, consultative and inclusive policy development informed by the voices of services users and consumers of services. The inclusion of service user voices draws on the notion of being given the power in respect to “having a voice,” and conversely, the notion of “silence” sometimes associated with feminism but equally ascribable to any marginalized or minority population (Hadfield and Haw 2001 ). Notably, experiences of youth are also often marginalized or they are spoken for by the parents or carers, and youth, if they do speak out, often assume that their voices will not be heard or respected as valid contributions in decision-making processes. There should be specific efforts to include youth in meaningful ways to voice their opinion in relation to matters that are of concern to them, without resulting in further inequalities. A Canadian paper, Promoting LGBT health and wellbeing through inclusive policy development , which also draws on literature from Australia, the UK and the USA, asserts that the marginalized LGBTQI+ community must be “explicitly included in policy development for a more inclusive form of health promotion” (Mulé et al. 2009 , p. 2). Because youth have authentic, legitimate experiences of the problems they encounter, qualitative research involving them will improve policies and future research (McLaughlin 2015 ). Hence, having the voice of young LGBTQI+ people available through qualitative research is imperative if we are to address the ecological, social, and pedagogical issues and ultimately the human rights of this marginalized group (Mockler and Groundwater-Smith 2015 ; UNICEF 1990 ).

The focus of this systematic review is to provide a comprehensive overview by collating and critically appraising the existing evidence-base of qualitative research studies of the last ten years (2008–2018), a decade that has seen a global increase in acceptance towards LGBT (Flores and Park 2018 ), which sought to provide a youth voice in regards to mental health challenges and experiences for LGBTQI+ people. This 10-year period has seen international changes in same-sex marriage laws, gay parenting rights, and gender reassignment as a protected characteristic (Stonewall Scotland 2018 ). In particular, this review aimed to identify and map themes from across the different types of qualitative research being undertaken, as well as identifying gaps in knowledge, to inform community-based LGBTQI+ service provision with a focus on ecological measures needed to support young LGBTQI+ people.

Search Strategy and Eligibility Criteria

For this literature search, several clinical psychology databases were identified to best represent the diverse fields of study relevant to this review, including ASSIA, CINAHL Plus, EMBASE, IBSS, MEDLINE and PsycINFO. With focus on qualitative studies published in the last decade characterized with marked changes of LGBTQI+ legislation, all database searches were limited to articles written in the English language, and published between January 2008 and April 2018. The search focused on international research articles appearing in peer-reviewed journals. Following the initial database search, a Google search and a manual back literature search were conducted in June 2018. The search strategy aimed to identify qualitative research literature on LGBTQI+ youth with particular attention to mental health issues, using Boolean operators and variations of the following keywords: qualitative, LGBT*, youth, young people, adolescent, teenager and mental health.

To identify relevant articles for this systematic review, inclusion and exclusion criteria were applied. Identified journal articles had to fulfill further inclusion criteria: (1) published between 2008 and 2018, (2) published in English language peer-reviewed journals, (3) focus on mental health of LGBTQI+ , (4) participants aged 12 to 24 years (using the New Zealand Government definition of youth age range being 12 to 24 years inclusively (Ministry of Youth Affairs 2002 ), (5) use of a qualitative methodology to the analysis of data. Journal articles were excluded if: (1) the study focus was on a specific, non-generalizable intervention or socio-economic population demographic, (2) the study had a medical perspective or focus on sexual health or practices, (3) the methodology did not include a qualitative methodology. All studies were evaluated according to these inclusion and exclusion criteria, and only studies that met the criteria were included in this systematic review. Studies that did not meet these inclusion criteria were discarded.

To identify relevant studies for this review, the inclusion and exclusion criteria were applied using a three-stage selection process (Meade and Richardson 1997 ): (a) looking only at the title, (b) looking at the abstract to identify its relevance to the research question and methodology, and (c) looking at the whole article. In cases where the researcher was not sure whether the paper was relevant and met inclusion criteria, the item was retained for the next screening stage.

Based on the outlined literature search strategy, 873 studies were initially identified. At this stage an additional manual search of Google using the same search terms and a manual back literature search of the articles included to date identified a further 21 articles. After duplicate removal and a title review of these studies, 676 were excluded and 52 were determined to meet inclusion criteria. Following another exclusion process, a total of 34 research articles were selected as having satisfied the eligibility criteria. A detailed overview of the search stages can be seen in the PRISMA Flow Diagram (see Fig.  1 ). The 34 articles include seven mixed methods studies where the results of the qualitative thematic analysis was deemed to add valuable data.

PRISMA flow chart

Data Extraction

Data of the included studies were extracted using a standardized format for systematic reviews of qualitative studies (NICE 2012a ). Characteristics identified from each of the 34 studies included research questions, methods, sample size and quality assessment. The extracted data were aggregated clearly and structured in a data extraction table (see Tables  1 , 2 , 3 , 4 and 5 ). To synthesize the findings of the studies, findings were extracted from the studies and grouped into thematic categories. Subsequently, patterns were sought across the findings to provide a more comprehensive understanding of the issues of concern to LGBTQI+ population using mental health services addressed in the studies.

Quality Assessment

Quality assessment of the retrieved journal articles was performed using the NICE guidelines quality appraisal checklist for qualitative studies (NICE 2012b ). Following these guidelines, assessment identifies the research question and the robustness of the methodology in relation to key findings and a valid conclusion. Six main domains are assessed: theoretical approach, study design, data collection, trustworthiness, analysis and ethics. A seventh overall assessment looks at the relevance of the study and grants an overall rating; “++” where all or most of the checklist criteria have been fulfilled, and where they have not, conclusions are highly unlikely to alter; “+” where some of the checklist criteria have been fulfilled, and conclusions are unlikely to alter; or a rating of “-” where few or no criteria are fulfilled. The seven mixed methods studies included in this systematic review had quality assessment performed only on the qualitative data methodology results of the research. In relation to the qualitative assessment of this systematic review, one reviewer initially assessed the quality of the included studies and subsequently, the quality assessment was verified by another reviewer.

The search identified 97 abstracts which were screened for relevance to qualitative research into mental health of LGBTQI+ youth. The full texts of 52 articles were assessed and 34 were identified as providing data pertaining to the aim of this systematic review. The 34 reviews were organized into five groups based on the research settings: (1) Internet search studies (see Table  1 ), (2) University student studies (see Table  2 ), (3) School or community group studies (see Table  3 ), (4) Studies focusing on Transgender (see Table  4 ), (5) Intervention studies (see Table  5 ). The results were compiled tables, and sorted into groups.

Included Study Characteristics

Population samples.

Of the 34 studies included in the systematic review, 19 studies (55.88%) focused on school or community populations, 9 studies (26.47%) were online- or Internet-based of which 3 studies were conducted using Internet-sourced data and 3 studies (8.8%) used university student populations, 3 studies (8.8 s %) focused on transgender subjects, and further 3 studies (8.88%) were related to the assessment of an intervention. The population numbers showed great variability from the smallest sample numbers (n = 10) (Diamond et al. 2011 ; Saltzburg and Davis 2010 ) to the largest study population (n = > 3700), taken from an online study (Peter et al. 2016 ).

Geographical Information

Of the studies included in this systematic review, 16 were done in the USA (47.06%), with 7 studies from the UK being the next highest geographical location (20.59%), followed by four in Australia (11.76%) and three in New Zealand (8.82%), and one in Canada (2.94%). Also included were international collaboration studies between the USA and Canada (Porta et al. 2017 ), Ireland, the USA and Canada (Catalpa and McGuire 2018 ) and the Universities of York, Leicester and Oslo (McDermott et al. 2013 ).

Of the identified studies for this systematic review, 23 studies were of high quality (67.65%) and 11 studies were of medium quality (32.35%). Of the 19 school and community population studies, 11 studies (57.89%) being of high quality and 8 (42.11%) of medium quality. The online Internet studies were assessed as having four (66.6%) high quality studies, and the university student population articles had two high quality studies (66.6%). The transgender and intervention study research groups both had all (100%) high quality studies.

Qualitative Methods

The most common methodology overall was thematic analysis, with 13 studies (38.23%), followed in frequency by four grounded theory (11.11%). Ethnographic and phenomenological approaches were used by three studies each (8.33% respectively). The remaining 11 studies (33%) used a variety of qualitative approaches, including one Foucauldian Discourse Analysis (McDermott 2015 ), one Life Story approach (Difulvio 2011 ), and a Go-Along Interviewing technique (Porta et al. 2017 ). There are three identified intervention studies in this systematic review. Porta et al. ( 2017 ) used an exploratory study to get a qualitative perspective from LGBTQI+ students (n = 25) about bathroom facilities, Lucassen and Burford ( 2015 ) evaluated a school-based workshop offered to students (n = 229), and a computerized e-resource aimed at sexual and gender minority youth with depression (n = 25) was also evaluated (Lucassen et al. 2015 ).

Synthesis of Themes

An analysis of the studies’ findings identified five core themes: (1) Isolation, rejection, phobia, need for support, ( 2) Marginalization, (3) Depression, self-harm and suicidality, (4) Policy and environment and (5) Connectedness. A diagram provides a visual outline of identified themes (see Fig.  2 ). The greatest proportion of studies (19) were categorized as School and Community services, and commonly identified all 5 themes, as did the Online/internet studies. The University studies concentrated on themes 1 to 4, the transgender studies identified all but the third theme, of suicidality, self-harm and depression, whereas the predominant theme of the three intervention studies was connectedness (see Fig.  2 ).

Diagram of identified themes

Isolation, Rejection, Phobia, Need for Support

Online studies, school and community based studies and transgender studies discussed themes of rejection and isolation, bullying and phobic behavior and the need for both more support and information to be made accessible to LGBTQI+ youth. Thematic narrative analysis of interviews and focus groups by Steinke et al. ( 2017 ) provided evidence of isolation as a reason that sexual and gender minority youth seek out Internet-based support channels, and further, the study by Wolff et al. ( 2014 ) of online-sourced media of completed suicides perceives isolation as both a precursor to suicidality and a warning sign of mental distress. Rejection from social, family and peer groups was a key trigger for distress in LGBTQI+ youth (Jones and Hillier 2013 ), and Higa et al. ( 2014 ) who identified negative and positive factors in a school-based sample, stated that the risk of rejection is potentially greater for those who are also at risk of racist or sexist bias, for example young women of color. Homophobia and transphobia towards sexual and gender minority youth was identified across several studies (Formby 2013 ; McDermott et al. 2017 ; McDermott et al. 2008 ). In McDermott et al. ( 2017 ), a high quality mixed-methods study involving thematic analysis of both online and face-to-face interviews, victimization through phobic behavior and attitudes of others towards sexual and gender minority youth was described as one of the five social determinants leading to suicidality, with 70.8% of their respondents having reported experiences of homophobia, transphobia or biphobia. These concepts of discrimination are re-framed as heterosexism by Nadal et al. ( 2011 ) and Roffee and Waling ( 2016 ), where the result of such discrimination and microaggressions contributes to negative effects on self-esteem and subsequent feelings of rejection and isolation.

The need for support in school and social environments for LGBTQI+ was put forward as an important factor for mental health, and in particular the availability of peer groups such as Gay Straight Alliance (GSA) groups and safe, inclusive community gathering places and events like RainbowYOUTH meetings. GSAs were specifically described as a source of safety and advocacy for youth (Porta et al. 2017 ; Russell et al. 2009 ). In particular, Steinke et al. ( 2017 ) suggest that a lack of any such supportive community for some sexual and gender minority youth is a valid driver of the need for online LGBTQI+ community groups, which is further supported by Higa et al. ( 2014 ) by pointing out that connecting via online interventions would be especially beneficial for those sexual and gender minority youth who are geographically isolated or who are either not “out” or who are not supported by their families to attend LGBTQI+ groups. The Internet, school GSA-type groups and community groups, such as RainbowYOUTH, were all found to be sources of information pertaining to gender or sexual minority identity as well as mental health support (Steinke et al. 2017 ; Waling and Roffee 2018 ). In a secondary inductive analysis of Concept Mapping Needs Assessments at two GLBT-focused youth centers in the U.S., Davis et al. ( 2009 ) argue that as well as material resources and information, having a person to talk to was a priority for sexual and gender minority youth who access these services, stating: “In fact, needing someone to talk to was the most important idea across groups for meeting youths’ emotional needs” (p. 1037).

Marginalization

Closely associated to “Isolation” is the concept of “Marginalization,” which can be defined as “Treatment of a person, group, or concept as insignificant or peripheral” (Oxford Dictionaries 2018 ). Both concepts, however can be differentiated to the extent that isolation refers to an individual experience, whereas marginalization describes the socio-political status of a population sub-group such as LGBT experiencing diminished community acceptance and systemic discrimination. The research articles identified in this systematic review put forward that marginalization for the LGBTQI+ community was a significant factor for mental health. For example, Alessi et al. ( 2017 ) conducted a grounded theory of focus groups to understand the role of minority stress and identified a continuum of marginalization experienced by first-year experience of LGBQ emerging adults attending a university in the Northeastern part of the United States. In a thematic analysis of qualitative interviews, Pallotta-Chiarolli and Martin ( 2009 , p. 200) also talk of young bi-sexual people “feeling like marginal X-files,” and the socio-political marginalization of sexual and gender minority youth makes it particularly critical that young bi-sexual people have a collective voice in order to be empowered to challenge the status quo (Russell et al. 2009 ). In a New Zealand ethnographic study, McGlashan and Fitzpatrick ( 2017 ) found that heteronormative environments, such as schools, create a culture where sexual and gender minority youth are more likely to be marginalized due to the dominant discourse of heterosexuality being positioned as “normal.” McDermott et al. ( 2008 ) and Scourfield et al. ( 2008 ) posit that despite increasing social acceptance of same-sex partnerships, marginalization is still prevalent for sexual and gender minority youth in the UK, and that until recently, sexual or gender orientation has not been recognized as a significant mental health risk factor, referring to the Preventing Suicide in England report (Department of Health 2012 ).

Depression, Self-harm and Suicidality

The previously identified themes of marginalization, isolation, rejection and being victims of phobic behavior are linked to poor mental health outcomes such as depression, self-harm and suicidality (Catalpa and McGuire 2018 ; Diamond et al. 2011 ; Difulvio 2011 ). In particular, self-harm was identified in the transgender population as an expression of dissatisfaction with the natal anatomy and physiology which was experienced to be erroneous or undesirable (McDermott et al. 2015 ). Jones and Hillier ( 2013 ) state in their mixed-methodology study findings that almost half of young trans-spectrum people have self-harmed. Scourfield et al. ( 2008 ), having used interviews and focus groups in their high quality study, discuss the ways in which this self-harm can manifest, from cutting to risky behaviors, and the question of whether sexual and gender minority youth identity has direct causality to these phenomena, or whether it is one factor among many in the lives of LGBTQI+ youth which may lead to self-destructive behaviors. Bullying and victimization by homophobic, transphobic or biphobic behavior was found to be a key component in self-harm behaviors (Formby 2013 ; Lucassen and Burford 2015 ; McDermott et al. 2017 ; Scourfield et al. 2008 ; Wolff et al. 2014 ). The inability to disclose sexual or gender orientation, or fear of “coming out” and negative experiences following disclosure were also found to be a strong predictor of depression and suicidality (Grafsky et al. 2018 ; Jones and Hillier 2013 ; McDermott et al. 2017 ).

Out of the 34 articles identified, 13 specifically dealt with the topic of suicide, and one online-based study by Wolff et al. ( 2014 ) was a frame analysis of completed suicides by sexual and gender minority youth in the USA, as reported in the media. The research was undertaken after a number of news reports, including six high-profile media stories involving young males aged 13 to 19 years who took their own lives in September 2010, linked the reported suicides to bullying and shame. Peter et al. ( 2016 ) also undertook research following a well-publicized youth suicide a year later in Canada, subsequent to reports of victimization, depression and self-harm for much of the victim’s life, and as with Wolff et al. ( 2014 ) there was a strong link between the suicide and a hostile school and community climate.

Policy and Environment

The “ Preventing Suicide in England ” report outlines how many LGBT pupils who are victims of bullying experience further negative academic, social and mental health outcomes, with the impact possibly persisting into adult life (Community Mental Health and 7 Day Services 2017 ). Hence, it is imperative that schools are safe, inclusive environments where pupils are able to learn and fulfill their potential. Developing and establishing inclusive policies that address bullying and homophobic, transphobic or biphobic behavior was a consistent theme from all groups of the identified studies. Several studies had school policy as a focus (Grossman et al. 2009 ; Peter et al. 2016 ), whereas others looked at the wider ecology of community and agency or government level policy (Harper et al. 2012 ; Pallotta-Chiarolli and Martin 2009 ; Scourfield et al. 2008 ). Curriculum inclusion of LGBTQI+ relevant topics was identified as an additional way to recognize diversity, particularly in the subject areas of health, humanities and the social sciences such as history (Formby 2013 ; Snapp et al. 2015 ). However, Formby’s ( 2013 ) high quality study of interviews and focus groups involving teachers, youth service workers and youth found that there was a disparity between the “visibility” of gay youth among their peers and the taboo nature of homosexuality within the school curriculum.

Formalized diversity programs and safe meeting spaces at educational institutions as well as community-based social groups such as RainbowYOUTH were strongly recommended for supporting the mental health of sexual and gender minority youth. The GLSEN report (Kosciw et al. 2014 , p. 68) states that: “Students who attended schools with a GSA were much more likely to report that their classmates were accepting of LGBT people.” Using phenomenological analysis of interviews conducted with undergraduate students who identify as LGBTIQ + attending a large Australian university, Waling and Roffee ( 2018 ) focus on diversity and inclusion programs in higher education facilities, whereas Lucassen and Burford ( 2015 ) evaluated the potential of an intervention involving a sexuality diversity workshop that was delivered in a high school setting in New Zealand. Having facilities such as bathrooms and changing rooms, which are gender neutral, therefore inclusive, was a recommendation from research conducted in Canada and the US (Porta et al. 2017 ) and Australia (Waling and Roffee 2018 ). In New Zealand a guide produced for schools (Ministry of Education 2015 ), directs that schools not only challenge bullying and marginalization of students, but also delivers a mandate to engender diversity through gender-neutral uniform policies and consideration of such things as inclusive sports and extracurricular events, and allowing same-sex partners for school dances, which address the needs of sexual and gender minority youth throughout the wider school community, rather than solely through the curriculum (McGlashan and Fitzpatrick 2017 ).

An important consideration for educators and professionals working with youth is continuing education on LGBTQI+ issues, as Wolff ( 2014 ) asserts that appropriate support for LGBTQI+ youth from educators and mental health professionals can mitigate the stress of “coming out” and navigating a heteronormative environment. Sherriff et al. ( 2011 ) and Jones and Hillier ( 2013 ) suggest that the needs of sexual and gender minority youth are not being met by community and educational services and that training for service providers is imperative, with opportunities provided to hear the voice of young LGBTQI+ as part of such training, so that subjective experiences of sexual and gender minority youth are heard and understood by professionals. The findings of Scourfield et al. ( 2008 ) evince “the need for sexual cultural competence in practitioners.” Likewise Snapp et al. ( 2015 ) advocate staff training policies on LGBTQI+ issues.

Connectedness

Sexual and gender minority youth connectedness to others was identified in the context of smaller groups such as GSAs, which then become part of a wider network that grants empowerment to marginalized LGBTQI+ youth (Russell et al. 2009 ). As such, the sense of solidarity and friendship in the face of isolation and a physical place such as GSA or community group, where sexual and gender minority youth can be physically and mentally safe while forging connections with peers, was found to be a vital protective factor for LGBTQI+ youth (Davis et al. 2009 ; Russell et al. 2009 ; Saltzburg and Davis 2010 ; Steinke et al. 2017 ). In the absence of these physical spaces an online support forum is an acceptable alternative (McDermott et al. 2015 ; Steinke et al. 2017 ). McDermott ( 2015 ) discusses the problems facing young LGBTQI+ in a heteronormative society and the difficulties they face in finding support and information, resulting in peer group interaction online being a strategy used to cope with emotional distress.

Parental and family acceptance for sexual and gender minority youth and the potential for disconnect was identified as a significant mental health factor (Diamond et al. 2011 ; Grafsky et al. 2018 ; Scourfield et al. 2008 ; Wolff et al. 2014 ). Parental acceptance versus rejection was signified in the transgender studies as key to resilience for transgender youth (Catalpa and McGuire 2018 ; McGuire et al. 2010 ). Capous-Desyllas and Barron ( 2017 ) discuss the concept of loss for parents of gender-variant children and learning to love and accept their child unconditionally, as well as issues of transgender youth acceptance by other ecological groups such as medical providers and religious communities. Having one caring adult providing connection and understanding, who is both confidante and advocate, is an invaluable resource for young LGBTQI+ people in their navigation of the heteronormative institutions of their early life ecology (Porta et al. 2017 ).

Each of the five themes identified in this systematic review of qualitative research intersect and overlap. The key overarching findings from the qualitative studies into mental health of LGBTQI+ youth are summed up succinctly by Higa ( 2014 ) stating that there is a need to address the persistent prejudice that can be experienced by LGBTQ[I+] youth in their community institutions and ecology.

Qualitative research into mental health issues experienced by LGBTQI+ youth, while not commonly undertaken, is essential to the provision of understanding and insight for community service providers, health professionals and for the youth themselves. Without a LGBTQI+ youth voice to influence policy and practice it is challenging to provide support within their ecosystem where the needs of these youth can be met. For this population much of their time is spent in their family, school or community environment, where acceptance and the ability to express their authentic self is paramount to mental well-being. To this end, this systematic review aimed to identify studies using qualitative research methods of enquiry into mental health in young LBGTQI+ people. Findings revealed consistent themes across the research methods and populations studied. 34 articles of high and medium quality with diverse content and focus were identified as relevant to the aim of this review. A subsequent synthesis identified five groups that characterize the focus and settings of the studies: online or internet based, school and community populations, university setting, focus on transgender, and intervention programs. These five characteristics of populations and setting further revealed five core themes relating to the mental health challenges faced by sexual and gender minority youth including (1) Isolation, rejection, phobia and need for support, (2) Marginalization, (3) Depression, self-harm and suicidality, (4) Policy and environment and (5) Connectedness.

In relation to the first core theme, isolation, rejection, phobia and need for support, this review identified that the internet is one means of addressing this isolation and need for support. Online websites, forums, chat groups and information services were identified as a valuable resource for sexual and gender minority youth, especially those who had limited access to other ecological supports (Capous-Desyllas and Barron 2017 ; Higa et al. 2014 ; Steinke et al. 2017 ). Paradoxically, online forums are perceived as a safe and accessible means for LGBTQI+ to access information, regardless of disclosure status, and to make meaningful connections with supportive peers (Hillier et al. 2012 ). For example, the GLSEN study (GLSEN CiPHR and CCRC 2013 ) found that two-thirds (62%) of sexual and gender minority youth had connected with other LGBTQI+ youth via the internet in the previous year, and sexual and gender minority youth were five times more likely to have looked online for information pertaining to their sexuality (62%) than their non-sexual and gender minority youth peers (12%), and for information regarding health (81% sexual and gender minority youth versus 46% non-sexual and gender minority youth).

In addition, the mental health risk factors of rejection and need for a supportive network can be addressed via access to school and community cultures and services where sexual and gender minority youth feel welcomed, accepted and valued. In relation to educational and social environments, government agencies have consistently acknowledged that having safe and supportive social environments in which to live and learn is a strong protective factor for the mental health of LGBTQI+ youth (Government Equalities Office 2018 ; Ministry of Youth Development 2015 ; U.S. Department of Health and Human Services 2017 ). Availability of support groups in the community and schools, such as RainbowYOUTH or GSAs provide connections for marginalized sexual and gender minority youth to interact with peers, access information and find a collective voice (Poteat et al. 2016 ). In particular, having such a collective voice in the face of bullying, victimization, stigmatization, homophobic, transphobic or biphobic behavior can lead to activism and civic engagement (Poteat et al. 2018 ; Russell et al. 2009 ). Social activism can act as a resilience factor for transgender youth and also ascribe the self-affirming value of being a role model for others (Singh et al. 2011 ).

By examining the findings of qualitative research reported in the last decade, it is clear that discrimination, marginalization and victimization cause much of the distress experienced by sexual and gender minority youth (King et al. 2008 ; Liu and Mustanski 2012 ). In relation to the second core theme, the socio-political marginalization of sexual and gender minority youth is responsible for feelings of systemic discrimination. This holds particular importance in predominantly heteronormative institutions such as schools, where straight cisgender individuals are “normal” and therefore sexual and gender minority youth are “not normal” (McGlashan and Fitzpatrick 2017 ). While acknowledging the marginalized status of LGBTQI+ youth, attention must be also paid to avoid pathologizing sexual and gender minority youth, either in their gender expression or sexual orientation, or in respect to having mental health issues (Drescher 2015 ; Lerner and Robles 2017 ; McDermott et al. 2015 ). Harper et al. ( 2012 ) describe adolescence as a time of developing one’s unique identity and acknowledge that research to date into mental health challenges for sexual and gender minority youth is crucial. At the same time, however, Harper et al. ( 2012 ) posit that many young LGBTQI+ are resilient and well-adjusted and that future research might benefit from a strengths-based focus.

Of particular relevance to the third core theme “depression, self-harm and suicidality,” resilience-focused research may grant insight into these poor mental health outcomes for sexual and gender minority youth. If almost half of trans-spectrum youth have self-harmed (Jones and Hillier 2013 ) and the link between suicide and mental distress due to sexual and gender minority youth status is established (Peter et al. 2016 , Wolff et al. 2014 ), then it is imperative to find ways of addressing these statistics and finding interventions that support and moderate the levels of depression and self-destructive coping mechanisms. This systematic review also identified a recommendation for service providers such as teachers, community workers and medical staff to have access to education on issues including suicide prevention, bullying interventions and sensitivity training (Pallotta-Chiarolli and Martin 2009 ; Scourfield et al. 2008 ; Sherriff et al. 2011 )). It was not until 1987 that homosexuality was removed from the Diagnostic and Statistical Manual (DSM-III-R) (American Psychiatric Association 1987 ) and in 1990 removed from the International Classification of Diseases (ICD-10) (World Health Organisation 1990 ) as a diagnostic category of psychopathology. Despite gains in civil rights, there is persistent discrimination against LGBTQI+ people (Dessel and Rodenborg 2017 ; Drescher 2015 ). Although attitudes are changing, societal misperceptions and discomfort about homosexual behavior and identity are persistent even among health care personnel (Dessel and Rodenborg 2017 ; Mayer et al. 2008 ; Scourfield et al. 2008 ). Changing attitudes and developing cultural competence is an ongoing socio-political process. To this end, Youth Scotland (LGBT Youth Scotland 2018 ) sets gold standards for achievement at LGBTQI+ inclusivity in the LGBT Charter program to which educational institutions can strive. This was achieved through consultation with LGBT service providers and their users and has provided a framework for organizations to develop their own LGBT policies and practices. Hence, this type of LGBTQI+ Charter community initiative, and the provision of ongoing training for professionals who work with youth, will increase efficacy and cultural competence for service providers and support emotional safety for sexual and gender minority youth (Kull et al. 2017 ; Swanson and Gettinger 2016 ).

In relation to policy and environment, the fourth key theme identified in this review, many western countries are fostering inclusive and non-discriminatory legislation and services, such as the Youth Scotland initiative. Most western nations have, at least in urban areas or online, support organizations such as RainbowYouth in New Zealand or MINUS18 in Australia. However, in the global context of LGBTQI+ mental health, it is notable that in more than 70 countries it is still illegal to be homosexual (United Nations 2011 ). The United Nations Committee on the Rights of the Child ( 2003 ) states that: “parties have the obligation to ensure that all human beings below 18 enjoy all the rights set forth in the Convention without discrimination, including with regard to ‘race, color, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status.’ These grounds also cover adolescents’ sexual orientation and health status.” There is still much to be done in the international arena at the very basic level of human rights before all sexual and gender minority youth are accepted and need not face discrimination.

Connectedness, the final core theme, is key at a societal level, where finding a group of peers fosters not only well-being but also opportunities for empowerment, solidarity and networking (Russell et al. 2009 ). Possibly the most important ecological environment within which connectedness engenders good mental health is that of the family, where attachment to parents or caregivers and acceptance by siblings and other family members leads to resilience in the face of more hostile community or societal institutions (Catalpa and McGuire 2018 , Ryan et al. 2010 ). Young people who identify as sexual or gender minority are a high-risk group who are developmentally vulnerable (Liu and Mustanski 2012 ) and the family environment has been identified as an important protective factor against stressors and mental health problems in LGBTQI+ youth. For example, in Growing up LGBT in America , a national survey of LGBTQI+ youth in the USA (Human Rights Campaign 2012 ) the most important factor identified as a problem in their lives was non-acceptance by families (26%). A lack of family connectedness or acceptance compounds the issues that sexual and gender minority youth have at school, further hindering their learning (Mallory et al. 2017 ), and suicidality in youth has been shown to be related to family connectedness, identified as the most protective factor against suicidal ideation and attempt (Stone et al. 2015 ).

From a resilience perspective, in The Health of LGBTQ Youth: Risk and Protective Factors , a Canadian report (Buote et al. 2012 ), family support for sexual and gender minority youth resulted in prevention of suicide, more positive levels of mental health, less substance use, better coping skills and more openness about their sexual or gender identity. Evidence supports these findings that family acceptance is protective for negative health outcomes such as depression, substance abuse, and suicidality (Ryan et al. 2010 ; Stone et al. 2015 ). This evidence underpins connectedness to and acceptance by family members of sexual and gender minority youth as a crucial factor for their mental health and well-being.

Limitations and Future Directions

Although this systematic review provides an important overview into the qualitative research that is being carried out, it has some limitations. Variations in the terminology used in LGBTQI+ literature and resources are extensive, and at least 23 variations on gender or sexual minority descriptors are in common use (Trans Student Educational Resources 2018 ). For this systematic review the general key term “LGBT*” was used in the search criteria, which may have excluded some articles that used terms such as non-binary, or non-cisgender. As such, the results obtained in this systematic review cannot make any valid and generalized statements about mental health needs and resources of specific groups that are represented under the LGBTQI+ label. To increase the population represented under the LGBTQI+ umbrella and to increase the level of specificity of the results, future systematic reviews should comprise a wider range of key terms that would provide a broader insight and overview of mental health and well-being in LGBTQI+ youth.

Such a relatively inclusive and broad use of key terms needs to be aligned with a set of equally broad research aims and questions. In this regard, to produce more valid results in relation to the various LGBTQI+ groups, future systematic reviews should narrow their search terms to increase the level of specificity, and thus be able to provide applicable and valid recommendations to improve mental health supports to the specific LGBTQI+ groups. Whereas characteristics of the identified studies varied greatly in respect to aim, sample size, methodology, population base and focus, which further impinges on the generalizability of the results, future systematic reviews could focus more specifically on certain criteria. Thus, systematic reviews should define from the onset the scope of the review and its desired level of generalizability to inform appropriate key term selection, methodological characteristics and research aims questions.

Deriving evidence to identify the mental health needs of LGBTQI+ groups is of great societal importance, as for example, transgender adolescents are particularly vulnerable as they navigate the cisgender world and manage the challenges of a changing body in which they do not feel they belong (Perez-Brumer et al. 2017 ; Peterson et al. 2017 ). However, there are noticeable limitations in gaining access to rich, experiential, qualitative data from transgender youth, their families and peers, which restricts understanding of mental health resource priorities for transgender youth. This gap in qualitative research relates to the issues and problems faced by families when adjusting to a child who wishes to change their gender expression, the complex nature of acceptance and coping in this situation, their possible resistance and the dynamic relationship between families and their access to services (Tishelman et al. 2015 ). Thus, systematic reviews are only able to synthesize existing data, and it becomes apparent that qualitative studies that explore lived experiences of LGBTQI+ youth within their family context are widely under represented. Here future empirical research needs to invest greater resources to produce more high quality studies that can be then included in systematic reviews.

The majority of the studies included in this systematic review (58.3%), identified their study population through school and community groups. These studies pointed out the difficulties in recruiting populations for research into LGBTQI+ youth and the effects this has on obtaining robust empirical evidence. In this sense, unknown numbers of youth who have not disclosed their sexual identity or who have barriers to accessing community support are not represented in any empirical research as to their mental health status or needs. The complexities of recruitment challenges and data collection are further confounded by the hidden nature of those who feel they cannot disclose due to cultural and ethnicity-based considerations of individual ecologies. Some of the research is Internet-based and thus only sexual and gender minority youth with access to the World Wide Web and computers or digital devices can be involved. Thus, the question remains largely unanswered of how many youth struggle with mental health issues because they feel different from heteronormative societal models but find no avenue to gain support, a sense of belonging or resources. This highlights wider patterns where voices of youth are marginalized in society and efforts to include youth in research, as outlined by the UN Convention on the Rights of the Child (1990), often results in further inequalities as youth of advantaged backgrounds have more opportunities for inclusion compared to disadvantaged youth. This leads then into a self-perpetuating cycle of exclusion. Here social science research needs to find ways to include youth across the social spectrum so that their voices are heard.

It is also important to mention that this study did not examine cultural, ethnic and faith-based differences in acceptance of LGBTQI+ youth. Religious beliefs and cultural homophobia, transphobia and bi-phobia are existing ecological factors in the lives of young sexual and gender minority youth that affect the level of societal and familial inclusion or exclusion experienced. The lack of data across cultures, genders, orientations and ethnicities is especially challenging for researchers, with some minority ethnic groups particularly underrepresented (Collier et al. 2013 ). Here, future research needs to be more rigorous to explore the relationship between culture, ethnicity and religion to obtain a better understanding of the wider socio-cultural influence on levels of experienced societal acceptance or exclusion of LGBTQI+ youth.

The review was also based on peer-reviewed journals that were published in empirical research over the last ten years, and hence literature selection was time limited and not exhaustive. As such future research could explore a wider range of available empirical research (e.g. book chapters and Ph.D. dissertations) and grey literature (e.g. government reports and policy statements), that extends beyond the 10-year time span of the present systematic report, to provide a more comprehensive insight into the topic. This would be of particular importance when tracing, comparing and mapping out existing debates and narratives, and their evolution over time, to derive a better understanding of mental health and wellbeing in LGBTQI+ youth.

Implications for Research and Practice

This is the first systematic review of qualitative research into the mental health of LGBTQI+ youth. Qualitative research provides a voice for the research participants to offer authentic experiential and perceptual evidence that can be used to inform and influence policy and mental health service provision from an evidence-based perspective. This systematic review provides a reference of qualitatively derived evidence-based knowledge by mapping out the themes and findings of qualitative research into LGBTQI+ mental health over the last decade.

The first implication for practice relates to the recognized and mandated provision of safe spaces and places in educational institutions and in the community with an emphasis on client-centered policy and in community planning at micro and macro levels of civil and state governance. For example, school and community level GSA-type services provide support within the micro-ecology of the young person whereas international law preventing discrimination on the grounds of sexual or gender minority status legislates at a global level. The provision of collective social opportunities facilitates a collaborative and united voice and empowerment to gain socio-political influence and thus to drive change for LGBTQI+ youth. As such a unified resistance to victimization and stigmatization challenges the pervasive heteronormative discourse, where, in particular, institutional policies must address bullying and marginalization of sexual and gender minority youth while demanding a cultural environment of inclusivity and acceptance.

A second implication for practice is the targeted education of service providers in all social, educational and health agencies and continuing efforts to address transphobia, biphobia and homophobia. To address disparities in well-being of sexual and gender minority youth, it is of vital importance to ensure that services for LGBTQI+ youth, such as drug and alcohol support, mental health services and sexual health clinics, adhere to a welcoming and inclusive ethos. Within these services, the provision of support must be provided by key adults with whom sexual and gender minority youth can make connections and feel valued in their identity choices.

This systematic review also identified directions for future research. For example, the Minority Stress Theory (Meyer 2003 ), with a focus on increased prevalence of mental health problems experienced by LGTBQI+ youth due to increased levels of social stress, (e.g., stigma, discrimination, prejudice and victimization), might provide a framework for further research to fill gaps in the knowledge to date. It is also vital that future research focuses on continued exploration of effective platforms for internet-based services, such as online forums, as a critical information resource, both for researchers to obtain an in-depth understanding of LGBTQI+ youth and their experiences relevant to mental health, and for the sexual and gender minority youth themselves. Thus these forums provide sexual and gender minority youth a means of access to help and advice online, and the experience of social networking, acceptance and connectedness. Further research is also needed within the realm of online e-therapy interventions such as Rainbow SPARX (Lucassen et al. 2015 ) that can be used as a treatment option for any LGBTQI+ youth that are experiencing emotional distress regardless of access to community services and disclosure status.

Transgender youth in particular are vulnerable to social isolation in the face of rejection by family and other ecological supports, and studies demonstrate the significantly greater number of homeless LGBTQI+ youth (Crossley 2015 ; Matthews et al. 2018 ; Oakley and Bletsas 2018 ). Thus it is of great importance that research investigates specific risk factors and markers for marginalized youth with a focus on the disparities in suicide and self-harm rates for sexual and gender minority youth. Similarly, there is a need for qualitative research to support quantitative evidence as well as interventions through social policy (Durso and Gates 2012 ; Kidd et al. 2017 ; McDonald 2018 ; Prock and Kennedy 2017 ). More strengths-based enquiries are needed into resilience and protective factors for sexual and gender minority youth and the ecological, psychosocial and cognitive characteristics of young LGBTQI+ people who are leading happy, well-adjusted lives within their microsystems and macrosystems. By having access to these rich qualitative data that can be evinced from analysis of nuanced lived experiences of marginalized but adaptive members of their communities, further support mechanisms can be devised and implemented with sexual and gender minority youth who are less resilient. Also, as suggested by Collier et al. ( 2013 ), there is a need for more longitudinal studies to provide data into the long-term outcomes, especially considering the developmental differences across adolescence.

Although quantitative investigations into sexual and gender minority youth have revealed poor mental health outcomes, and identified risk and protective factors, there are gaps in our understanding of how these effects arise. To address this we performed a systematic review of qualitative investigations into the experiences of LGBTQI+ youth. The results identified five core themes: isolation, rejection, phobia and need for support; marginalization; depression, self-harm and suicidality; policy and environment; and connectedness. These five themes became apparent across the differing methodologies and population samples, providing rich information. The implications for policy, practice and future research are clear from this synthesis of research findings. The voices of LGBTQI+ youth call for inclusive environments, acceptance and support from service providers and family members, and a community to which they can belong, either in their own geographical ecology or internet-based. Addressing these key needs provides resilience in the face of marginalization, isolation, and victimization. Safe environments and anti-discrimination policy alleviate the stressors which make the challenges faced by sexual and gender minority youth greater than those of their peers. These results provide a source of rich information to inform the provision of services and policies that will address the disparity into mental health statistics for the sexual and gender minority youth population.

*Denotes study included in systematic review

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The authors would like to thank the researchers of the included articles for their diligence in applying qualitative research methods to exploring LGBTQI+ youth and mental health.

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Wilson, C., Cariola, L.A. LGBTQI+ Youth and Mental Health: A Systematic Review of Qualitative Research. Adolescent Res Rev 5 , 187–211 (2020). https://doi.org/10.1007/s40894-019-00118-w

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5 key findings about LGBTQ+ Americans

Pew Research Center has been tracking Americans’ attitudes toward same-sex marriage , gender identity and other LGBTQ+ issues for more than a decade. In that time, we have also done deep explorations of the experiences of LGBT and transgender and nonbinary Americans.

As the United States celebrates LGBTQ+ Pride month , here are five key findings about LGBTQ+ Americans from our recent surveys:

Some 7% of Americans are lesbian, gay or bisexual, according to a Pew Research Center survey of 12,147 U.S. adults conducted in summer 2022. Some 17% of adults younger than 30 identify as lesbian, gay or bisexual, compared with 8% of those ages 30 to 49, 5% of those 50 to 64 and 2% of those 65 and older. Similar shares of men and women identify with any of these terms, as do similar shares of adults across racial and ethnic groups.

Pew Research Center sought to provide an overview of findings on LGBTQ+ Americans. The overview is based on data from Center surveys and analyses conducted from 2019 to 2022, including a 2019 analysis of 2017 survey data from Stanford University. Links to the methodology and questions used can be found in the text and at the bottom of this overview.

More Americans identify as bisexual than as gay or lesbian. Among adults who are lesbian, gay or bisexual, 62% identify as bisexual, while 38% are gay or lesbian, according to the same 2022 survey.

Among Americans who are lesbian, gay or bisexual, the vast majority of women say they are bisexual (79%) while the majority of men say they are gay (57%).

Adults younger than 50 who are lesbian, gay or bisexual are far more likely to identify as bisexual (69%) than as gay or lesbian (31%). The opposite is true among those ages 50 and older: 66% identify as gay or lesbian and 34% as bisexual.

Bisexual adults are far less likely than gay or lesbian adults to be “out” to the important people in their life,  according to a 2019 Center analysis of survey data from Stanford University. Only 19% of those who identify as bisexual say all or most of the important people in their life are aware of their sexual orientation. In contrast, 75% of gay or lesbian adults say the same. About one-quarter of bisexual adults (26%) say they are not “out” to any of the important people in their life, compared with 4% of gay or lesbian adults.

One factor that might contribute to bisexual adults being less likely to be “out” is that most (82%) bisexual men and women who are married or living with a partner are in a relationship with someone of the opposite gender, according to a new Center survey .

Some 1.6% of U.S. adults are transgender or nonbinary – that is, their gender differs from the sex they were assigned at birth.  Adults under 30 are more likely than older adults to be trans or nonbinary . Some 5.1% of adults younger than 30 are trans or nonbinary, including 2.0% who are trans men or trans women and 3.0% who are nonbinary – that is, they are neither a man nor a woman, or not strictly one or the other. (Due to rounding, subtotals may not add up to the total.) This compares with 1.6% of those ages 30 to 49 and 0.3% of those 50 and older who are trans or nonbinary.

Related: Essay: The experiences, challenges and hopes of transgender and nonbinary adults

The share of U.S. adults who are transgender is particularly high among adults younger than 25. In this age group, 3.1% are trans men or trans women, compared with just 0.5% of those ages 25 to 29. There is no statistically significant difference between these two age groups in the share who are nonbinary.

While a relatively small share of U.S. adults are transgender or nonbinary, many Americans say they know someone who is. More than four-in-ten U.S. adults (44%) say they personally know someone who is trans , and 20% know someone who is nonbinary.

About a quarter of U.S. adults (27%) say they have a trans friend, while 13% say they have a co-worker who is trans and 10% say they have a trans family member. About one-in-ten adults (9%) say they know a trans person who is younger than 18.

A  2021 Center survey  found that 26% of U.S. adults personally knew someone who goes by gender-neutral pronouns such as “they” instead of “he” or “she,” up from 18% in 2018 .

Note: This is an update of a post originally published June 13, 2017. Findings from two surveys were used in this analysis:

• July 18-Aug. 21, 2022: Survey questions, with responses , and methodology
• April 10-16, 2023: Survey questions, with responses , and methodology
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Anna Brown is a research methodologist focusing on social and demographic trends research at Pew Research Center .

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Mental health challenges of lesbian, gay, bisexual and transgender people: An integrated literature review

Miriam m. moagi.

1 Department of Nursing Science, Faculty of Health Sciences, University of Pretoria, Tshwane, South Africa

Anna E. van Der Wath

Priscilla m. jiyane, richard s. rikhotso, associated data.

Data sharing is not applicable to this article as no new data were created or analysed in the article.

Lesbian, gay, bisexual and transgender (LGBT) individuals are often stigmatised and discriminated against. This population is expected to experience poorer mental health outcomes compared with heterosexual and cis-gendered people, a phenomenon healthcare providers need to take note of and act upon. This study aimed to explore and describe the mental health challenges of LGBT people. An integrative literature search was conducted. The following electronic databases were searched: Academic Search Premier, Africa-Wide Information, Business Source Premier, eBook Collection (EBSCOhost), E-Journals, ERIC, Family & Society Studies Worldwide, Health Source: Nursing/Academic Edition, Humanities Source, MasterFILE Premier, MEDLINE, PsycARTICLES, Social Work Abstracts, TOC Premier, WorldCat.org, Taylor and Francis Journals, Biomed Central and Wiley Online Library. An internet search was also carried out using Google and Google Scholar databases. The following search terms were identified: ‘LGBT’ OR ‘LGBT community’ AND ‘mental health challenges/problems’ OR ‘mental/psychiatric illness’. The reviewed literature comprised research conducted globally between 2010 and 2019. From the 2545 titles, 345 abstracts were examined, resulting in 57 articles. The 57 full-text articles were examined to verify whether they addressed the scope of the literature review, of them, 21 addressed the mental health challenges of LGBT people. Lesbian, gay, bisexual and transgender people experience the following mental health challenges: emotional distress, stigmatisation, victimisation, discrimination and barriers to accessing healthcare services. The results showed that although LGBT has been legalised in many countries, LGBT communities still experience significant mental health challenges. Healthcare providers are in a position to address challenges related to social and healthcare structures and act as advocates in order to promote the mental health of LGBT individuals.

Introduction

The acronym LGBTQ (also LGBTQAP+, LGBTQA, GLBTIQ, LGBT, LGBTQ and other alternates) is an umbrella term that stands for lesbian, gay, bisexual, transgender, intersex, and queer or questioning people. This acronym has its origins in the shorter version lesbian, gay, bisexual and transgender (LGBT), which covers a heterogeneous group of LGBT people who often feature together as a group in efforts to gain better social representation and more political support (Salminen 2015 :11). Although the term LGBT has its restrictions and does not cover all possible identities and orientations (Salminen 2015 :11), it is used in this article to denote all people who belong to sexual and gender minorities.

The LGBT community was historically marginalised, mistreated and ignored by society and healthcare delivery systems (Farmer & Yancu 2015 :36; Institute of Medicine 2011 :1). This community faces various obstacles to gain access to quality healthcare (Duby et al. 2018 :8; Sequeira, Chakraborti & Panunti 2012 :379) and experiences poorer health and mental health outcomes compared with heterosexual and cis-gendered (gender identity matches the sex assigned at birth) people (Cochran & Mays 2007 :2048; Farmer & Yancu 2015 :41). Understanding the mental health needs of sexual minorities and the causes of mental health disparities is a rapidly growing area of research, especially regarding mental health outcomes with implications for policies (Mongelli et al. 2019 :47). This article presents the results of an integrative literature review with regards to the mental health challenges experienced by LGBT people.

Mental health is fundamental to appropriate psychological processes, healthy relationships and living a fulfilled life. The promotion, protection and restoration of mental health are vital to individuals, communities and societies throughout the world. Programmes targeted at vulnerable people, including minorities, are seen as ways to strengthen worldwide responses to mental health (World Health Organization 2018 ).

The LGBT people face significant social and legal barriers; in 76 countries, same-sex sexual acts are still criminalised with penalties that can include fines, several years of imprisonment or even execution (United Nations Programme on HIV/AIDS 2013 :4). For example, in Ukraine, LGBT people who wish to be legally recognised must undergo a compulsory, psychiatric evaluation to confirm or reject a diagnosis of ‘transsexualism’. Some transgender people are arrested by police who sometimes sexually abuse them under the pretext of cleaning up public spaces (Ghoshal & Knight 2011 :24). In other countries, such as South Africa, the constitution protects every person irrespective of sexual orientation. This assurance occurs in various human rights accords and confirms the self-respect and self-worth of each person, including LGBT individuals (Constitution of the Republic of South Africa 1996 : Section 9).

The acronym LGBT combines sexual orientation with gender identity. Sexual orientation is the ‘enduring emotional, romantic, sexual or affectional attraction to another person’ (American Psychological Association 2008 :1). For gay men, this attraction is primarily to men, and for lesbians, this is primarily to the woman. Gender identity is a person’s self-perception as a man or woman (Farmer & Yancu 2015 :37). Transgender refers to people whose gender identity is at odds with the gender they were assigned at birth according to their sex and physiological characteristics (Fredriksen-Goldsen et al. 2014 :3). Sexuality encompasses at least three key components: sexual identity, sexual attraction and sexual behaviour. Sexual identity refers to the cognitive and emotional meaning one attaches to expressions of sexuality (Farmer & Yancu 2015 :37), which includes romantic, emotional and social preferences (Morgan 2013 :53). Sexual orientation, sexual identity and gender identity are not static and may change over a person’s life course. The LGBT individuals have unique experiences that are shaped by multiple factors, such as race/ethnicity, socio-economic status, geographical location and age, not just sexual orientation (Farmer & Yancu 2015 :37).

The lesbian, gay, bisexual and transgender people differ from ‘traditional’ minorities in two aspects: (1) they are not necessarily recognisable through physical characteristics and (2) they are still perceived in many contexts as acting against natural processes (Takács 2015 :10). These people suffer from various forms of socio-economic and cultural injustices, but mostly they feel they are denied recognition, meaning that heterosexuality is privileged and homosexuality is devaluated (Takács 2015 :9). In order to fully understand the challenges the LGBT community faces, it is important to understand the concept of heteronormativity, which is still accepted in many segments of society and refers to the ‘normalisation of heterosexuality through social structures, social practices, and social institutions’ (Javaid 2018 :84). The belief that other sexual orientations are abnormal or inferior to heterosexuality is a source of oppression, resulting in heterosexism and homophobic attitudes, creating a hostile climate for LGBT people (Mostert, Gordon & Kriegler 2015 :116; Salminen 2015 :11).

This integrative literature review aimed to review the current literature and to explore and describe the mental health challenges of LGBT people.

An integrative review method as proposed by Whittemore and Knafl ( 2005 :547–549) was used, as it allowed for the inclusion of diverse methodologies (experimental and non-experimental research) to explore different perspectives on the mental health challenges of LGBT people. The following four stages were followed: literature search, data evaluation, data analysis and presentation of findings (see Figure 1 ).

PRISMA flow diagram describing the inclusion process of the integrative literature review.

Literature search

A literature search was performed according to the following inclusion criteria: quantitative or qualitative research or reports from experts and different organisations or institutions with a vast interest in the mental health challenges of the LGBT community, published between 2010 and 2019 in English (translation cost was too high for publications in other languages). Letters, editorials and commentaries were excluded as the review focused on research findings and expert reports on the topic. In order to increase the robustness of the search, the authors requested an experienced librarian to review the literature for inclusion or exclusion criteria and suggest databases and websites include in the search. The following search terms were identified: ‘LGBT’, OR ‘LGBT community’ AND ‘mental health challenges/problems’, OR ‘mental/psychiatric illness’.

Given the fact that LGBT is a social, political, health and economic problem; an electronic search was launched through the Cumulative Index of Nursing and Allied Health Literature (CINAHL), using the databases Academic Search Premier, Africa-Wide Information, Business Source Premier, eBook Collection (EBSCOhost), E-Journals, ERIC, Family & Society Studies Worldwide, Health Source: Nursing/Academic Edition, Humanities Source, MasterFILE Premier, MEDLINE, PsycARTICLES, Social Work Abstracts, TOC Premier, WorldCat.org, Taylor and Francis Journals, Biomed Central and Wiley Online Library. An internet search was also carried out using Google and Google Scholar databases to find reports from experts and different organisations/institutions with interest in the mental health challenges of the LGBT community. The search results were initially broad and were narrowed using more specific search topics. The reference lists from retrieved studies were manually searched.

The literature search as described above resulted in 2890 citations. The titles of these publications were screened for potential relevance. The researchers excluded 2545 publications based on the inclusion and exclusion criteria. Duplicated publications were also excluded. The abstracts of the remaining 345 publications were assessed by two researchers who are experienced in mental health nursing. The researchers analysed the abstracts to select publications directly related to the mental health challenges experienced by LGBT people. Using the stipulated criteria, a further 288 documents were excluded. After a critical appraisal of the full text of the remaining 57 publications, 36 more publications were excluded, which were not describing the mental health challenges experienced by LGBT people, but focused on other aspects, for example, mental health challenges experienced by people diagnosed with a bipolar mood disorder. Twenty-one publications remained within the review, which was relevant to the mental health challenges experienced by LGBT people.

Data evaluation

The final 21 selected publications consisted of theoretical and empirical reports. All publications were tabulated according to the author(s), year of publication, country, design and method, population and sampling, and purpose. Owing to the diverse representation of sources, six criteria evaluating methodological quality (modified based on Kangasniemi, Pakkanen & Korhonen 2015 :1746; Whittemore & Knafl 2005 :549–550) were used to evaluate the publications on a three-point scale as ‘high’, ‘low’ or ‘not reported’ ( Table 1 ). The majority of the empirical reports followed a quantitative approach where data were collected through surveys, whilst two studies used qualitative methods. In three publications, the authors based the discussion on a conceptualisation or briefing of different theoretical approaches. Three studies followed a longitudinal or retrospective design. One study piloted a mental health programme, and five publications provided literature or historical overview.

Evaluation of publications.

Source: Adapted from Kangasniemi, M., Pakkanen, P. & Korhonen, A., 2015, ‘Professional ethics in nursing: An integrative review’, Journal of Advanced Nursing 71(8), 1744–1757. https://doi.org/10.1111/jan.12619

LGBTQ, lesbian, gay, bisexual, transgender and queer; LGBTI, lesbian, gay, bisexual, transgender and intersexual; LGBT, lesbian, gay, bisexual and transgender; LGB, lesbian, gay and bisexual.

Data abstraction and synthesis

Two researchers analysed the selected publications independently by thematic analysis. Key results or meanings related to the research aim were highlighted in the publication and summarised and listed. The lists of key results or meanings were clustered according to themes and sub-themes. The researchers reached a consensus on the themes and sub-themes to describe mental health challenges of LGBT people. The results from the data analysis are displayed in Table 2 . The results are presented as three main themes, and each theme is presented under the following headings: sub-themes, key findings and sources (author, year and country).

Results of the integrative review.

Ethical consideration

This article followed all ethical standards for a research without direct contact with human or animal subjects.

This section discusses the key results of the literature review under the following themes: (1) emotional distress as a mental health challenge; (2) stigmatisation, discrimination, victimisation and social exclusion as mental health challenges; and (3) barriers to accessing mental healthcare services as a mental health challenge. The research populations used in the reviewed publications are indicated by different acronyms, such as LGB or LGBT.

Theme 1: Emotional distress as a mental health challenge

Emotional distress reported in the studies included adverse childhood experiences, depression, anxiety, suicidal ideation and attempts. The minority stress theory is used to explain the effects of the unique stressors experienced by LGBT individuals.

Blosnich and Andersen ( 2015 :3) mentioned that LGB individuals reported significantly higher mean totals of adverse childhood experiences than their heterosexual peers. These pre-existing stressors, such as sexual abuse, physical abuse and peer victimisation, may exacerbate the poorer mental health outcomes of LGB people compared with heterosexual individuals. With regards to specific mental health problems, the consensus study of the Institute of Medicine ( 2011 :4) found that LGB youth are at increased risk of suicidal ideation and attempts and depression, whilst LGB adults appear to experience more depressive and anxiety disorders and suicidal ideation and behaviour than heterosexual adults. Little research has examined the prevalence of depressive and anxiety disorders amongst transgender people (Institute of Medicine 2011 :233). A literature review similarly indicated that LGBT populations are vulnerable to higher rates of depression and suicidality in the midst of facing numerous mental health disparities (Mongelli et al. 2019 :47). According to Kerr, Santurri and Peters ( 2013 :185), bisexual women and lesbians had a greater likelihood of having mental health issues and used significantly more mental healthcare services than heterosexual women. The higher utilisation was ascribed to respondents who had free access to campus mental healthcare services. Bisexual women reported the worst mental health status with anxiety, anger, depressive symptoms, self-injury, and suicidal ideation and attempts. Up to 14 times more suicidal attempts were reported amongst LGBTI people, and rates of depression were over five times higher amongst transgender people and 3.5 times higher amongst LGB people than in the general population (Rosenstreich 2011 :16–18).

In addition to emotional distress, five studies explored the minority stress theory. According to the theory, LGB individuals experience unique social stressors, including victimisation and discrimination, as a result of their minority position. These stressors trigger related internal stress that has negative effects on the health of LGB individuals (Mongelli et al. 2019 :28). Internal stress includes experiences, such as homophobia, expectations of rejection and identity concealment (Fredriksen-Goldsen et al. 2014 ). Attempts to conceal LGBTQ status, prejudice and internalisation of negative societal views led to stress, self-isolation, lowered self-esteem and negative mental health outcomes in LGBTQ individuals (Heck 2015 :3–4; Mongelli et al. 2019 :28). There is a need for studies to explore intrapersonal strengths or coping strategies as ways to overcome minority stress (Russell & Fish 2016 :9).

Hatzenbuehler et al. ( 2014 :9–10) suggested that the psychosocial stress experienced by sexual minorities may represent an indirect pathway through which structural stigma contributes to mortality. This is illustrated by a rise in cardiovascular disease-related deaths in high-stigma communities compared with low-stigma communities.

Theme 2: Stigmatisation, discrimination, victimisation and social exclusion as mental health challenges

Stigmatisation, discrimination and victimisation emerged as the most evident determinants of mental health problems, whilst different forms of social exclusion were also mentioned in some studies. Some publications investigated only one of these determinants, whilst others explored the combined effects of two or more determinants. The latter studies are presented in this section, followed by a discussion of each determinant as a sub-theme.

According to Fredriksen-Goldsen et al. ( 2014 :8), it is not so much sexual orientation, itself, that causes mental health problems, but rather social and structural determinants that contribute to sexual orientation-based mental health disparities. The stigmatisation, discrimination and violence that LGBT individuals suffer during their lifetime related to their sexual and gender minority status undeniably affect their mental health status (Institute of Medicine 2011 :5; Utama 2017 :25–26). A historical overview of LGBT identities and issues in Thailand linked to stress, depression, substance use and suicidality to stigmatisation, victimisation and familial rejection (Ojanen, Ratanashevorn & Boonkerd 2016 :41). Similar results by Lozano-Verduzco, Fernández-Niño and Baruch-Domínguez ( 2017 :224) linked depressive symptoms and alcohol use to homophobic discrimination, violence and low-community connectedness towards LGBT communities in Mexico.

Distress and dysfunction (family, social, work or scholastic) were strongly predicted in transgender individuals who experienced social rejection and violence (Robles et al. 2016 :856). The emotional distress caused by heterosexism, heteronormativity, homophobia, transphobia and stigma is further exacerbated by fears of stigma and discrimination that hinder access to mental healthcare services (Rosenstreich 2011 :16–18).

Stigmatisation as a mental health challenge

This sub-theme explains the types and effects of stigma, as well as pathways through which stigma perpetuates health disparities in LGBT individuals.

Stigma is defined as ‘the co-occurrence of labeling, stereotyping, separation, status loss, and discrimination in a context in which power is exercised’ (Hatzenbuehler, Phelan & Link 2013 :813). Stigma presents itself in different ways. Overtly expressed, enacted stigma takes the form of explicit behaviours, such as labelling, discrimination and violence, targeting people because of their perceived gender nonconformity (Institute of Medicine 2011 :62). Covert stigmatisation includes, for example, LGBT-related policy statements that used stigmatising terminology and perpetuated anti-LGBT prejudice in Thailand (Ojanen et al. 2016 :41). Stigmatisation may have devastating effects. LGBT individuals who live in communities with greater prejudicial attitudes against sexual minorities die sooner than those who live in communities with low levels of structural stigma (Hatzenbuehler et al. 2014 :9).

Stigma restricts health access to LGBT individuals, be it structural stigma based on institutional processes or felt stigma based on an internal awareness that the potential for stigma exists in a specific situation (Institute of Medicine 2011 :64). Two pathways are suggested through which stigma perpetuates health disparities in LGBT individuals. Firstly, LGBT people who experience internalised stigma (self-stigma), which leads to the denigration of the self, may feel that they do not deserve respect from healthcare providers or the same access to healthcare as heterosexual people. As a result, they may not disclose relevant information to healthcare providers or may avoid seeking treatment (Institute of Medicine 2011 :64). Secondly, stereotypes attached to LGBT individuals within the healthcare services (also known as health-related stereotype threats) lead to fear of communicating with providers about mental health and delays in seeking mental healthcare services. These threats significantly predicted self-reported poor mental health outcomes in LGBT individuals (Ojeda-Leitner & Lewis 2019 :9–10).

It is clear from the above information that stigmatisation of sexual minorities may disrupt or inhibit access to structural, interpersonal and psychological resources otherwise available to avoid or minimise poor health conditions (Hatzenbuehler et al. 2013 :819).

Victimisation as a mental health challenge

The publications focused on how different forms of victimisation inter-relate with mental health consequences in LGBT individuals.

Victimisation against LGBT individuals takes many forms, such as harassment, bullying and elevated levels of violence (Institute of Medicine 2011 :42; Mallory et al. 2017 :37 & 43). Mustanski, Andrews and Puckett ( 2016 :531) found that 10.3% of LGBT youths in Chicago experienced significant increases in victimisation and 5.1% maintained high levels across time, placing LGBT youths at risk for depression and post-traumatic stress disorder. High and average levels of violence were positively associated with depressive symptoms and alcohol use in LGBT individuals in Mexico; the greater the violence, the more likely the depressive symptoms and alcohol use (Lozano-Verduzco et al. 2017 :224).

Utama ( 2017 :26) illustrated the way victimisation of LGBTI people in Indonesia interrelates with other social determinants to increase the risk of mental illness. Some LGBTI people are disconnected from their families because of rejection that manifests itself in physical and psychological violence. Some decided to leave school because of exposure to peer group violence, leaving them at risk for unemployment. In some cases, employers terminated the services of gay and lesbian people because of their sexual orientation. Feeling victimised, ostracised, and without social and financial security and support, these individuals are at risk for mental health problems (Utama 2017 :26).

Discrimination as a mental health challenge

Four studies in the review indicated the correlation between discrimination against LGBT persons at personal, familial and societal levels and mental health problems.

In Texas, discrimination that denies LGBT people equal access to essential social structures, such as housing, public accommodation and employment, not only led to economic instability and lack of productivity but also rendered them vulnerable to health and mental health disparities (Mallory et al. 2017 :3–6). A Canadian study (Steele et al. 2017 :120) measured the effects of discrimination based on unfair treatment by employers, bosses and supervisors because of LGBT status and verbal insults or abuse. Experiences of discrimination, lower levels of social support and systemic exclusion from healthcare partly explained higher rates of unmet needs and untreated depression in transgender and bisexual individuals. Transgender individuals reported higher odds of reported discrimination, depressive symptoms and suicidal attempts compared with non-transgender individuals.

A lack of self-acceptance of LGBT identity was associated with depressive symptoms in a US study (Su et al. 2016 :19). Even average levels of discrimination from families, schools and the healthcare system were positively associated with alcohol use and aspects of mental health in LGBT individuals (Lozano-Verduzco et al. 2017 :224).

Theme 3: Barriers to mental healthcare services as a mental health challenge

Four studies indicated how barriers to accessing mental healthcare services contributed to unmet healthcare needs amongst LGBT people.

The mental health disparities that LGBT individuals suffer are explained by differences in social factors, discrimination, lower levels of social support and systemic exclusion from healthcare services (Steele et al. 2017 :120). Transgender women in Canada were 1.6 times more likely to report untreated depression and 2.4 times as likely to report an unmet need for mental healthcare compared with cisgender heterosexual women. Bisexual women were 1.8 times as likely to report an unmet need for mental healthcare compared with cisgender heterosexual women (Steele et al. 2017 :120).

Two qualitative studies explored LGBT-specific barriers to accessing mental healthcare services. Mental healthcare providers highlighted low practitioner knowledge of LGBT issues and the stereotyping of LGBT clients as barriers (Rutherford et al. 2012 :908). The LGBT individuals in the study by McCann and Sharek ( 2014 :4–6) experienced subtle ways of stigma and discrimination, such as being overlooked (‘not having a voice’) and being stereotyped during a consultation. They were concerned about getting the ‘right therapist’ (a therapist sensitive towards LGBT issues) and ‘being diagnosed and being LGBT’, referring to concerns that being LGBT is linked to mental health issues.

The overview of mental healthcare services in Thailand distinguished between client-related barriers (anticipation that practitioners may not be accepting or understanding of LGBT identities) and practitioner-related barriers (stereotyping remarks during the consultation) (Ojanen et al. 2016 :50).

Lesbian, gay, bisexual and transgender individuals made suggestions to improve their access to mental healthcare services. They wished for ‘responsive, seamless, and holistic services’ and being treated with dignity and respect. Some ideas for curbing stigma and discrimination included good practice guidelines and training for mental health practitioners on LGBT issues. They also wanted mental healthcare practitioners to provide psychoeducation at their workplaces and for significant others (McCann & Sharek 2014 :5–7). Rutherford et al. ( 2012 :907) recommended the development of a practice focus on LGBT mental health, LGBT-sensitive mental healthcare services and LGBT mental health training programmes.

Lesbian, gay, bisexual and transgender individuals experience higher levels of emotional distress. The minority stress model (Meyer 2003 :35) helps to understand the relationships between (1) external stressors such as stigmatisation, discrimination and victimisation based on a person’s minority status and (2) internal stressors such as expectations of rejection, concealment of sexual orientation and internalised homophobia. The internal distress may lead to negative mental health outcomes, whilst coping strategies and social support may counteract these negative outcomes. Additional emotional distress may relate to adverse childhood experiences, but research is recommended to understand why LGB individuals are more likely to report childhood victimisation (Blosnich & Andersen 2015 :3).

Fredriksen-Goldsen et al. ( 2014 ) presented the Health Equity Promotion Model to stimulate more inclusive LGBT research. This model highlights (1) heterogeneity and intersectionality within LGBT communities; (2) the influence of structural and environmental context; and (3) health-promoting and adverse pathways that encompass behavioural, social, psychological and biological processes. Social status, for example, marginalisation, and social isolation may lead to negative self-worth that is linked to internalisation of discrimination. Social support, however, fosters resilience to withstand the negative effects of external stressors. Psychological processes include effective ways of coping, such as problem-solving, opposed to ineffective ways of coping, such as avoidance (Fredriksen-Goldsen et al. 2014 :7–10; Mayock et al. 2009 :137). Whilst LGBT individuals share collective experiences of stigmatisation and discrimination, experiences of oppression may vary across subgroups, leading to different mental health outcomes (Smalley, Warren & Barefoot ( 2016 :100).

Interpreted within the results of this review, the models link negative external processes (stigmatisation, discrimination and victimisation) to negative internal processes (emotional distress). Mental healthcare services are well-positioned to assist LGBT individuals to mobilise positive external processes (social support) and to develop positive internal processes (effective coping strategies, resilience and self-worth). However, LGBT people still experience barriers to accessing mental health services and are frequently ‘invisible’ to healthcare providers and researchers. Overcoming this invisibility in healthcare services and research settings are critical to eliminating health disparities (Institute of Medicine 2011 :14). An assessment of the evidence in the United Kingdom (Semlyen, Johnson & Barnes 2018 :4) identified not only effective services that offer LGBT-specific interventions but also significant gaps in service provision and knowledge. More research is needed to develop culturally appropriate models of care for LGBT people. Bidell ( 2016 :9) highlighted structural barriers such as lack of sensitive, affirmative and competent clinical services, as well as practitioner-related barriers where the provider’s personal beliefs conflict with professional LGBT ethical standards. Stigma remains to be an important barrier, as well as LGBT clients choose not to identify themselves as LGBT (Smith et al. 2019 :202).

Whilst competent and ethical LGBT mental healthcare services and professional training may help to address the mentioned barriers, more innovative methods such as self-reflection and self-awareness are required to address practitioners’ personal beliefs (Bidell 2016 :9). Providers should focus on the creation of a safe, non-judgmental environment to help clients realise that they will not face discrimination if they identify themselves (Smith et al. 2019 :202).

Implications and recommendations

The review has implications for healthcare and mental healthcare providers alike. Healthcare providers need to take note of the results and treat LGBT people with sensitivity and respect so that they may feel free to access healthcare services and raise their mental health concerns without fearing discrimination, victimisation and stigmatisation. The LGBT people with signs and symptoms of emotional distress ought to be referred to mental healthcare providers for psychosocial interventions in order to prevent the development of psychiatric disorders. Psychological interventions are essential to facilitate the development of effective coping strategies and resilience. Social interventions should focus on two levels: firstly, family interventions to facilitate acceptance and support, and secondly, advocacy for and participation in right-based and empowering policy initiatives related to the LGBT population. As said by Fredriksen-Goldsen et al. ( 2014 :11), the achievement of health equity requires empowering LGBT people to take action and address the environmental and structural barriers that influence their health.

Whilst the evidence from this review indicates both provider-based mental healthcare disparities and perceived disparities based on LGBT individuals’ expectations, further research is recommended to explore the inter-relationship between different types of disparities to provide possible interventions.

The mental healthcare needs of minority populations and subsequent treatment implications should be included in the curricula of healthcare providers. Inservice training using reflective techniques may help to facilitate mental healthcare providers’ awareness of their own beliefs and stereotypes that may hinder effective management of LGBT individuals.

Limitations

The researchers used the acronym LGBT as a search term, thereby overlooking literature referring to other sexual minority subgroups. The results reflect the collective mental health challenges experienced by the LGBT community, and not so much the between-group differences within this community. By following this approach, the review fell short of providing a more in-depth understanding of each subgroup’s individual mental health needs.

The results showed that LGBT communities still experience significant emotional distress and mental health challenges as a result of stigmatisation, victimisation, discrimination and barriers to accessing mental healthcare services. Specifically, LGBT youth still experience a magnitude of mental health problems, and there are few empirically supported approaches for working with LGBT youth in clinical settings (Russell & Fish 2016 :15). If healthcare providers acknowledge and apply their ethical duty to treat all people with respect and dignity, this can help to relieve the mental health disparities of LGBT people. Future studies need to explore how mental healthcare providers can support LGBT individuals to develop resilience and challenge social discourses that maintain discriminatory and stigmatising practices, most of all in mental healthcare services. To meet the diverse needs of the LGBT community, future reviews should explore and compare mental health challenges across different subgroups.

Acknowledgements

Competing interests.

The authors have declared no competing interests exist.

Authors’ contributions

All authors contributed equally to this work.

Funding information

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data availability statement

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

How to cite this article: Moagi, M.M., Van Der Wath, A.E., Jiyane, P.M. & Rikhotso, R.S., 2021, ‘Mental health challenges of lesbian, gay, bisexual and transgender people: An integrated literature review’, Health SA Gesondheid 26(0), a1487. https://doi.org/10.4102/hsag.v26i0.1487

† , This article is dedicated to the memory of the late Dr Richard Rikhotso (1969–2020).

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• NATURE CAREERS PODCAST
• 02 June 2023

How to deliver a safer research culture for LGBTQIA+ researchers

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LGBTQIA+ scientists describe the changes needed to make workplaces more welcoming to members of their communities.

A professor invites colleagues and their partners to a Christmas party but reacts negatively when a young gay researcher asks to bring his future husband along. A Black carnivore researcher conceals their bisexuality and personal pronouns when doing fieldwork in sub-Saharan Africa.

These two experiences are among those recounted in this Working Scientist podcast about the challenges faced by researchers from LGBTQIA+ communities.

Paleantologist Alison Olcott, who co-authored a 2020 study of 261 LGBTQIA+ geocientists and their experiences of fieldwork, tells Adam Levy how some academic institutions are changing fieldwork policies in light of the study’s findings.

They are joined by Florence Ashley, a bioethics and legal scholar whose research on trans youth care at the University of Alberta, Canada, has resulted in death threats and accusations of grooming.

This is the sixth episode of a seven-part podcast series about freedom and safety in science. This episode and the five earlier ones conclude with a follow-up sponsored slot from the International Science Council about how it is exploring freedom, responsibility and safety in science.

doi: https://doi.org/10.1038/d41586-023-01400-7

Paid content: International Science Council (ISC)

The International Science Council is exploring freedom and responsibility in science. What are the responsibilities of scientists in the twenty-first century? How can scientists be protected from threats to scientific freedom?

We’ll hear perspectives on freedom and responsibility from the global scientific community.

In episode 6, Elisabeth Bik, Science Consultant, delineates the growing problem of scientific misconduct and how it is damaging public trust in science.

And Soumya Swaminathan, Chairperson of the M S Swaminathan Research Foundation, contemplates the ways in which trust can be enriched, including lessons learnt from the recent COVID-19 global health emergency.

Find out more about this type of paid content .

Adam Levy: 00:03

Hello, I’m Adam Levy and this is Working Scientist, a Nature Careers podcast. This episode: the freedom and safety of LGBTQIA+ researchers.

Across the world, inside and outside of academia, people face threats due to their identity and orientation.

Whether through discrimination from researchers or through legal restrictions, this affects both scientists and science which fits under the LGBTQIA+ rainbow, LGBTQIA+ standing for people who are lesbian, gay, bisexual, transgender, queer, intersex, asexual, or otherwise part of the community.

In this episode, we’ll speak with researchers about the challenges they’ve faced because of their identities. In other words, how colleagues and collaborators have reacted to those identities. We also discuss how research itself can come under assault because of the questions it addresses.

And at the end, we’ve got a follow up sponsored slot from the International Science Council (the ISC), about how it’s exploring freedom, responsibility, and safety in science.

In our second episode, looking at scientific integrity, we spoke with Jacob Carter, Research Director for the Center for Science and Democracy at the Union of Concerned Scientists in the United States. Jacob is a gay scientist, and there were moments where he was made to feel excluded because of his sexuality.

Jacob Carter: 01:43

There was a time when I was doing my PhD. And there was a Christmas party that a professor was having at their house.

And at the time, I was dating a guy who I was engaged to get married to. And the professor that was hosting this event had children, and actually pulled aside some other graduate students and expressed to them that they were very worried about me showing up with my partner because they would not know how to explain that to their kids.

I ended up ultimately not going to this party. It made it a very uncomfortable situation for me and my partner.

Adam Levy: 02:37

While experiences like these strengthened Jacob’s resolve to build his career, for many, such exclusion can ultimately mean exiting academia entirely.

Jacob Carter: 02:48

From, you know, the research that has been done, the small amount of data that has been collected, these sorts of things do ultimately lead to more LGBTQIA+ people dropping out of STEM careers because of harassment, bullying they may face, or the sort of subtle, discriminatory actions that people you know, take, that really affect LGBTQIA+ people.

Adam Levy: 03:17

But there's still a huge amount we simply don't know about the lives and careers of LGBTQIA+ researchers in countries around the world.

For example, in the United States, the National Science Foundation doesn’t currently collect information on sexual orientation in their exit survey for graduate students.

Without this data, it’s hard to know just what representation looks like, and what barriers LGBTQIA+ researchers are coming up against.

Today, though, I wanted to capture a couple of snapshots, understanding what being LGBTQIA+ in research means to particular individuals.

First up is Gabi Fleury, who is a PhD student at the University of Wisconsin Madison in the United States. Gabi is a livestock carnivore practitioner in Sub Saharan Africa.

Gabi Fleury: 04:12

So basically I try to prevent carnivores from eating livestock. I work closely with farmers to try to prevent farmers from shooting carnivores.

Adam Levy: 04:22

Gabi may be based in the United States, but they travel for field work. And I was keen to find out how they’re treated because of their identity, both in the US and overseas.

Gabi Fleury: 04:34

I identify personally as non-binary, which is a huge umbrella term, under, under the kind of LGBTQIA+ identity banner.

And essentially, it’s any identity that falls outside of the identity of a man or a woman. So it can mean pretty much anything. And for me, that tends to, I feel a bit more androgynous. I'm also bisexual. So I think having, being in that community, and especially working internationally can be particularly challenging, but even even domestically, it very much depends on the culture of the institution.

So some of the places I’ve worked have been very open, and then some have been a little bit unsure about it, or not quite understanding, and then maybe asking potentially, you know, inappropriate questions that they don’t know are inappropriate, just in an effort to understand.

So I’m also a Black researcher. So there's intersectional identities, right? It's not just being LGBTQIA. You also have class and race and nationality, and all these other things. And as you work, internationally, all those things come into play as well. So it becomes quite complicated.

Adam Levy: 05:40

You mentioned that it’s not always been the most plain sailing domestically. Have, have there been instances where you’ve been made to feel othered by other researchers or, or even feel less than safe in institutions?

Gabi Fleury: 05:55

Now, within the States, I think it's more of a question of people being curious than anything and expecting people to educate them, which is, is a little difficult, because you know, I'm not a gender studies major. I’m just a person with an identity, right?

Bringing in, you know, diversity, and inclusion efforts into organizations can be really helpful in that, because then we can all have these conversations, without the burden kind of falling on one person. I’m just representative of myself.

So I think that my experience may be very different from someone else's experience. So I think it’s, it’s more of a question of people like being being curious, or maybe not respecting pronouns, sometimes, I think can be quite challenging.

They’re not preferred pronouns, theory are people’s pronouns. So just respecting that and just admitting when you you make a hiccup and moving on from there.

Adam Levy: 06:43

Within the United States, there has been increased political debate about LGBTQIA+ identities. Has this been felt by you, within American institutions, this shift to very publicly discussing these identities?

Gabi Fleury: 06:59

Definitely. With the caveat that I haven't been in the workforce all that long. So I wasn’t able to experience what things were like, for example, like a decade ago, where it was very, very different from my colleagues that I’ve chatted with. But I have even in the last couple years seen more openness about those discussions, especially as Gen Z has entered the workforce, about talking about these things, and about discrimination being more heavily focused on as a bad thing. But I’ve been quite lucky to, to at least see an effort towards more inclusion,

Adam Levy: 07:33

As an LGBTQIA+ researcher, who is also Black, can you explain how these aspects of your identity, of your person, intersect and do affect your life as a researcher?

Gabi Fleury: 07:47

I work internationally, just to clarify. I work mostly in Sub Saharan Africa. So a lot of the time I'm working with people, such as farmers who actively don’t like carnivores.

So it’s allowed me to kind of have a very open perspective about how to interact with a variety of different people, how to use diplomacy to try to connect people, and find those common grounds, and trying to look at things from completely different perspectives that might not be my own.

In my case, it’s been helpful. It is both a challenge and a privilege to be able to have such a kaleidoscope of identities and to use that in my work.

Adam Levy: 08:25

So as someone who travels far beyond your institution for your fieldwork, can you explain whether this ever poses any practical or safety issues for you?

Gabi Fleury: 08:37

Yeah, so there are some places I just can't work, right? Well, I probably could work, but it would definitely potentially be dangerous for me to work in those places.

I, essentially when I’m in the field, have to fly under the radar. I don’t talk about my sexuality or my identity, and I don’t use my pronouns.

I use she/her, which is a choice that I’ve made working internationally because I’ve kind of had to thread that needle of wanting to keep myself safe in the field and wanting not to telegraph my identity when it could potentially be a danger to me.

But it does come with mental health costs, of course, because you’re you’re kind of having to deny and pretend you’re not who you are, in order to work safely or effectively. I feel like how I work in the States is extremely different from how I work abroad.

Adam Levy: 09:27

Do you feel that other colleagues and maybe your advisor in your department understand those compromises that you have to make, understand the places you can’t go, and, and the challenges you have in the places that you do go to?

Gabi Fleury: 09:39

I think intellectually I t.hink it’s hard if that’s not their lived experience. I know that my department’s very supportive and my advisor is extremely supportive and fantastic. And that’s why that’s why I decided to go to the university I go to, but unless someone goes through that experience, it’s hard to explain it.

And that's one of the reasons why I do a lot of mentorship. So especially if you’re also, you know, a person of colour, I think it’s, it’s really important to have someone who can be that support system for you.

Adam Levy: 10:06

What do you think can be done to improve the safety and the freedom of LGBTQIA+ researchers, as well as take into account that that might just be one part of their personhood, one part of their identity?

Gabi Flery: 10:20

Field safety’s a major one, or just having these conversations. Because a lot of the time we’re working in very remote areas, very isolated areas. And these conversations often aren’t had, right like, what do you do if you find yourself in an unsafe situation where you go, because a lot of the people who are in positions of power, in my field specifically don’t share any of my marginalizations, they don’t even have to think about it. I remember my mom being shocked when I didn’t get she’s like, “Do you get self defense training?”

And I'm like, “No.” You know, so it’s not just about research, but about, you know, whether your resources if something were to go wrong, and as a big part of the conversation that I think needs to be built into the universities. Because there’s countries you can go to that it’s illegal, like your identity may be illegal, there could be prison consequences for, you know, being yourself, essentially. So I do think that's something to be honest about.

Adam Levy: 11:15

We’ve discussed any challenges that you've had, because you fall under the LGBTQIA+ umbrella, but has been a Black researcher presented any problems from other researchers owing to racism?

Gabi Fleury: 11:30

That’s kind of a complicated answer. So yes, I think it’s less external, in the States, at least, at least in my case, where people won't necessarily be directly racist towards me. It’s more in terms of like, I think microaggressions.

Or I might be considered, I might be taken less seriously. Or I might be considered more aggressive than a white woman would be.

So yeah, I definitely think that it’s harder, especially since conservation is so white-dominated, and still so male-dominated in kind of the upper echelons of the field.

So when I was a kid, no, all my heroes were, they were white men. They were Steve Irwin, and the Craft Brothers and David Attenborough, you know, like they were my conservation heroes, or Jane Goodall, the only woman among them that I knew of.

The representation is so important for people who are kind of coming up. I’ve been engaged in a program called Skype for Scientists, where you can speak to the schools, and I’ve been trying to do as much media as I can to, to show kids that, you know, you can be Black and be a conservationist. You can be LGBT and be a conservationist.

And although there are challenges, I don’t necessarily like to focus on the challenges, because they’re there. But I think it’s also important to, to show people that you can succeed, and that there is a place for them in the field.

Adam Levy: 13:01

What would you hope to see change in the future, regarding how we understand what it means to be LGBTQIA+ in research?

Gabi Fleury: 13:11

You know, we’re academics. So I think publishing on these things, and getting data about some of the challenges that people face and some of the potential ways to overcome it, I think is really important.

That’s what we do. We collect data, and we analyze data, and we see patterns, and then we can respond appropriately to those things.

And I think, rather than kind of seeing it as like an HR thing, you know, that is removed from science. That’s part of our science.

Adam Levy: 13:36

That was Gabi Fleury. And this question of data around the LGBTQIA+ researchers comes up again and again. As Gabi mentioned, fieldwork can present particular challenges. And a pair of US geologists set out to gather data on the challenges LGBTQIA plus researchers face out in the field.

I called up Alison Olcott, a paleontologist at the University of Kansas in the United States, who was one of the researchers behind the survey.

Alison Olcott: 14:09

Geology, paleontology is so rooted in fieldwork, this sort of Indiana Jones idea of you know, you go out with your bullwhip and your khaki shorts, and you stride around and you pick up rocks and find bones.

And I think a lot of the underlying safety factors just aren't considered by everyone who's organizing a field trip.

Adam Levy: 14:27

For researchers who aren’t LGBTQ+, or maybe researchers who are but don’t conduct fieldwork, could could you explain why this can pose difficulties?

Alison Olcott: 14:39

There can be difficulties faced on many different levels by LGBTQ researchers. One the sort of biggest level is in many places, LGBTQ identities are criminalized or just dangerous to have.

So you could send your students out, you could take a field trip, you could send an expedition to a place where the very existence of some of the people on the field trip is illegal, which is a huge danger for those people.

But at a more basic day-to-day level, gender actually ends up underlying so much of what we do in the field from, you know, a pit stop, where you say, “Boys go to this side of the road to go the bathroom, girls go to this side.”

Or how you make students have room together on a field trip or in a field camp. You know, boys go in this cabin, girls go in this cabin, gender underlies so much of the day to day functioning of a field trip.

Adam Levy: 15:29

You and collaborators actually conducted a survey to investigate these issues and how they affect geologists. How do these impacts actually affect researchers at different stages of their careers?

Alison Olcott: 15:43

One of the biggest effects is that at early stages in the career, there’s just less control over where you're going in the field.

We actually found when we researched the levels people had felt this effect, the biggest effects were felt at the grad school level.

We think it’s because as undergraduates students have control over what classes they take, so if there’s a trip that’s not set up well, if you don’t feel safe, if the destination doesn’t feel safe, maybe you don’t take that class.

If you’re a faculty member, if you are leading a trip, maybe you don’t take a trip to a place, you don't feel safe, or you set up the trip with your own safety in mind.

But if you’re a graduate student, quite often you’re just being sent somewhere by your advisor. And you have very little control over whether or not you get to go, or even sometimes how that trip is set up.

And so there are power imbalances as well, within these relationships. So the same power imbalances you see across academia, also are reflected in these LGBTQ geoscientists as well.

Adam Levy: 16:44

And from this survey, just how widespread are these kinds of issues that we’re talking about?

Alison Olcott: 16:49

This was very, very widespread. A huge proportion of the people we surveyed have reported feeling unsafe in the field. And they also reported not doing research, not taking advantage of opportunities because of their feelings of safety.

So a huge proportion of scientists are going out and doing things that makes them feel unsafe. But also, just science isn’t occurring because people don't feel safe. So in some ways, we can’t even quantify what the effects are.

Because things aren’t happening, people aren’t going to the field. People aren’t making discoveries, because they feel that their own personal safety would be too impacted.

Adam Levy: 17:27

Given just how extensive this issue is, why do you think that researchers who aren’t LGBTQ plus can overlook this so easily?

Alison Olcott: 17:36

I think it can be hard to think through all the issues other people might face. And I think also, in many ways, the geosciences is still quite traditional.

So I have come across other geoscientists who will say things to me, like, “I don’t need to worry about these issues. I just teach about rocks. And so I just need to focus on the rocks.”

So although it is changing, I think there is still this tendency among some geoscientists that just the field is the great equalizer and everyone loves the field.

And for many geoscientists going out in the field was their transformative moment that made them become a geoscientist. So it can be very hard for them to think that for other people, the field could be a source of stress and trauma.

Adam Levy: 18:19

Could you share any stories that came through from this survey, which really capture the kind of problems that LGBTQ+ geologists might actually face out in the field?

Alison Olcott: 18:31

There were the big stories, you know, about “I was sent to a place where I felt unsafe.”

But the ones that really struck me were these these day-to-day stories, somebody reached out and told us that when he was in the camp, he was just tortured the whole time, because he was an out gay man. And he was put in the boys’ cabin. And just he felt very uncomfortable.

His cabin mates were very mean to him because of his identity, he felt very unsafe, and that he had nowhere to turn to. And so that meant he spent every night at field camp stressed and upset. Just because of where he was assigned to sleep.

People talked about troubles at sea, where you know, you’re you’re out in the field, stuck on a boat with people where they were being abused for their identity, because they had no bathroom to go to that matched their gender identity.

So it just it can be a very unsettling experience for people. These very small details, you know, that are so important. Where do I sleep? Where do I go to the bathroom? That can be so fraught in some of these situations.

Adam Levy: 19:35

What can or perhaps should other academics and academic institutions do to address these issues?

Alison Olcott: 19:42

No one should ever be punished because they can’t go on a field trip. I think universities need to have alternative pathways to do field trips if they’re required for students. There are lots of reasons not just for identity, there can be disabilities, there can be family issues. So I think universities need to give students options.

But I also think as a PI, whenever you organize a field trip, there is a standard set of safety information you gather. You know, where are we going, what are the hazards, what do I need to warn my students about?

And we advocate that these LGBTQ issues need to be part of that standard safety practice for all trips, you know, gather information about what it will be like where the field trip is going.

Figure out things like, where are you stopping to go to the restroom? How are you organizing sleeping arrangements? And then just presenting that information to students the same way you present any other safety information to really make it just a standard part of field trip preparation.

Adam Levy: 20:41

You discuss the findings of this survey in an article Eos magazine titled “The challenges of fieldwork for LGBTQ+ geoscientists.” Did this receive much of a response?

Alison Olcott: 20:55

It did. It was really heartening the response that people had to this article. But what we found was that people really have embraced the study. A lot of schools, a lot of institutions have started changing their policies around fieldwork in reaction to this work.

It’s been really nice to see the community recognize that this is an issue, and watch institutions try to plan, and try to help students of all identities feel more comfortable in the field, which I think can only help make the geosciences richer.

Adam Levy: 21:26

Alison Olcott there. So far this episode, we've been focusing on LGBTQIA+ researchers who are based in the United States, and the potential risks of travel.

But some researchers face serious threats to their lives and safety in their countries of origin. And in many parts of the world. LGBTQIA+ orientations and identities are not only persecuted, but criminalized.

In the fourth episode in this series, I spoke with Stephen Wordsworth, about the work his organization, the Council For At Risk Academics, carries out to protect academics who are under threat. He also explained to me that as well as, for example, helping those fleeing conflict, they have also worked with LGBTQIA+ researchers.

Stephen Wordsworth: 22:20

It simply reflects the prejudices in their own countries, whichever countries those are, where there are a number of countries across Africa and Asia, where being gay is simply unacceptable in the view of local people there, including local extremists.

And so they need help urgently to get away. So we define academic broadly, we define risk broadly. But if somebody who meets those criteria is at risk of violence, death, or just not being able to work, because they’re ostracized, excluded, then we will help them.

Adam Levy: 22:59

But threats to safety can come for many reasons and in many forms, and as we learned in last week's episode where we spoke about the harassment climate scientists face, academics studying controversial politicized topics, can find themselves on the receiving end of a deluge of hatred.

And this is the case for several researchers who investigate issues connected to transgender people, people whose gender does not match up with the gender that they were assigned at birth.

In the last years there has been an increasing public and political focus on transgender people. I wanted to speak with someone who researches questions around transgender wellbeing and rights. Some of the people I contacted were scared of the threats and backlash they might receive through speaking publicly. But Florence Ashley, a researcher at the University of Alberta, Faculty of Law, in Canada, gave me a call.

Florence Ashley: 24:00

I do quite a lot of different types of work across law, bioethics, and the health and social sciences, all around transgender issues. Quite a large chunk of my work is around access to gender affirming care for minors.

Adam Levy: 24:23

Given how much of the political debate around transgender people focuses on transgender young people, Florence has found themselves at the centre of this controversy. When I called Florence up, I asked them what it was like doing this work when they first got started in their career.

Florence Ashley: 24:42

So I started doing this work more in 2015-2016.

And back then the public conversation was so much less hostile than it is now. In many ways things were so much better back then in terms of public conversation, which isn’t to say, we didn’t get a lot of pushback.

Whenever I would I write opinion articles in the media or would go on TV or go on radio, the comments were, you know, full of people calling me mentally ill, calling trans people mentally ill, saying we should not support that. But it didn’t really gained the same sort of public prominence, it was largely reserved for the common sections. But this has really evolved since then,

Adam Levy: 25:30

Can you give people a sense of the kind of reactions, either from inside or from outside academia, that you've had to the work that you're doing?

Florence Ashley: 25:39

I’ve had right-wing media write articles about my work, essentially calling it horrendous. I’ve, of course, like many other people, have received death threats, mostly not credible ones. But I know a lot of people who have received very credible ones, unfortunately.

I’ve had people that are in my field, who are professors, senior professors, say that they would try to end my career and prevent me from having a career.

I’ve had people, you know, defame me and call me a groomer for the work that I do, including by academic peers.

And then, of course, I have to deal with the things that aren’t directed at me, but are directed at people like me, and people who do the work that I do, which is seeing people call for the eradication of quote unquote, transgenderism.

Or call for even, you know, hanging and public hangings of those who offer gender-affirming care to minor or who support it. And, you know, given how much of my work is around increasing access to gender-affirming care, this is something that I feel quite targeted by,

Adam Levy: 27:02

And how does that actually affect your ability and your desire to carry out this work?

Florence Ashley: 27:08

It makes doing this kind of work very difficult in many ways, personally, because of who I am as a person, despite fuels my work, the anger fuels, my work, and so I want to do this work even more.

But I know so many people who just can't go on, and I often have a lot of days where I really struggle to to get up and do the work and have the motivation. 1, because it feels like it’s helpless and endless. But also because there is a sense of like, nobody is going to support me.

And through that, well, that, you know, worsens depression, worsens anxiety, and just makes it really difficult to do that work.

And there is also the reality of the fact that I’ve grown quite numb emotionally to a lot of the bad things that happen in my life through not only the hatred that I get, but also the number of people around me who have died, (usually to suicide), because of all that hatred in society and that numbness is really not good.

You know, after that’s my few days, my therapist would say, “Yeah, that’s, that’s not a healthy thing.”

But it’s, I guess, what my brain has had to do to just keep me keep an eye on.

Adam Levy: 28:38

To what extent then has this reaction to your work fed into your your personal life, your personal well being because of course, we all care about our work, but these are questions that also affect you directly as a trans person?

Florence Ashley: 28:53

Absolutely. It has an immense impact on my personal life. In fact, it has simply made it difficult for me to have a sort of like healthy personal life, because I’m always dealing with these anxieties.

And I’m always dealing with the sense that if I am not personally doing something to fight against this wave of hatred, then that gets hashed out in in costs of lives.

Any help that I can give, you know, might help turn the tides when added to the work of others. And so there is unfortunately a sense oftentimes, if I don’t do this, if I don’t fight back with all the privilege that I have, then I’m failing my communities.

But then the problem with that is it means that my own personal wellbeing takes a backseat and I always have to be sort of like flirting with depression, flirting with burnout, and and really not having the ability to take care of myself in a way that I should be able to take care of myself.

And in a way that most researchers are able to do once they leave the lab, leave the office and go back home.

Adam Levy: 30:18

What if anything, do you feel other academics and academic institutions should be doing to support researchers whose work becomes so actively politicized?

Florence Ashley: 30:31

In terms of academics, please show up for your colleagues, please show up for people who are not, you know, immediate colleagues, but who are in sufficient proximity to you that you can give them emotional and material support.

We need people to speak out about it, to be very public in their support of their trans colleagues, and of their colleagues who work in trans issues.

And then at the institutional level, we need institutions to stand behind their trans faculty and students. We need them to have clear policies around safety around, how to respond to harassment campaigns and death threats.

We need them to have adequate mental health support. A lot of institutions will represent their faculty if they are targeted by legal threats, most notably in life defamation, which are often a way of shutting up scholars, but one, they need to be sure that they are really robust in these protections. And then also they will need to extend them to their students.

Adam Levy: 31:44

How typical do you think are the experiences that you've had compared to other people researching in this area, potentially, in in different countries?

Florence Ashley: 31:53

I would say I'm actually on the better end of things. While I’m very involved, online, and Canada is far from free from hatred, the intensity of that hatred is far, far worse in many other places. I’m thinking, notably, the UK, I’m thinking the US, among other places.

And, you know, in many ways, I’ve had it easy, I haven’t had people picketing my office. I have colleagues who want to participate in public conversations and have to back out of them because of the level of threat that they are personally experiencing.

And the level of death threats that are credible to because, you know, it's it's one thing to receive death threats as I do. And I mean, I’m always shocked by the boldness of people literally signing their names onto their death threats.

But it’s quite another one when you when they do that. And then it so happens that the death threat is, you know, left at your workplace without a postage stamp, meaning that they’ve it’s been personally delivered.

And I know so many people who have experienced that, and who experience that on a daily or weekly basis.

So my experiences are, in a way representative of the fact that there is so much harassment and evil going on towards trans scholars and scholars who work on on trans health.

But at the same time, a lot of people have it. So much, so much worse.

Adam Levy: 33:35

That was Florence Ashley. And harassment is unfortunately all too common for researchers, whether because they’re investigating LGBTQIA+ questions, or because they are LGBTQIA+ themselves.

And being targeted by harassment in any shape can have serious impacts on scientists, careers, and their lives.

We’ll be discussing harassment in the workplace in our next episode, the last in this special series. Now it’s time for our sponsored slot from the International Science Council, (the ISC) about how it's exploring freedom, responsibility and safety in science. Thanks for listening. I’m Adam Levy.

Soumya Swaminathan 34:32

Trust is something that is built over a long period of time. It’s a two-way process. It involves investment and therefore it’s important to build on that.

Elisabeth Bik 34:42

So we can easily create photos of cells or tissues that look very realistic and that technology can be used to create all kinds of fake news and fake science.

Marnie Chesterton 34:53

Hello and welcome to this podcast series from the International Science Council on freedom and responsibility in science. I’m Marnie Chesterton, and in this final episode, we’re looking at trust. How can we combat malpractice and misconduct in research? And how do we promote trust in scientists and the work they do?

So many of the important decisions we make in society are based on scientific evidence. From how we treat diseases or educate our children to the interventions we make to protect the planet. It’s vital that science is credible and reliable, and yet despite the advances we have made this century, scientific fraud is on the rise.

Elisabeth Bik 35:41

There’s obviously several kinds of misconduct you could see in a paper, but the most visible ones are photos. Images, photos of plants, or mice, or cells, or tissues or blots, things like that.

Marnie Chesterton 35:54

This is Elisabeth Bik. A microbiologist by training, she now specializes in the detection of fake images in scientific papers.

Elisabeth Bik 36:03

Things like photoshopping or using the same image twice to represent two different experiments. You might see statistical errors. You might see impossible numbers or numbers that look very similar, either between tables or across papers, suggesting that the data has been made up. And then there’s the misconduct you cannot see just because the person is smart and is hiding it, and you could only catch it when you’re sitting next to that person doing the misconduct. If they use a different antibody or a different cell line, or if they just dilute their samples a little bit, you can make your results look exactly the way you want it without doing that experiment.

Marnie Chesterton 36:46

Catching scientific misconduct isn’t always possible, but Elisabeth has tried to get a sense of the scale of the problem when it comes to images.

Elisabeth Bik 36:54

I scanned 20,000 papers and I found that 4% of those 800 papers had signs of image duplications, and we estimated about half of those had been done deliberately. So that would mean that 2% of the papers that I scanned had signs of misconduct. Now, I think the real percentage of misconduct has to be higher, maybe the 4 or 10% range, and I do think it’s getting worse. You see that there are paper mills, and those are companies that make fake papers and sell the authorship positions to those authors who need those papers. But it’s hard to catch them, so journals luckily are getting more aware of this problem and are screening their incoming manuscripts better to catch these fake papers.

Marnie Chesterton 37:43

Publication fraud like this is damaging in all kinds of ways, and in the long run ends up hurting all of us.

Elisabeth Bik 37:51

For example, with these paper mills that we have discovered, it’s damaging the people who are honest scientists who are doing really good science. But it’s also damaging for science because we already have seen in the past couple of years during the COVID pandemic that there is a group of people who have a huge distrust in science. And I think the stories about misconducting science could actually help those people be more convinced that science is all fake and we cannot trust scientists any more.

Marnie Chesterton 38:19

So what can we do about this growing problem? Well, according to Elisabeth, it’s going to take action on multiple fronts.

Elisabeth Bik 38:27

It takes a village. It takes not just the scientists themselves, but the institutions that they work at, the scientific publishers, the readers, and maybe even a government to make sure that science is done properly. So the papers that I found, I reported all of those to the publishers, and I found that only one third of those papers were corrected after waiting five years. I would love to see that there were some consequences for people who are caught photoshopping in science. I feel that that paper should be retracted and those people after an investigation should be punished, maybe lose their job. And I think we need to move towards a reproducibility model of scientific publishing. We tend to focus too much on novel science, which is great, but I think we’re moving too fast. We need to take a step back, reproduce more experiments, and then give the people who are able to reproduce experiments recognition for that.

Marnie Chesterton 39:25

Researchers, institutions and governments all have a role to play in ensuring that science is done responsibly. But trustworthiness isn’t the same as trust. The COVID-19 pandemic showed that not everyone was willing to put their faith in experts, and we saw the life-threatening consequences of inaccurate information. So whose responsibility is it to build public trust in science?

Soumya Swaminathan 39:52

I would start with school teachers and parents who need to inculcate in children the spirit of scientific inquiry, inquisitiveness, curiosity, the need to question and, to, as they grow, to be able to distinguish between credible sources of information and what could be perhaps false information.

Marnie Chesterton 40:17

This is Soumya Swaminathan, former Chief Scientist at the World Health Organization and currently the chairperson of the M S Swaminathan Research Foundation in Chennai, South India.

Soumya Swaminathan 40:29

But of course, I think scientists also have a responsibility. And I think fundamental understanding of science is that it evolves constantly, that it’s a community, really, not individuals that ultimately come up with solutions to problems. Sometimes there is a proof that actually overturns what was believed earlier. I think we also have as scientists and, as well as, as public health experts, a duty to communicate what we understand in language that’s simple, that’s easy to understand, that’s not talking down to people but engaging them in a conversation, treating them as equals, and trying to address the myths and misconceptions that we might find around us.

Marnie Chesterton 41:19

But unfortunately, we’ve all seen how these days communicating research findings or debunking myths online comes with its own challenges.

Soumya Swaminathan 41:28

There’s a lot of online abuse and hate, and I think particularly for women, sometimes, you know, this can be very ugly as well, and it can get very personal. There needs to be norms of behaviour on what you can and cannot say on social media and what kind of language, you know, you can and cannot use. And I would like to see these rules being put in place and enforced. That’s the only way to have constructive and open debate. Because a lot of people were thrust into social media at the time of the pandemic, when they were desperate for knowledge, and there was a lot of confusing information out there, what we call the infodemic. So I think there’s a lot of education to be done, really, in all of these areas before we can get much more enlightened and maybe civil discourse going on some of these topics.

Marnie Chesterton 42:20

The COVID pandemic put public trust in science to the ultimate test. So what lessons can we learn? And looking to the future, are there reasons to be hopeful?

Soumya Swaminathan 42:32

What I find very encouraging is that if you ask people whom they trust, their trust in scientists and their trust in the medical profession seems to be quite high. After all, it was science that delivered for us during the pandemic. So many vaccines developed within a year of identifying a new virus and a whole lot of understanding of how this virus spreads and what the immune responses are. And again, studies have shown that in countries where there’s high trust between people and between government and people, their outcomes were generally much better. The people were much more willing to comply with government instructions than in places where there was less trust. I would say, however, that trust is not something that can be built overnight. One has to get into communities, one has to engage with them, they have to be participants in the process. Top-down measures usually are not the way to build trust.

Marnie Chesterton 43:43

That’s it for this final episode on freedom and responsibility in science from the International Science Council. The ISC has released a discussion paper on these issues titled ‘A contemporary perspective on the free and responsible practice of science in the twenty-first century’. You can find the paper and learn more about the ISC’s mission online at council.science/podcast . And in July 2023, the ISC will produce another paper through its newly established Centre for Science Futures on public engagement and trust in science. Insights from the paper will provide a robust framework to interpret, mediate and explain scientific knowledge, and provide advice, recommendations and policy options. Visit futures.council.science for more information.

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2024 U.S. National Survey on the Mental Health of LGBTQ+ Young People

Introduction.

The Trevor Project’s 2024 U.S. National Survey on the Mental Health of LGBTQ+ Young People amplifies the experiences of more than 18,000 LGBTQ+ young people ages 13 to 24 across the United States.

For the sixth year, the U.S. National Survey uncovers the reality that there is a significant association between anti-LGBTQ+ victimization and disproportionately high rates of suicide risk — and that far too many young people struggle to access the mental health care they need.

The survey critically provides data-driven ways we can all show support and acceptance for the LGBTQ+ young people in our lives, based on their own responses — as well as the potentially life-saving benefits of creating affirming spaces and communities.

For the first time, we asked respondents to share a message of advice or encouragement to other young people in the LGBTQ+ community. There is no doubt that this has been a challenging year for LGBTQ+ young people. Yet despite these challenges, including the historic wave of anti-LGBTQ+ legislation that has targeted them, these young people remain powerful, optimistic, and resilient.

The Trevor Project remains unwavering in our commitment to support them, and we will continue fighting toward a world where all LGBTQ+ young people feel safe, accepted, and loved exactly as they are.

Thank you to all the LGBTQ+ young people who took this survey, honestly and bravely sharing their experiences with us. We hope these findings help to equip fellow researchers, policymakers, educators, and other youth-facing professionals and organizations with the data they need to protect and uplift LGBTQ+ young people in their communities and to help us end the public health crisis of suicide, once and for all.

- The Trevor Project

Want to help support The Trevor Project?

Your donation helps to support future, meaningful research about LGBTQ+ youth and power the life-saving services we provide.

Key Findings

39% of LGBTQ+ young people seriously considered attempting suicide in the past year — including 46% of transgender and nonbinary young people. LGBTQ+ youth of color reported higher rates than White peers.

More than 1 in 10 (12%) LGBTQ+ young people attempted suicide in the past year.

50% of LGBTQ+ young people who wanted mental health care in the past year were not able to get it.

More than half (54%) of transgender and nonbinary young people found their school to be gender-affirming, and those who did reported lower rates of attempting suicide.

90% of LGBTQ+ young people said their well-being was negatively impacted due to recent politics.

45% of transgender and nonbinary young people reported that they or their family have considered moving to a different state because of LGBTQ+-related politics and laws.

Nearly half (49%) of LGBTQ+ young people ages 13-17 experienced bullying in the past year, and those who did reported significantly higher rates attempting suicide in the past year than those who did not experience bullying.

LGBTQ+ young people who reported living in very accepting communities attempted suicide at less than half the rate of those who reported living in very unaccepting communities.

Mental Health & Suicide Risk

LGBTQ+ young people are not inherently prone to higher suicide risk because of their sexual orientation or gender identity. Rather, they are placed at higher risk because of how they are mistreated and stigmatized in society.

Mental Health & Suicide Risk:

Suicide Risk

Anxiety & depression.

39% of LGBTQ+ young people seriously considered attempting suicide in the past year

including almost half of transgender and nonbinary young people (46%) and 3 in 10 cisgender young people (30%).

12% of LGBTQ+ young people attempted suicide in the past year

including 14% of transgender and nonbinary young people and 7% of cisgender young people.

Rates of considered and attempted suicide among LGBTQ+ young people

Explore Data by:

• Sexual Orientation
• Gender Identity
• Race/Ethnicity

Considered suicide in the past year

Attempted suicide in the past year.

Questioning

Cisgender Men

Cisgender Women

Transgender Women

Transgender Men

Nonbinary/ Genderqueer

Asian American/ Pacific Islander

Black/ African American

Hispanic/ Latinx

Middle Eastern/ Northern African

Native/ Indigenous

More than one race/ ethnicity

10% of White young people attempted suicide in the past year

compared to…

• 24% of Native/ Indigenous young people
• 16% of multiracial young people
• 14% of Middle Eastern/ Northern African young people
• 14% of Black/ African American young people
• 13% of Hispanic/ Latinx young people
• 10% of Asian American/ Pacific Islander young people

66% of LGBTQ+ young people reported experiencing recent symptoms of anxiety

including over 7 in 10 transgender and nonbinary young people (71%) and nearly 3 in 5 cisgender young people (58%).

53% of LGBTQ+ young people reported experiencing recent symptoms of depression

including nearly 3 in 5 transgender and nonbinary young people (59%) and more than 2 in 5 cisgender young people (44%).

Anxiety & depression symptoms reported among LGBTQ+ young people

Experienced symptoms of anxiety, experienced symptoms of depression.

Access to Care

Despite the prevalence of anxiety, depression, and suicide risk among LGBTQ+ young people, half of them were not able to access the mental health care they desired. And among the small percentage of transgender and nonbinary young people who said they received gender-affirming medical care, nearly 3 in 5 were worried about losing access to this care.

Access to Care:

Mental Health Care

Gender-affirming medical care.

Among all LGBTQ+ young people, 84% wanted mental health care.

50% of LGBTQ+ young people who wanted mental health care in the past year were not able to get it

including nearly half of transgender and nonbinary young people (49%) and more than half of cisgender young people (52%).

Among the 42% of LGBTQ+ young people who received psychological or emotional counseling in the past 12 months

the majority accessed services through in-person one-on-one therapy (69%) or virtual/online therapy over video (53%).

Desire for and access to mental health care

Desire for mental health care, access to mental health care.

• 50% Wanted but did not receive care
• 50% Wanted & received care

LGBTQ+ young people who wanted mental health care but were unable to get it cited the following top ten reasons:

I was afraid to talk about my mental health concerns with someone else

I could not afford it

I did not want to have to get my parent’s/caregiver’s permission

I was afraid I wouldn’t be taken seriously

I was scared someone would call the police or involuntarily hospitalize me

I was afraid it wouldn’t work

I was not out about my LGBTQ+ identity and was afraid of being outed

I did not feel they would understand my sexual orientation or gender identity

I did not want people to think something was wrong with me

I have had a previous negative experience and did not want to have another one

Among transgender and nonbinary young people, 13% reported being on gender-affirming hormones, and 2% reported taking puberty blockers.

61% who were on gender-affirming hormones were somewhat or very concerned about losing access to this care.

Anti-LGBTQ+ Policies

A record number of anti-LGBTQ+ policies have been introduced and implemented in the last year — and they’re having a negative impact on LGBTQ+ young people’s mental health.

The overwhelming majority (90%) of LGBTQ+ young people said their well-being was negatively impacted due to recent politics. Over half (53%) said their well-being was negatively impacted by politics a lot.

Nearly 2 in 5 (39%) LGBTQ+ young people said that they or their family have considered moving to a different state because of anti-LGBTQ+ politics and laws.

Nearly half (45%) of transgender and nonbinary youth reported that they or their family have considered moving to a different state due to anti-LGBTQ+ politics and laws.

How often have recent politics negatively impacted your well-being?

• 37% Sometimes

Anti-LGBTQ+ Victimization

Experiences of anti-LGBTQ+ victimization were associated with higher suicide risk among LGBTQ+ young people. In separate analyses, those who reported being physically threatened or harmed, discriminated against, subjected to conversion therapy, or bullied because of their sexual orientation or gender identity had more than twice the rate of attempting suicide in the past year, compared to LGBTQ+ young people who did not report any of these anti-LGBTQ+ experiences.

Anti-LGBTQ+ Victimization:

Negative Experiences at School

Physical harm, discrimination, conversion therapy, among those enrolled, lgbtq+ young people reported that these negative experiences happened to them while in school:.

I was verbally harassed because people thought I was LGBTQ+

I wasn’t allowed to dress in the way that fit my gender identity or expression

I was disciplined for fighting back against bullies

I experienced unwanted sexual contact because people thought I was LGBTQ+

I believe I was disciplined more harshly because teachers/staff thought I was LGBTQ+

I left a school because the mistreatment was so bad

I was physically attacked because people thought I was LGBTQ+

23% of LGBTQ+ young people reported that they have been physically threatened or harmed in the past year due to either their sexual orientation or gender identity.

15% of LGBTQ+ young people reported that they have been physically threatened or harmed in the past year due to their sexual orientation.

28% of transgender and nonbinary young people reported that they have been physically threatened or harmed in the past year due to their gender identity.

Rates of LGBTQ+ young people who have been physically threatened or harmed in the past year

Due to their sexual orientation, due to their gender identity, lgbtq+ young people who attempted suicide in the past year, comparison across those who:.

Experienced physical threat or harm due to their sexual orientation or gender identity in the past year

Have not experienced physical threat or harm due to their sexual orientation or gender identity in the past year

60% of LGBTQ+ young people reported that they have felt discriminated against in the past year due to their sexual orientation or gender identity.

46% of LGBTQ+ young people reported that they have felt discriminated against in the past year due to their sexual orientation.

65% of transgender and nonbinary young people reported that they have felt discriminated against in the past year due to their gender identity.

Rates of LGBTQ+ young people who have felt discriminated against in the past year

Cisgender men

Cisgender women

Transgender women

Transgender men

Felt discriminated against due to their sexual orientation or gender identity in the past year

Have not felt discriminated against due to their sexual orientation or gender identity in the past year

LGBTQ+ young people who reported being threatened with or subjected to conversion therapy:

• 87% Not threatened with or subjected to conversion therapy
• 8% Threatened with conversion therapy
• 5% Subjected to conversion therapy

13% of LGBTQ+ young people reported being threatened with or subjected to conversion therapy

including approximately 1 in 6 transgender and nonbinary young people (16%) and nearly 1 in 10 cisgender young people (9%).

Rates of being threatened with or subjected to conversion therapy among LGBTQ+ young people

Nonbinary/Genderqueer

Black/African American

Middle Eastern/Northern African

Were not threatened with or subjected to conversion therapy

Were threatened with conversion therapy

Were subjected to conversion therapy

49% of LGBTQ+ young people ages 13-17 reported being bullied in-person within the past year, and 26% of those ages 18-24 reported the same.

35% of LGBTQ+ young people ages 13-17 reported that they had been electronically (cyber) bullied during the past year, and 24% of those ages 18-24 reported the same.

LGBTQ+ young people who experienced bullying of any kind reported three times the rate of attempting suicide in the past year compared to those who were not bullied.

Were not bullied

Experienced either in-person or electronic (cyber) bullying

Ways to Support LGBTQ+ Young People

LGBTQ+ young people report lower rates of attempting suicide when they have access to affirming spaces and communities. They also need the people in their lives to better understand and support their identities and advocate for them.

Ways to Support LGBTQ+ Young People:

• Access to Affirming Spaces
• Supporting Transgender and Nonbinary Young People

LGBTQ+ young people who had access to LGBTQ+-affirming spaces, and transgender and nonbinary youth who had access to gender-affirming spaces, reported lower rates of attempting suicide compared to those who did not.

Transgender and nonbinary young people who had access to gender-affirming clothing, gender-neutral bathrooms at school, and had their pronouns respected by the people they live with had lower rates of attempting suicide compared to those who did not.

Most LGBTQ+ young people who attend school (78%) reported having at least one adult at school who is supportive and affirming of their LGBTQ+ identity.

LGBTQ+ young people reported the following top ten actions as ways people in their life can best show their support and acceptance:

Trusting that I know who I am

Standing up for me

Not supporting politicians that advocate for anti-LGBTQ+ legislation

Looking up things about LGBTQ+ identities on their own to better understand

Respecting my pronouns

Showing support for how I express my gender

Asking questions about LGBTQ+ identities to better understand

Accepting my partner(s)

Showing support on social media

Having or displaying pride flags

Access to Affirming Spaces and Communities

Affirming spaces among lgbtq+ young people:.

Community Events

Affirming spaces among transgender and nonbinary young people:

Lgbtq+ young people who attempted suicide in the past year, comparison across access to lgbtq+-affirming spaces:, not lgbtq+-affirming, lgbtq+-affirming.

*There was no significant difference in the suicide attempt rate among LGBTQ+ young people who had access to LGBTQ+-affirming worship spaces compared to those who did not.

Transgender and nonbinary young people who attempted suicide in the past year, comparison across access to gender-affirming spaces:

Not gender-affirming, gender-affirming.

*There was no significant difference in the suicide attempt rate among transgender and nonbinary young people who had access to gender-affirming worship spaces compared to those who did not.

How accepting of LGBTQ+ people is the community where you currently live?

• 13% Very unaccepting
• 23% Somewhat unaccepting
• 48% Somewhat accepting
• 16% Very accepting

LGBTQ+ young people who attempted suicide in the past year, comparison across access to how accepting of LGBTQ+ people are in their communities:

Very unaccepting

Somewhat unaccepting

Somewhat accepting

Very accepting

Supporting Transgender and Nonbinary Youth

Transgender and nonbinary young people reported lower rates of attempting suicide when all of the people they live with respected their pronouns and/or they had access to a gender-neutral bathroom at school., how many of the people you live with respect your pronouns.

• 37% None of the people I live with
• 27% Some of the people I live with
• 37% All of the people I live with

Transgender and nonbinary young people who attempted suicide in the past year, comparison across the number of people they live with who respected their pronouns:

None of the people I live with

Some of the people I live with

All of the people I live with

Is there a gender neutral bathroom at your school?

Transgender and nonbinary young people who attempted suicide in the past year, comparison across having a gender-neutral bathroom at their school:, transgender and nonbinary young people who had access to binders, shapewear, and gender-affirming clothing reported lower rates of attempting suicide in the past year compared to those who did not:*.

Access to most

*Binders and shapewear refer to undergarments, such as tank tops or bodysuits, that help young people who are experiencing gender dysphoria align the appearance of their body with their gender identity.

Most LGBTQ+ young people (65%) reported knowing at least one older LGBTQ+ person they would consider a role model or someone they look up to.

Older lgbtq+ role models identified by respondents:.

Someone I follow on social media (like TikTok, Instagram, SnapChat)

Another family member of mine

My teacher/professor

My classmate

My coworker

My parent/caregiver’s friend

Someone else who works at my school

My parent/caregiver

Advice and Encouragement from LGBTQ+ Young People

We asked LGBTQ+ young people to share a message of advice or encouragement to other young people in the LGBTQ+ community. Here were some of their responses:

• You have millions of queer siblings across the world who would accept you for who you. It is the most rewarding experience to live sourrounded by people who love you for your whole, true self.

• Finding a community, people you can be yourself aroud, is life changing
• You aren't alone my friend. Remember, there's a whole wide world with people like you and me.

• Be the role model you always needed.
• Treat yourself as a friend.
• You've come so far, and I am so, so proud of you.

• You are so extremely valid and I am prod of you.
• Keep on going, you're strong for existing.
• You are enough.

• The greatest act of rebellion is to go on living authentically and truthfully; find spaces where you can be yourself unapologetically.

• Just remember no one else can decide who you are for you, you know yourself the best and nothing and no one can change that.

• We deserve happiness. We're allowed to want a future of our own design, with the people we love. One day I'll get that and so will you.
• Finding out who you truly are take time. You've got this.

• You don't have to figure it out now, and you're allowed to not know. Figuring it out is for YOU first and foremost, so do it in your time and in your way.

• Takes as much time as you need to figure things out. There's no time limit.
• Nothing is better than living your authentic self, but you don't need to rush it. If the time isn't right, it just isn't right.

• You are beatiful! You bring so much light into the world and there is so much joy out there waiting for you.

• Queerness is glorious and essential and deeply human. It is poetry and starlight. Thank you for being here!

Methodology

The content and methodology for The Trevor Project’s 2024 U.S. National Survey on the Mental Health of LGBTQ+ Young People were approved by an independent Institutional Review Board.

A quantitative cross-sectional design was used to collect data through an online survey platform between September 13 and December 16, 2023. A sample of individuals ages 13 to 24 who resided in the United States, including its territories, was recruited via targeted ads on social media. No recruitment was conducted via The Trevor Project’s website or social media channels. Respondents were defined as being LGBTQ+ if they identified with a sexual orientation other than straight/heterosexual, a gender identity other than cisgender, or both. In order to ensure a diverse sample, targeted recruitment was conducted to ensure adequate sample sizes with respect to geography, gender identity, and race/ethnicity. Qualified respondents completed a secure online questionnaire that included a maximum of 134 questions. The questionnaire was offered in English and Spanish. Questions on considering and attempting suicide in the past year were taken from the Centers for Disease Control and Prevention’s Youth Risk Behavior Survey to allow for comparisons to their nationally representative sample. Each question related to mental health and suicide was preceded by a message stating, “If at any time you need to talk to someone about your mental health or thoughts of suicide, please call The Trevor Project at 1-866-488-7386 or the National Suicide Prevention Lifeline at 1-800-273-8255 or 988.”

A total of 72,424 individuals began the survey. However, 17,078 did not consent and 5,259 did not pass demographic screening requirements (e.g., age, United States [U.S.] residency, being LGBTQ+). This resulted in an eligible sample of 50,087 LGBTQ+ young people ages 13 to 24 in the U.S. Of those, 29,768 did not pass completion requirements (i.e., spend at least 5 minutes on the survey and complete at least 50% of it), 468 did not pass attention or honesty checks, and 1,188 did not pass duplicate or bot checks (e.g., built-in Qualtrics checks, IP address matching). This resulted in a final analytic sample of 18,663 LGBTQ+ young people ages 13 to 24 in the U.S.

Chi-square tests were used to examine differences between groups. Unless otherwise noted, all reported comparisons are statistically significant at least at p<0.05. This means there is less than a 5% likelihood these results occurred by chance.

This report uses “transgender and nonbinary” as an umbrella term to encompass non-cisgender young people, which includes young people who identify as transgender and nonbinary as well as other labels outside of the cisgender binary, including genderqueer, agender, genderfluid, gender neutral, bigender, androgynous, and gender non-conforming, among others.

Comparability

In order to better understand how our sample compares to a national probabilistic sample, we included questions regarding considering and attempting suicide that were identical to those used by the Centers for Disease Control and Prevention (CDC) in their Youth Risk Behavior Survey (YRBS).

Analyses were conducted to compare rates of seriously considering suicide and attempting suicide in the past 12 months among young people ages 13 to 18 in our sample (n = 11,346) to the 2021 YRBS sample of high school students who identify as lesbian, gay, bisexual, questioning, or another non-heterosexual identity (LGBQ+; n = 3,850).

The YRBS rate among LGBQ+ young people for seriously considering suicide in the past year (45%) was similar to the rate among the same age range in our sample of LGBTQ+ young people (44%).

Additionally, 22% of LGBQ+ young people in the 2021 YRBS reported a suicide attempt in the past 12 months compared to 14% in our sample of LGBTQ+ young people ages 13 to 18.

Sample Breakdown of Respondents’ Demographics

By sexual orientation.

• 4% Straight or Heterosexual
• 16% Lesbian
• 28% Bisexual
• 16% Pansexual
• 1% Questioning
• 10% Asexual

By gender identity

• 33% Girl or Woman
• 28% Boy or man
• 33% Nonbinary, bigender, genderfluid, or genderqueer
• 6% Not sure or questioning

By transgender & nonbinary identity

• 41% Cisgender
• 6% Questioning if transgender or nonbinary
• 53% Transgender or nonbinary

By race/ethnicity

• < 1% Middle Eastern/Northern African
• 1% Native/Indigenous
• 6% Asian American/Pacific Islander
• 8% Black/African American
• 12% Hispanic/Latinx
• 12% More than one race/ethnicity

By socioeconomic status

• 73% More than meets basic needs
• 27% Just meets basic needs or less
• 16% Northeast
• 23% Midwest

By intersex

Acknowledgements:.

The Trevor Project’s Research team expresses deep gratitude to all of the LGBTQ+ young people who participated in the survey and shared their insights. Special thanks to Greg Thomas, Abie Peacock, and Kinzi Sparks for their leadership in recruitment efforts. We also extend our appreciation to Antonia Clifford, Alfredo Pizaña, Carrie Davis, Fiona Hilton, Joseph Kwan, Kasey Suffredini, Kevin Wong, Megan Ford, Miranda Jaramillo, Dr. Myeshia Price, Nathanio Strimpopulos, Nelson Fernandez, Nolan Scott, Paul Pham, Ryan Bernsten, Steve O’Donoghue, Sue Cardenas-Soto, William Young, and Zach Eisenstein for their contributions to the research.

Suggested citation:

Nath, R., Matthews, D.D., DeChants, J.P., Hobaica, S., Clark, C.M., Taylor, A.B., Muñoz, G. (2024). 2024 U.S. National Survey on the Mental Health of LGBTQ+ Young People. West Hollywood, California: The Trevor Project. www.thetrevorproject.org/survey-2024

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LGBTQIA+ Studies: A Resource Guide

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It's important to note that the terms homosexual/heterosexual did not exist until 1868, so for earlier research, you will want to develop a list of historical vocabulary and vernacular. The first uses of the homo/heterosexual term is often considered to be the printing of an 1869 pamphlet by Kertbeny, Károly Maria, 1824-1882. The terms caught on after the work of Kertbeny appeared in the sexology periodical Jahrbuhch Fur Sexuelle Zwischenstufen. Havelock Ellis was an earlier adopter of the terms, further securing it's vernacular use. To find information or primary sources on a specific subject, especially for newspapers and periodicals, it is highly recommended that you consult subject indexes where available (For example, (An Index to The Advocate: The National Gay Newsmagazine). 

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Psychology of Sexual Orientation and Gender Diversity ® is the official journal of the Society for the Psychology of Sexual Orientation and Gender Diversity (APA Division 44). Read an interview with the Editor M. Paz Galupo, PhD.

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Edited by Douglas C. Haldeman This volume explores the history and effects of so-called conversion “therapy” on LGBT people.

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Edited by Megan C. Lytle and Richard A. Sprott This book reviews timely, pragmatic interventions and strategies to support LGBTQ students in K-12 schools.

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What Boys Do

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Jacob’s School Play

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Evelyn Hooker and the Fairy Project

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LGBTQI+ People and Substance Use

• Research has found that sexual and gender minorities, including lesbian, gay, bisexual, transgender, queer, and intersex people (LGBTQI+), have higher rates of substance misuse and substance use disorders than people who identify as heterosexual. People from these groups are also more likely to enter treatment with more severe disorders.
• People in LGBTQI+ communities can face stressful situations and environments like stigma and discrimination , harassment, and traumatic experiences . Coping with these issues may raise the likelihood of a person having substance use problems.
• NIDA supports research to help identify the particular challenges that sexual and gender minority people face, to prevent or reduce substance use disorders among these groups, and to promote treatment access and better health outcomes.

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