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Workshop Summary: Promoting Mental Health for Sexual and Gender Minority Youth: Evidence-Based Developmental Perspectives

June 10-11, 2024
 

Table of Contents

Day 1: Welcoming Remarks

Day 2: Welcome

Day 1: Welcoming Remarks

Opening Remarks

Stacia Friedman-Hill, Ph.D., (she/they), NIH Workshop Planning Committee, National Institute of Mental Health (NIMH)
Admiral Rachel L. Levine, M.D., (she/her), Assistant Secretary for Health, U.S. Department of Health and Human Services (HHS)
Shelli Avenevoli, Ph.D., (she/her), Deputy Director, National Institutes of Mental Health (NIMH)
Karen L. Parker, Ph.D., M.S.W., (she/her), Director, Sexual and Gender Minority Research Office, National Institutes of Health (NIH)
Monica Webb Hooper, Ph.D., (she/her), Deputy Director, National Institute on Minority Health and Health Disparities (NIMHD)
Wilson Compton, M.D., M.P.E., (he/him), Deputy Director, National Institute on Drug Abuse (NIDA)

Dr. Stacia Friedman-Hill welcomed attendees to the workshop and highlighted the collective efforts of several NIH Institutes, Centers, and Offices to coordinate it. She invited HHS and NIH leaders to present their welcoming remarks.

Admiral Rachel Levine introduced herself as the first transgender Senate-confirmed federal official and the first transgender four-star Admiral in the U.S. Public Health Service Commission Corps. She underscored the critical impact of adverse childhood events (ACEs) among LGBTQI+ youth, who are disproportionately affected by discrimination, bullying, child abuse, neglect, sexual violence, dating violence, unstable housing, and food insecurity. She emphasized the importance of recognizing not only the ACEs common to this community, but also the positive childhood experiences (PCEs) that can improve health and well-being. PCEs could include nurturing relationships with parents, friends, and other adults in the community; feelings of belonging at school or in their community; and engaging in after-school activities and cultural traditions. Admiral Levine acknowledged the politically- and ideologically-motivated attacks on LGTBQI+ communities in the U.S. and called for the nation to do better.

Dr. Shelli Avenevoli reviewed data from the Centers for Disease Control and Prevention (CDC) 2021 Youth Risk Behavior Surveillance (YRBS) Surveys for high school students, which showed increases in mental illness symptoms among females and LGBTQI+ high school students. Nearly 60 percent of female students and 70 percent of LGTBQI+ students experienced persistent feelings of sadness or hopelessness. Approximately 10 percent of female students and more than 20 percent of LGTBQI+ students attempted suicide. Sexual and gender minority (SGM) youth often experienced disparities in mental illness, access to healthcare, quality of care, and experiences of trauma and adversity; youth with more than one marginalized identity experienced even greater disparities. Dr. Avenevoli highlighted NIMH’s efforts to expand knowledge, remove barriers to conducting research, and strengthen the community of researchers in this field.

Dr. Karen Parker emphasized the critical need to improve data collection on sexual orientation and gender identity and expression (SOGIE) among minors. She highlighted existing gaps in research, calling for studies that capture the full spectrum of nuanced experiences, perpetual misconceptions, and critical health disparities in this community. She noted that this workshop was a pivotal opportunity to challenge this status quo and push the boundaries toward more inclusive and comprehensive health research.

Dr. Monica Webb Hooper highlighted NIMHD’s commitment to addressing the mental health needs of SGM youth and noted the official designation of SGM groups as a population experiencing health disparities for research purposes. She spoke of two recent NIMHD efforts to advance this area of science: a March 2023 workshop on the leading causes of death among SGM communities and a cross-NIH funding opportunity on SGM health disparities. Dr. Webb said that there were three priority research areas to address mental health concerns among SGM. First, there was a need for research on prevention and intervention strategies that include multilevel mechanisms and promote culturally-competent, gender-affirming, and trauma-informed care. Second, there was a need for research on the nuances of intersectionality and interventions that recognize the heterogeneity of this community. Third, there was a need to develop a workforce of SGM researchers. She called for a world in which all young people, including SGM individuals, could thrive mentally, emotionally, and physically.

Dr. Wilson Compton explained that there were higher rates of substance use among SGM youth and the importance of understanding both risk factors and resilience. He noted that while the increased incidence of ACEs in this community could have an impact on substance use, it was important to recognize that the issue was not simple but rather had multiple, overlapping risks. He called for a focus on risk factors and resilience, more inclusive and comprehensive research, and improved data collection standards to enhance research. Dr. Compton highlighted the Adolescent Brain Cognitive Development (ABCD) Study as a key resource for understanding adolescent brain development and developmental trajectories.

Developmental Trajectories, Epidemiological Trends, and Measurement of Sexual Orientation and Gender

Discussant: Kathleen A. Ethier, Ph.D., (she/her), Director, Division of Adolescent and School Health, U.S. Centers for Disease Control and Prevention (CDC)
Moderator: Parisa Parsafar, Ph.D., (she/her), Office of Health Equity, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)

Minority Stress and Health—Are Younger LGBT People Faring Better Now?

Ilan Meyer, Ph.D., (he/him), Williams Institute, UCLA School of Law

Dr. Ilan Meyer noted that stigma, homophobia, and transphobia were deeply rooted in culture and referenced the Minority Stress Model to explain how societal structures and disadvantaged statuses contribute to both external (distal) and internal (proximal) stress. He reviewed his Generations study to determine whether societal changes over the past 60 years had led to improved mental health outcomes among LGB individuals. He looked across three generations of LGB adults: the “pride/identity formation” cohort of LGB individuals aged 52-59 in 2016, the “visibility” cohort of LGB individuals aged 34 to 41 in 2016, and the “equality” cohort of LGB individuals aged 18 to 25 in 2016.

In terms of “coming out,” the younger cohort came out nearly 10 years earlier than older cohorts, indicating changes in societal acceptance and self-awareness. Younger cohorts also reported higher levels of violence, everyday discrimination, stigma, and internalized homophobia than older cohorts. The youngest cohort experienced higher levels of depression, anxiety, and suicide attempts—particularly after coming out. There was no significant reduction in exposure to conversion therapy across all age groups. Despite today’s culture of not identifying with specific LGBT terms, there was still a strong connection to LGBT identity among all age groups.

Dr. Meyer concluded that there were significant ongoing challenges in healthcare access and outcomes among LGBT individuals despite societal progress, indicating a need for research and interventions to address disparities. He also noted that transgender individuals had not been included in his hypothesis and study because there had not been a significant reduction in attitudes towards transgender individuals over the years.

Using Gender and Sexuality Measures in the Adolescent Brain Cognitive Development (ABCD) Study to Promote Wellness

Alexandra S. Potter, Ph.D., (she/her), Department of Psychiatry,University of Vermont

Dr. Alexandra Potter reviewed the ABCD Study as a research resource to help investigators better understand SGM youth. The ABCD Study began in 2015 and was a longitudinal neuroimaging study of nearly 12,000 youth aged 9 to 10 at enrollment. The study aimed to characterize developmental trajectories and explore the factors influencing development. ABCD data were released annually and was open source. The study encompassed several domains, each with oversight by a workgroup, experts, and a steering committee. The domain on gender identity and sexual health was developed in partnership with the CDC Division of Adolescent and School Health (DASH) to help them improve their measures.

The gender identity and sexual health workgroup was charged with recommending developmentally sensitive assessments of gender and sexuality. Initially, baseline assessments included a question about being transgender. At the one-year follow-up, they added an additional measure about felt gender. At the three-year follow-up, participants were asked two-step gender identity questions about sex assigned at birth and current gender identity. Dr. Potter noted that felt gender described how much a person felt like a certain gender, whereas gender identity was an internal choice of a gender term. Only 1 percent of the participants declined to answer the gender-related questions, indicating high acceptance. At ages 10 to 11, approximately 80 percent of participants identified with their sex assigned at birth. By ages 13 to 15, this distribution became more varied across gender identity.

Dr. Potter described the questions about sexual orientation. At baseline, participants were asked whether they identified as gay or bisexual. Over time, they expanded these questions to include a broader range of sexual attraction and identity. Whereas at the two-year mark, just over 8 percent of participants identified as gay or bisexual, more than 25 percent identified as such by the five-year mark. Later in the study, they added a question that framed sexuality by attraction—the results of which were consistent with the measure for sexual orientation. Dr. Potter emphasized that these data provided a unique opportunity for investigators to advance research on SGM youth.

Mental Health and Suicide Research with LGBTQ+ Young People

Derrick D. Matthews, Ph.D., M.P.H., (he/him), Director of Research Science, The Trevor Project

Dr. Derrick Matthews talked about The Trevor Project’s mission to prevent suicide prevention among LGBTQ+ youth through crisis services and research. Their research priorities span three areas: 1) knowledge acquisition—through monthly research briefs and peer-reviewed manuscripts, 2) internal knowledge sharing—ensuring that research supports their crisis services and other activities, and 3) external knowledge sharing—to ensure that their research is accessible to people outside of the organization.

Dr. Matthews presented key findings from their 2024 U.S. National Survey on the Mental Health of LGBTQ+ Young People. More than 18,000 participants aged 13 to 24 and living in the U.S. were recruited via social media. The participants completed a comprehensive survey of approximately 134 questions offered in both English and Spanish. The survey revealed that nearly 40 percent of LGBTQ+ youth seriously considered suicide, and 12 percent had attempted suicide in the past year. Among these, individuals under the age of 18 were the most likely to consider and attempt suicide. There were differences across sexual orientation, with those identifying as queer, pansexual, or questioning youth having the highest rates of considering and attempting suicide. Across gender identity, transgender, non-binary queer, and questioning youth had the highest rates of considering and attempting suicide. Across race, Native and Indigenous LGBTQ+ youth overwhelmingly had the highest rates of considering and attempting suicide, followed by those who identified as multiracial. The majority of LGBTQ+ youth reported experiences of anxiety and depression.

Dr. Matthews emphasized the need to capture diverse gender identities and sexual orientations in research to help disentangle the experiences of diverse subgroups. He also emphasized the importance of capturing intersectionality. He noted that The Trevor Project was changing their survey to be administered every other year instead of every year so that they could engage in additional research efforts such as longitudinal, qualitative, and state-level studies.

Longitudinal Research Involving Trans and Non-Binary Youth

Johanna Olson-Kennedy, M.D., (she/her), Keck School of Medicine of USC, Children’s Hospital Los Angeles

Dr. Johanna Olson-Kennedy started by highlighting challenges in trans and non-binary youth research. First, the number of trans and non-binary youth accessing services was very small. In the U.S., 2017 to 2021 marked the first five years in which there was a real increase of people accessing puberty blocker services—but this still represented less than 5,000 people. Gender-affirming hormone services started increasing a few years earlier, but only 14,000 youth were receiving these services. With more than 120,000 youth receiving a diagnosis of gender dysphoria during these years, the number of youth receiving services represented less than 10 percent.

Another challenge was the ability to conduct longitudinal research. Data beyond 5 to 7 years after utilization of these services were scarce because the services among youth were relatively new. Further, data collection for transitioning youth could be a challenge as these individuals aged out of pediatric care. There were also ethical challenges in using control arms in studies because of the strong evidence of the benefits of these services. The current bans on youth care and data misinterpretation by anti-trans groups also limited the ability to collect data.

Dr. Olson-Kennedy shared preliminary findings from the NIH-funded Trans Youth Care study, an observational study that began in 2015 with 84 youth using puberty-blocking services and 315 youth starting gender-affirming hormones. Two-year data showed that the youth had stable mental health (assessed with the NIH Emotional Health Toolbox) before and after services, with some reductions in rule-breaking behaviors. Dr. Olson-Kennedy noted that these youth often had strong parental support, which was crucial for both their mental health and access to services. She also noted that most participants were non-Hispanic white individuals and called for investigators to explore how to increase access to these services among communities of color. Although the use of puberty blockers was being attacked in the U.S., this research showed the tremendous benefits the services can have on this community.

Challenges in Measuring Sexual Orientation and Gender Identity in Youth and Young Adults

Gregory Phillips II, Ph.D., (he/him), Feinberg School of Medicine, Northwestern University

Dr. Gregory Phillips expressed enthusiasm for the CDC’s YRBS as a tool for better understanding SGM youth. The YRBS was a biennial survey that assesses health behaviors among high school students in the U.S. YRBS was both a national survey managed by the CDC and a jurisdictional survey that states and jurisdictions could alter to suit their local needs. In 2015, questions about sexual orientation were added. In 2017, questions about transgender identity were piloted in certain jurisdictions.

Dr. Phillips talked about a particular challenge in the YRBS—the “not sure” category for sexual orientation created confusion. In 2019, 3.2 percent of high school students responded, “not sure.” However, the response could indicate uncertainty about sexual orientation, a lack of understanding about the question, or dissatisfaction with the answer options. In 2021, the YRBS was updated to break “not sure” into three distinct categories: 1) “I describe my sexual identity some other way,” 2) I am not sure about my sexual identity or questioning,” and 3) “I do not know what this question is asking.” This change allowed for a better understanding of responses. As another example of the importance of precise sex and gender definitions, Dr. Phillips explained how the 2017 pilot of transgender status paired with a binary question about sex (male or female) created a challenge of not knowing whether an individual identified as trans male or trans female.

Dr. Phillips reviewed his research on the impact of the COVID-19 pandemic on youth under the RADx-Up initiative, which revealed significant mental health challenges related to disrupted developmental processes such as identity formation and community building, exacerbated stigma, and loss of autonomy. However, there were some positives during the pandemic, including finding online communities and having an opportunity to come out to their families. He concluded by advocating for using existing data such as the YRBS, an expansive list of SGM identity questions to allow respondents to pick multiple terms, a recognition that identity can change over time, and a focus on mixed-methods research to contextualize findings.

The Common Intersection of Autism and Gender Diversity

John F. Strang, Psy.D., (he/him), Children’s National Hospital, George Washington University School of Medicine and Health Sciences

Dr. John Strang talked about the intersection between gender diversity and autism. Gender-supporting clinicians had been observing a significant overlap between gender diversity and autism for more than 20 years. As of 2024, more than 50 studies had been conducted on this intersection, and a 2023 meta-analysis indicated that approximately 11 percent of gender-diverse individuals were diagnosed with autism as compared to 2.3 percent of the general population. Dr. Strang emphasized that this intersection was also evident at the trait level, with a significant relationship between both autistic and gender diversity traits among individuals who were not diagnosed as autistic or who did not identify as gender diverse or transgender.

There was a disparity in the timing of autism diagnosis between cisgender and gender-diverse individuals, with a 4- to 6-year delay among gender-diverse youth as compared to their cisgender peers. This delay created missed opportunities for early intervention, which was associated with a greater mental health burden and poorer quality of life. This was particularly challenging among transgender youth, who already faced significant stressors. One potential reason for the later diagnosis was that the social challenges could be misattributed to transgender identity, delaying referral for diagnosis and support. Another potential reason was related to the association between late diagnosis and higher verbal IQ status. Gender care providers had also observed a subset of transgender youth who appeared to be at the margin of an autism diagnosis, with notable social challenges only emerging during middle childhood and adolescence.

Functional magnetic resonance imaging (fMRI) studies of the default mode network had shown differences in connectivity between autistic and non-autistic individuals. Dr. Strang’s research team found a stair-stepped pattern in neural connectivity, with non-autistic transgender youth showing the least connectivity, subclinical transgender youth showing more connectivity, and autistic transgender youth showing the most connectivity. Dr. Strang reviewed two theories for this finding: 1) there was a biological link between certain prenatal hormones and the likelihood of both autism and gender diversity, and 2) autistic people may be less driven by social gender norms. He noted that autistic transgender advocates called for a research focus on the needs of this community rather than an etiology. Dr. Strang said that it was important for researchers to consider the proportional overrepresentation of autism among gender-diverse communities, to identify personalized care approaches to meet their unique clinical needs, to characterize this overrepresentation—particularly in the interpretation of research findings, and to conduct longitudinal research on the impact of transgender limiting legislation.

Discussion

Dr. Kathleen Ethier reflected on the panel presentations, noting that:

  • The quality and types of available data have improved over the last decade, which has benefited research on the SGM youth community. For instance, transgender identity data will be included for the first time in the 2023 YRBS, which will be released in August 2024.
  • It was not easy to change many data surveillance systems. For example, YRBS survey questions were decided by a balloting process through coordinators from all states. While this could protect the survey questions from being changed through political mechanisms, it could also limit the ability to include how young people identify themselves in a timely manner. There remained a need to include more comprehensive LGBTQ+ questions to include diverse identities and emerging issues.
  • Research efforts using existing data sources, such as the YRBS, the ABCD Study, or data from the Trevor Project survey, could provide valuable insights. Specifically, there was a need to address the societal impact of supportive and unsupportive policies on developmental and emotional outcomes among SGM youth. For example, YRBS data collected information about school policies and practices, which showed that schools with safe spaces for LGBTQ+ youth saw decreases in depressive symptoms and suicidal thoughts, behaviors, and attempts.

Dr. Ethier welcomed panelists to a Question and Answer session.

Question: Is it getting better?
Answers: Dr. Potter said there was a parallel between the YRBS school data and ABCD data analyzing anti-gender law policies across the state. About half of the students lived in states with negative laws, which was associated with higher rates of interpersonal violence, bullying, and harassment at school—not only among gender-diverse youth but among all youth. Dr. Ethier noted that the data showed that what was good for one group of youth was good for all and, conversely, what negatively impacted one group also negatively impacted all. This spoke to the interconnected nature of young people and demonstrated the broader impact of targeted policies.

Dr. Olson-Kennedy said that the answer was yes and no. While understanding was improving and access to care was becoming more available, there was also pushback on care specifically for trans and non-binary youth. She noted that her team’s multisite R01 study had received nine FOIA requests, which took time and resources to respond to. Additionally, pediatric hospitals that offered youth care clinics were unprepared to take on the political challenges. For example, these hospitals were absorbing patients from other states, and there was not enough capacity to do so.

Dr. Meyer said that things were getting better in terms of public attitudes around sexual orientation if not transgender issues. However, the lives of LGBTQ+ people were not necessarily getting better. It was important to consider microenvironments because policies did not penetrate the everyday lives of every person. Additionally, many religious organizations had a negative impact on LGBTQ+ people. It was important to remember that history did not bend towards justice but rather dueling forces. The advances of one side escalated the response of the other side.

Question: How can clinicians and others working with LGBTQ+ youth translate research into practice?
Answers: Dr. Matthews answered that the ability to assess common co-occurring needs and challenges, such as housing insecurity, could be addressed in clinical settings, and clinicians could prepare themselves to refer their patients to the right services. There were also ways to engage the community in conversations rather than just clinical assessments, which might make it easier for young people to share their challenges and feelings. There was also a lot of individual and community-level resiliency that could be leveraged and learned from to help clinicians when talking to young people.

Dr. Strang added that it was important for clinicians to acknowledge the high disparity in access that LGBTQ+ people experienced. There were often waitlists of one to two years for those seeking a gender consultation—even in metropolitan areas. It could be idealistic to talk about the application of research into practice when there was still a crisis in access.

Dr. Olson-Kennedy said that access to mental health services was also desperately needed, particularly in service deserts—not just among trans youth, but all youth. It was important to note that the population of youth needing these services was also increasing.

Question: What could be done to promote more diverse activities in school environments? How would school initiatives that support LGBTQ+ youth impact the school environment more broadly?
Answer: Dr. Ethier said that the CDC DASH had been making progress with LGBTQ+ youth in schools, but that arc of progress had changed in the last two years. Considering the youth mental health crisis at large, there was a need to call attention to how school-based LGBTQ+ laws and practices were doing harm to all young people. She hoped these policies would shift back to what the CDC knew was supportive, such as places for youth to gather and share their identities, accessible and identifiable safe adults, and policies against bullying and harassment. They had also heard that teachers and school staff can feel discrimination in schools with negative laws and practices. Some had even lost their jobs as a result. It was important to support not just the young people but also the adults.

Question: Are there shifting expectations of what constitutes well-being in general? For example, younger LGBTQ+ individuals may have higher expectations for how they should be treated.
Answer: Dr. Meyer said that the data indicated that it was not just about changing expectations but rather very serious, objective measures of health and well-being that were not being met by the education system. Suicide data on LGBTQ+ youth was a type of thermometer for progress, but the data had been disappointing. The problem was not about expectation gaps but of delivery gaps.

Dr. Olson-Kennedy commented on the importance of social media and the ability of young people to connect and provide support for each other. Social media algorithms were always talked about as bad, but they could also be valuable for young people looking for community. In terms of schools, if there continued to be an erasing of progress, such as the availability of certain books, it would be problematic not just among LGBTQ+ youth but all youth. It was important to remember that anti-racism and broadening minds needed to be a built-in effort, not a tacked-on one.

Social and Structural Determinants of Health: Community, Culture, and Policies

Discussant: Brian Altman, J.D., (he/him), Director, National Mental Health and Substance Use Policy Laboratory, Substance Abuse and Mental Health Services Administration (SAMHSA)
Moderator: Crystal L. Barksdale, Ph.D., M.P.H., (she/her), Division of Community Health and Population Science, National Institute for Minority Health and Health Disparities (NIMHD)

In Harm’s Way: Multilevel Stigma and Depression Among a National Sample of U.S. Black and Latino/x LGBTQ+ Adolescents

Skyler Jackson, Ph.D., (he/him), Yale School of Public Health, Yale University

Dr. Skylar Jackson talked about the significant mental health disparities experienced by LGBTQ+ adolescents. Although there had been a history of misattributing mental health disparities among LGBTQ+ individuals to their sexuality or gender identity as a pathology, today, there was a recognition that social stigma drives and sustains these disparities. Dr. Jackson talked about two major gaps in the literature. First, there was unequal attention to how different levels of stigma manifest to drive mental health disparities. Specifically, structural stigma, or the stigma rooted in discriminatory laws, policies, and oppressive norms, was given less attention than interpersonal stigma (everyday experiences of bias, discrimination, and bullying) and internalized stigma (negative societal attitudes internalized as homophobia or transphobia). Second, there was inadequate attention on how the intersection of multiple minority statuses could uniquely impact mental health.

To address these gaps. Dr. Jackson’s team conducted a study of the effects of different forms of stigma on depression among Black and Latino/x LGBTQ+ individuals. The study used data from more than 2,500 participants aged 13 to 17 from the National Survey on LGBTQ+ Young People. They found that more racial/ethnic bullying and sexual orientation bullying (both considered forms of interpersonal stigma) were associated with higher odds of recent depression. However, those who experienced both forms of bullying were nearly 2.5 times more likely to have experienced recent depression than those who experienced neither form of bullying.

Next, they sought to develop a state-level structural stigma index for LGBTQ+, using seven different areas of protective or harmful state-level policies that informed a composite index score. They found that Black and Latino/x LGBTW+ adolescents who lived in the most stigmatizing states had a 32 percent greater likelihood of recent depression. Dr. Jackson noted that the data used for the index was from 2017 and that there had been an increasing number of harmful state-level policies in some states since then. As of last week, the American Civil Liberties Union (ACLU) was tracking more than 500 anti-LGBTQ+ bills across states.
 

>Latinx LGBTQ+ Youth and Their Families and Communities: Contextualizing the Role of Cultural Values and Traditions

Roberto L. Abreu, Ph.D., (he/him/él), Department of Psychology, University of Florida

Dr. Roberto Abreu talked about the role of cultural values and traditions in the interactions between Latinx youth and their families. He underscored the necessity of understanding these cultural nuances in research rather than viewing all LGBTQ+ individuals and their family relationships as homogeneous. Research showed that family acceptance of LGBTQ+ youth leads to positive outcomes such as positive identity development, higher self-esteem, and better mental health outcomes. Conversely, more rejection leads to higher substance use, more sexual risk-taking, and internalized stigma. However, most research looked at the experiences of LGBTQ+ individuals and their white mothers. Very little was known about their relationships with fathers, and even less was known about the experiences of families of color. Studies that do consider families of color often compared them to their white counterparts rather than capturing their unique culture and traditions.

Dr. Abreu explained that this research focus created a narrative that communities of color were more homophobic, transphobic, and biphobic—presenting white communities and white families as safer and more accepting. He conducted a series of qualitative and quantitative studies to fill this research gap. He found that family support and harmony were nuanced, involving complex family dynamics. Traditional gender norms, such as machismo and family loyalty, played a significant role in how families interacted with their LGBTQ+ children, and reframing those norms within a cultural context could help families accept their LGBTQ+ children. Respect for elders, dignity, religion, and spirituality were other key cultural factors in family acceptance. Families could embrace, reject, or reframe their beliefs to support their LGBTQ+ children.

Dr. Abreu’s research emphasized that parental and family acceptance of LGBTQ+ individuals was not universal and that cultural values and traditions significantly influenced these relationships. He advocated for culturally specific interventions and future research to further explore how different cultural values could interact with systems of oppression to impact the mental health of LGBTQ+ youth.

Mental Health Needs of LGBTQ+ Youth Involved in the Criminal Legal System

Jane Hereth, Ph.D., (she/they), University of Wisconsin, Milwaukee

Dr. Jane Hereth highlighted the overrepresentation of LGBTQ+ youth in the criminal legal system and the negative mental health impacts that result from this involvement. She noted that while approximately 9 percent of youth in the U.S. identified as LGBTQ+, 20 percent of youth within the juvenile justice system identified as LGBTQ+ and gender nonconforming. Further, 85 percent of LGBTQ+ and gender nonconforming youth in the criminal legal systems were youth of color. Once inside the system, these youth often faced a range of adverse outcomes and traumatic experiences. They encountered discrimination and bias at multiple levels—including police, lawyers, judges, facility staff, and other youth. This discrimination led to increased surveillance, harsher sentences, and worse treatment—all of which significantly impacted their mental health. Once inside, these youth were often hypervisible, segregated, and routinely denied gender-affirming and other health care.

Dr. Hereth talked about three pathways to the criminal legal system: the criminalization of LGTBQ+ individuals, the school-to-prison pathway, and criminalized survival. In terms of the criminalization of LGBTQ+, bias and stigma contributed to perceptions that LGBTQ+ were deviant, resulting in laws targeting LGBTQ+ communities, increased surveillance, and unjustified arrests. This, in turn, led to an inherent mistrust of police and the legal system among LGBTQ+ youth. The school-to-prison pathway describes the direct and indirect impact of policies that push students out of school and into the criminal legal system. School policies such as zero-tolerance and police presence contributed to disproportionate rates of detention, suspension, and expulsion, particularly among LGBTQ+ youth of color. This led to an avoidance of school, conflicts at home, involvement in the child welfare system, and eventually homelessness. Criminalized survival described behaviors such as theft, panhandling, and sex work that were needed to survive family rejection, homelessness, unemployment, poverty, and discrimination.

Dr. Hereth noted that, despite these adverse experiences, LGBTQ+ youth were incredibly resilient but should not have to be to survive. Interventions along the three pathways were needed to keep these youths from involvement in the criminal legal system in the first place. These interventions could include increasing LGBTQ+ affirming practices and services across all contexts (i.e., mental health services, schools, the child welfare system), as well as holding the criminal legal system accountable for bias and victimization. Individuals could resist anti-LGBTQ+ policies, whether locally in schools or nationally in elections.

Youth with Diverse SOGIE and Public Systems Involvement: Research/Practice Gaps and Opportunities.

Dana Prince, Ph.D., (she/her), Case Western University

Dr. Dana Prince presented on suicide risk among SOGIE youth who were involved in the child welfare system. There was a well-documented heightened risk of suicidal thoughts, behaviors, attempts, and deaths among SOGIE youth. SOGIE youth were also more likely to enter the child welfare system, have more placements within an episode of care, and have more episodes of care than their heterosexual and cisgender peers. SOGIE youth were also more likely to have adverse outcomes upon exiting care and lower reunification rates with their families of origin. Between 16 and 32 percent of youth in child welfare or juvenile justice systems were SOGIE. Regardless of sexual identity or gender identity, 25 percent of individuals involved in foster care or juvenile court reported lifetime suicidal ideation—double that of their non-involved peers. They were also at three times greater risk for suicide planning, attempt, and death. There had also been an alarming trend in increased suicide attempts among Black boys and the fastest increase in suicide behaviors among Black girls.

Therefore, Dr. Prince focused her research on the nexus of being LGBTQ+ and being involved in child welfare or juvenile court with suicide risk. She highlighted the complex interplay of factors that led to the overrepresentation of SOGIE youth in the child welfare system, underscored by three drivers: harmful policies and practices, abuse and neglect, and familial rejection. She talked about the reinforcing loop of being “hard to place,” which involved a greater likelihood of being placed in restrictive care settings such as group homes or residential treatment facilities or rejection from lower care settings such as foster homes back into more restrictive settings.

Dr. Prince spoke about a demonstration project in Cuyahoga County aimed at transforming child welfare practices to support SOGIE youth. Central to the project was safe identification, which ensured that the appropriate questions were being asked to accurately identify SOGIE at risk of suicide. With safe identification, they were able to identify 20 percent of SOGIE youth entering child welfare, as compared to 3 percent before safe identification. In addition to safe identification, the project promoted coordinated mental health referrals to affirming peer support—that is, individuals with lived experiences as SOGIE youth who had overcome their suicidal ideation. Dr. Prince emphasized the need for systemic changes to address the unique challenges of SOGIE in the child welfare system, as well as the need to use community assets and peers to improve outcomes among this vulnerable population.

State Policy, School Environments, and the Mental Health of LGBTQ+ Youth

Kerith Conron, Sc.D., (she/her), Williams Institute, UCLA School of Law

Dr. Kerith Conron made a call for action to understand and address the impact of public policies on LGBTQ+ youth in high school—a particularly vulnerable group because of their dependence on parents and compulsory school attendance. When given a choice, LGBTQ+ individuals will seek more supportive environments. For example, LGBTQ+ individuals were four times more likely to choose a four-year college in a more supportive state than their non-LGBTQ+ peers. However, high school students did not have that choice, making it critical for high schools to provide a safe space to learn.

Over the years, there had been changes in the number of both protective and harmful laws that impacted LGBTQ+ high school students. On the positive side, 21 states had anti-bullying laws that protected LGBTQ+ youth, which had been shown to improve mental health and reduce suicide risk. On the negative side, seven states banned any discussion about LGBTQ+ people or issues, enacted restrictions on LGBTQ+ curricula, and banned the use of gender identity pronouns. Eight states passed parental notification laws that would out trans students to their parents. Dr. Conron talked about a study using 2021 Access to Higher Education survey data. Among the 18- to 24-year olds who were asked to look back to their high school years, more LGBTQ+ than non-LGBTQ+ people experienced depression, anxiety, bullying, and sexual harassment and assault. Fewer LGBTQ+ than non-LGBTQ+ people reported feeling a sense of belonging, and very few reported the presence of a gay-straight alliance.

Dr. Conron noted the importance of not only monitoring bullying and sexual assault experiences but also the perpetrators and contexts involved in order to make high schools safer. There was also a need to monitor high schools broadly and robustly to have a dataset large enough to study the impact of public policies. She also expressed gratitude for the inclusion of a question about ACEs in the YRBS and called for those questions to also be included in state core surveys to assess the effects of policy environments and school climates on student mental health. She advocated for large-scale studies to assess the impact of both protective and harmful policies and stressed the importance of developing effective anti-bullying strategies and promoting socio-emotional competencies.

“It Makes me Feel Hopeless”: Anti-Trans Policies and the Mental Health of Gender Diverse Youth

Megan Pacely, Ph.D., (they/them), University of Connecticut
Spencer Evans, L.M.S.W., (she/her), University of Connecticut

Ms. Spencer Evans discussed the state of research on state-level legislation and its impact on LGBTQ+ youth. Since 2021, there had been an onslaught of anti-trans legislation in states across the U.S. Starting in 2021, 125 proposed state policies aimed to limit access to affirming school and healthcare support for transgender and LGBTQ+ youth. By the first half of 2024, more than 600 proposed bills across 42 states had impacted nearly 300,000 young people. Notably, Florida was the only state to receive a do-not-travel designation due to laws that allowed for the arrest of transgender people who use bathrooms associated with their gender identity and not their sex assigned at birth. Other legislation aimed to restrict access to gender-affirming care for minors, name and gender changes, use of gender-specific places, and sports involvement on gendered teams. Some legislation required public institutions to inform parents of their child’s pronoun or name changes at school and mandated the use of names and pronouns assigned at birth.

Dr. Pacely talked about the dearth of research on the impact of these policies on LGBTQ+ youth. One study from The Trevor Project that used data from early 2021 found that LGBTQ+ youth reported significant impacts of legislation on their mental health and well-being. Nearly half of families with trans youth considered moving to a different state. In a follow-on study that aimed to quickly understand the impact of the rapidly-shifting legislation, three themes emerged from focus group discussions: 1) perceived impacts on mental health—with participants expressing feelings of sadness and hopelessness, 2) structural supports—such as increased barriers to affirming care and decreased access to safety, and 3) messages they wanted to share with policymakers. Dr. Pacely presented some of the voices of lived experience as examples of the impact these policies had on daily lives. They also talked about the importance of engaging youth as research partners throughout the process.

Dr. Pacely emphasized that the harm was not only a result of policies but also the rhetoric and stigma associated with the proposed legislation. They called for more research in this area, particularly cross-sectional and longitudinal studies, and an examination of the decision-making processes for families in high-risk states. They also recommended research on how medical and mental health providers support trans and LGBTQ+ youth in light of these policies and increased funding opportunities to support these studies.

Discussion

Mr. Brian Altman reflected on the presentations and recent federal actions, noting that:

  • The higher rates of behavioral health conditions among LGBTQ+ youth were related to the stigma, discrimination, bullying, and harassment associated with their identities.
  • The 988 Suicide & Crisis Line had a line dedicated to LGBTQ+ people, who could text PRIDE to 988 to receive specialized services.
  • More research was needed to understand and address the underlying factors that impacted mental health and well-being among LGBTQ+ people.
  • Because family acceptance and support were key, SAMHSA launched a grant opportunity focused on LGBTQ+ family support.
  • Interpersonal interactions were compounded by structural stigma driven by anti-trans and anti-LGBTQ+ legislation. Structural factors were also involved in the disproportionate number of LGBTQ+ youth in child welfare and juvenile justice systems.
  • The Administration for Children and Families (ACF) recently released a Designated Placements rule that child welfare and foster care systems must provide LGBTQ+ youth with a placement that is supportive and affirming.
  • CDC recommended that the stigma and discrimination that LGBTQ+ youth experience should be considered ACEs.
  • SAMHSA did not use the term conversion therapy but rather sexual orientation and gender identity change efforts. Aligned with this language, SAMHSA released the Moving Beyond Change Efforts, which outlined an evidence-based roadmap for supporting and affirming LGBTQ+ youth.
  • Further research was needed on policy environments, cultural norms, anti-LGTBQ+ rhetoric, and the intersection of systems and identities.

Mr. Altman invited panelists to participate in a Question and Answer session.

Question: Compounding stigma is harder for those who are disabled, Two Spirit, and LGBTQI+. How can the experiences and impacts on multiple stigmatized identities be addressed?
Answer: Dr. Prince talked about NIH’s recent move toward the inclusion of more disability research, which was shaped by people with disabilities, disability leaders, and activities, as well as intersectional oppression. It was important to consider the queer disability culture and how it could inform how to share resources and care for one another. There was also an opportunity to recognize that disability involved multiple cultures, not just a single checked box.

Dr. Conron added that investigators with R01s should encourage students with disabilities and other identities to write supplemental grants for smaller projects within the R01 mechanism.

Question: Are there more opportunities to apply for family support grants?
Answer: Mr. Altman answered that the open competition ran last spring and summer. SAMHSA received 53 applications, but only had funding for four grants. SAMHSA later found additional funding to support another four grants, but no additional funding was available at this time to post a new notice of funding opportunity.

Panel Discussion with Youth-Serving Organizations

Moderator/Discussant: Tamar Mendelson, Ph.D., (she/her), Bloomberg Professor of American Health, Director for the Center for Adolescent Health, Bloomberg School of Public Health, Johns Hopkins University
Moderator: Stacia Friedman-Hill, Ph.D., (she/they), Division of Translational Research, National Institute of Mental Health

Advocates for Youth

Louie Ortiz-Fonseca, M.A., (he/they), Director, LGBTQ Health & Rights
Sebas Abbate, (they/she/he/ella), LGBTQ+ Youth Activist, YouthResource Council

Mx. Louie Ortiz-Fonseca said that Advocates for Youth was primarily known for championing to ensure that all young people had access to affirming, factual, inclusive sex education. They worked with community-based organizations, organizing groups, national organizations, and a collective of youth activist cohorts/councils. Some youth activist cohorts included Young Women of Color 4 Reproductive Justice Collective, Muslim Youth Leadership Council, Engaging Communities Around HIV Organizing (ECHO), and YouthResource Leadership Council.

Mx. Sebas Abbate talked about their experience as a cohort member of Youth Resource, which worked with young people on HIV prevention. They also hosted their young adult program, providing a safe social space, and a sexual health and education program called Pride and Pleasure. Mx. Abbate talked about their work in the context of living in Florida and the need for safe spaces.

Human Rights Campaign

Ted Lewis, M.Ed., (they/them), Director of Youth Well-Being
Kei Smith, (she/they), Human Rights Campaign Youth Ambassador

Mx. Ted Lewis said that the 501(c)4 entity of the Human Rights Campaign conducted political organizing to help pro-equality officials get elected. The 501(c)3 entity worked on education and advocacy for LGBTQ+ communities, with several programs focused on youth and young adults. They also had a Historically Black Colleges and Universities (HCBU) initiative and an All Children – All Families program that worked on child welfare and foster care systems. Some of their new initiatives included their Economic Empowerment Programs, including Next Level, which supported young adults around financial wellness and job readiness. They also conduct a survey every five years in collaboration with the University of Connecticut, which provides them with data on LGBTQ+ youth across the country. Youth Ambassadors were another important part of their program.

Mx. Kei Smith talked about her experience in the Youth Ambassador program, a group of youth activists who worked in their communities and with other Youth Ambassadors to pool resources and ideas.

It Gets Better

Justin Tindall, (he/they), Senior Director, Programs and Operations
Rae Sweet, (they/them), Senior Coordinator, Education
Alejandro Jiménez de Ferry, (he/him), It Gets Better Alumnus

Mx. Justin Tindall said that the mission of It Gets Better was to uplift, empower, and connect LGBTQ+ youth around the globe through storytelling and community building. It Gets Better was best known for its digital storytelling, which provided positive messages of hope from members of their community and helped them navigate the current environment. They also had a program called 50 States. 50 Grants. 5,000 Voices., which distributed grants of up to $10,000 to schools across the U.S. The program had distributed more than $1 million over the last two years. They also recently launched Queerbook, a compilation of poetry, art, photography, and other elements.

Mx. Rae Sweet talked about their community engagement in schools and resources that educators could use to bring their stories into the core standards for classrooms. One of their programs was Youth Voices, a group of LGTBQ+ youth who attend skill-building workshops to help build their confidence in storytelling and connect them with opportunities to tell their stories to the public.

Mr. Alejandro Jiménez de Ferry said that participating in It Gets Better was one of the highlights of his high school career because it was the first time in his life that someone like him was able to tell his story. He also contributed to the Queerbook. He noted that there were a number of Latin American chapters of It Gets Better across the world for Spanish speakers.

True Colors United

Aleya Jones, M.Ed., (she/her), Senior Policy Officer

Ms. Aleya Jones said that True Colors United implemented innovative solutions to youth homelessness by focusing on the experiences of those who were most impacted—LGBTQ+ and BIPOC youth. One of their activities focused on ending youth homelessness, led by a group of young people who contributed to the national dialogue on how to make youth homelessness rare, brief, and non-reoccurring. This ensured that the conversation was informed and filtered through the perspectives of young people who experienced homelessness. Another activity was their state-based work advocating against the rampant anti-LGBTQ+ and anti-trans legislation, focusing particularly on the dangerous trends impacting youth and young adults.

Discussion

Dr. Tamar Mendelson invited the panelists to a Question and Answer session.

Question: There has been a lot of discussion about the challenges that LGBTQ+ youth face right now. What about the sources of joy?
Answer: Mr. Jiménez de Ferry said that queer media was at an all-time high and provided examples such as the movie Bottoms which had representation of queer and women of color, as well as performing artists such as Billie Eilish, Chappell Roan, and Reneé Rapp. It had been eye-opening to discover how many queer celebrities there were, and it made him wonder what the future held with so many trailblazers forging a path for others.

Mx. Smith added that they found queer joy through solidarity between communities. For instance, they worked at a domestic violence organization for Asian American women and trans people, which largely catered to cis-gendered women but had also been reaching out to queer people in the Asian community. There had been a large shift toward creating spaces for intersectionality in general. Although there was a lot of depressing news, there was also a lot of good work happening.

Mx. Tindall talked about a research study showing that a greater percentage of children and young adult books had an animal as the protagonist than an LGTBQ+ person. However, this was rapidly changing. They had also been hearing from young people that there were now spaces where they felt safe to be themselves, such as table gaming, crafting, and photography. It was a silver lining to the legislative attacks—despite the negative rhetoric, LGBTQ+ youth were finding spaces where they could thrive and connect with others like them. This was radically different from the experiences of previous generations.

Mx. Abbate echoed that there were more in-person gatherings and safe spaces that have been bringing them joy. A lot of the youth they work with did not come from safe homes, and it had been important to provide them with spaces to be themselves without worrying about family or protestors. Pride Month also provided a lot of opportunities for safe spaces, even in Florida. It was also very important that the spaces were created by the youth in order not to feel like they were being catered to with pink-washing or queer-capitalism.

Ms. Jones talked about the idea of “collective care,” which involved leaning on each other to find different supports and resources. There was a sense of obligation in the community to not only check on oneself, but also other people. Collective care meant that people did not have to go through it alone. Although society tended to be very individualistic, it was important to uplift the message that people could get through the challenges collectively.

Question: From your organization’s perspective, how are you seeing LGBTQ+ youth contributing to their communities?
Answer: Mx. Ortiz-Fonseca answered that there had always been a certain kind of young person who was elevated or provided a space at the table, but there was a question of what they could do to move things and be taken seriously. This had changed with the advent of social media. The LGBTQ+ culture had been reminded of its Black roots and had a space to be unapologetically Black without having to code-switch to gain space at the table. It had helped expand the conversation about what it was like to be queer beyond coming out. Mx. Ortiz-Fonseca spoke about being a young person who had always wanted conversations about mental health and growing up with parents with addictions. While that was not a conversation that could be had in the 90s, it was a conversation that was happening now. The conversation was about the experience of an LGBTQ+ young person, particularly among those of color, as a whole or a sum of their parts. They added that young people had developed toolkits about how to divest from policy and invest in sex education. It was important to amplify and expand the work the young people accomplished while also supporting their emotional and mental health. Their organization did not provide a direct service, but they still felt a responsibility to support their young leaders. This could mean providing workshops on protest safety or aid to those who had lost their jobs. Community care was foundational to LGBTQ+ identity.

Mx. Tindall agreed and added that adults who worked in major institutions tended to think they had the answers about what was best for LGBTQ+ youth, but this was not always the case. Great intentions did not always lead to great success. The most success they had seen was when they handed the mic or the reins over to the youth. It was important not to prescribe what a community needed with grant funding, for instance, but rather to ask the community what they needed to make school environments more welcoming. It was critical to truly listen and believe the youth knew what was needed to make a program successful. They encouraged researchers to work with LGBTQ+ youth, take the time to listen, and learn and grow from what they had to share.

Mx. Sweet talked about the LGBTQ+ youth who contacted It Gets Better to become a youth voice, expressing interest in making a TikTok, writing a blog post, contributing to Queerbook, or applying for a grant, for instance. They had also seen young people testify in public hearings and speak at rallies. There had been so much energy, passion, dedication, and fearlessness that it was incredible to see in light of what was happening politically.

Mx. Lewis said that it was easy to forget that goalposts moved with progress. For instance, older generations never thought they would see same-sex couples getting married. However, this was a reality for younger generations, and that particular goalpost was well behind them. Therefore, touting that as progress was not helpful for LGBTQ+ youth of today, particularly in states such as Florida, Texas, and Tennessee. It was helpful for older generations who had been working in this movement for a while to recognize that past victories did not always impact the lived experiences of young people. It was also important to recognize that living in a hostile state often came with a certain level of resistance that young people often did not understand. A young person could post on TikTok and reach millions of people. Their voices had a way to reach places people could not before, and sharing their experiences and inviting others to share their experiences made a huge difference. Mx. Lewis noted that many parents had mentioned being able to understand their child who had come out because someone else in the neighborhood already had. Youth could be role models for each other, often more so than adults. Simply being out and proud in a hostile state was a form of resistance. Even small things, such as wearing a pronoun pin or displaying pronouns on a TikTok profile, mattered.

Mx. Tindall added that society often thought of queer issues as adult issues. Therefore, a lot of the attacks had focused on adults, whether through housing or job discrimination or attacks against marriage equality. However, more young people were coming forward, sharing their stories and perspectives, and talking about what they needed and wanted. The attacks were now focused on young people, somewhat like retribution for speaking up when they had previously been an invisible subpopulation. As unfortunate as that was, these young people were resilient, determined, passionate, and energetic. They were not going to let up, even if the attacks continued. They were making a difference in their communities.

Question: How do your organizations work with others to amplify and coordinate efforts to strengthen collective impact?
Answer: Mx. Lewis said that the Human Rights Campaign did not have the best record of partnering, in part because of the way the nonprofit industrial complex worked. It could be difficult to partner while still carving out one’s space, finding funding and resources, and paying people to do the work. These were real hurdles in collective work, particularly when these organizations were often underfunded, under-resourced, and understaffed. However, because of the political landscape, there were some opportunities to partner with organizations that were not directly working with LGBTQ+ youth to meet the needs of the moment. For example, the Human Rights Campaign had an initiative called Project Thrive that worked with more than 40 national partners that had pledged to help LGBTQ+ youth thrive. Some were large organizations such as the National Association of Social Workers, the National Education Association, the American Medical Association, Big Brothers, and Big Sisters. There were opportunities to approach these mainstream organizations and ask them to dedicate resources, time, and collateral to help uplift LGBTQ+ youth. LGBTQ+ organizations often heard from others that their work was biased or progressive. When other industries spoke up, it helped with legislation. When people in mental health or physical health professions talked about the harms caused by denying gender-affirming care, for instance, it could go a long way toward turning the tide.

Mx. Smith said that it was important for nonprofits to recognize that there were youth who were organizing grassroots work and that they were successful in making connections and pooling resources. Youth were really good at building communities, and that was something that nonprofits and large institutions could learn from.

Mx. Sweet agreed and added that partnerships helped to fill gaps in organizations that were underresourced and understaffed. For example, It Gets Better partnered with the Hope Lab to connect them with participants in their Youth Voices to help them create a digital mental health resource for LGBTQ+ youth (imi.guide). Another example was an organization called No Filter, which was creating resources for safe online activities for youth. It Gets Better connected them with their youth cohorts to help them create a guide on being safe online as an LGBTQ+ person. It Gets Better also collaborated with corporate partners for career days.

Mx. Ortiz-Fonseca said that everything outward-facing that Advocates for Youth created had to be reviewed by young people. Knowing this helped them consider partners that made the most sense because some things were not in their wheelhouse. For example, mutual aid was not something they could do, but they could pass it off to another organization. It was important that young people served as a guide, deciding what was important for them rather than being told what to do in their community.

Mx. Abbate said it was helpful to have partnerships to expand into the national or digital spaces. It could be limiting to work in a space that was specific to a county or physical space. There could be times when youths wanted to serve, but they were one city too far away. Having national platforms such as HIV/AIDS Awareness Days could help voices reach the ears of those who needed the messages. That amplification was something that could be challenging to do in a small organization.

Question: This workshop is sponsored by NIH, a research organization. What kinds of research questions and data do you wish researchers had that would impact your work?
Answer: Ms. Jones talked about the trends they had seen among SGM youth. For example, there was a lack of comfort and safety that unhoused LGBTQ+ youth faced because many youth shelters were homophobic. In particular, faith-based shelters could be very discriminatory against the trans community. Another trend was the deaths of Black trans youth. It was vital to acknowledge their need to be protected and the violence eliminated. It would also be important to understand what was happening at the state level in terms of anti-LGBTQ+ legislation and how that impacted young people. However, it was not enough to collect quantitative data. It was also important to collect qualitative data—stories to amplify the numbers and let young people use their voices to explain how it felt to be going to school in these times.

Mx. Abbate added that a lot of HIV and safer sex studies did not include the voices of trans-masculine people. Cisgendered women who were in these studies had very different experiences than trans-masculine people. Trans-feminine people had different experiences than cisgender men. The companies doing this research might say that the population was too hard to find, but it was important to find them because they wanted their experiences to be represented and to have safer sexual lives. Mx. Abbate suggested that researchers partner with LGBTQ+ organizations to create that bridge.

Mx. Lewis asked researchers to make their study accessible to the public. Too often, these studies were behind paywalls, and organizations often used their college interns to access the articles. It was also important to translate 500-page research reports into something accessible, such as an infographic or a top line.

Mx. Tindall talked about their work on an advisory committee for Equality California and their Safe and Supportive Schools Report Card, which reported on how well districts in the state were performing in terms of support for LGBTQ+ students. However, that survey was completed by adults who talked about the policies that were in place. If they were to instead ask the LGBTQ+ students whether the policies actually reached them, their answer would likely be “no.” Therefore, researchers should include more perspectives from young people, including recommendations for solutions that accompany the research.

Concluding Remarks

Beshaun Davis, Ph.D., (he/him), Office for Disparities Research and Workforce Diversity, NIMH

Dr. Beshaun Davis thanked the panelists and attendees for their participation and expressed gratitude for learning about all the work being done. He noted some key takeaways he had from the panel presentations, including:

  • Programs targeted toward improving the mental health and safety of LGBTQ+ students also improved the mental health of all students.
  • Despite historical progress, the goalposts had changed, and there were many needs that were not being addressed by current mental healthcare systems.
  • Systems such as child welfare services could put LGBTQ+ youth at a disadvantage, and this challenge was not being fully addressed.
  • There was a critical need for community-engaged research approaches that centered on the perspectives of LGBTQ+ youth.
  • There were many organizations working to empower young people and amplify their voices. This helped to not only focus on a deficit perspective, but also a strengths perspective that leveraged the ability of youth to form communities, share their experiences on media platforms, and have a positive impact on their communities.

Day 2: Welcome

Irene Avila, Ph.D., (she/her/ella), Assistant Director, Sexual & Gender Minority Research Office, NIH
Alison Cernich, Ph.D., (she/her), Deputy Director, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
Helene M. Langevin, M.D., (she/her), Director, National Center for Complementary and Integrative Health (NCCIH)

Dr. Alison Cernich discussed NICHD’s mission to understand human development and improve the lives of children and adolescents, including those with diverse gender and sexual identities. She highlighted the critical need to address the significant mental health disparities that SGM youth face, such as higher rates of depression, anxiety, substance use, and suicide—which was driven by discrimination, stigma, social and structural barriers, and a lack of access to culturally competent care. Dr. Cernich called for accurate and inclusive measures of sexual orientation and gender, research on developmental factors impacting the mental health of SGM youth and evidence-based strategies. She acknowledged the challenges in conducting research with minors and advocated for their inclusion. NICHD’s Population Dynamics Branch supported research on improving sexual orientation and gender identity measures, developing inclusive educational curricula, and preventing dating and relationship violence. NICHD also supported research on factors that influenced youth mental health, such as the stress of the pandemic, cyberbullying, dissatisfaction with family relationships, and unmet medical needs. Dr. Cernich expressed appreciation to the organizers and panelists for making this important workshop happen.

Dr. Helene Langevin expressed gratitude for the opportunity for NCCIH to collaborate with NIMH in this workshop. She noted that the workshop aims aligned with the NCCIH strategic plan, which emphasized research on complementary health to address health disparities and advance emotional wellbeing. One of NCCIH’s key priorities was whole-person health, which considered interconnected body systems, including biological, behavioral, social, and environmental domains. Dr. Langevin underscored the importance of multi-component and preventive interventions that reduce risk and enhance protective factors. She concluded by highlighting two NCCIH funding opportunities. One opportunity evaluated mindful self-compassion among SGM young adults, who often experience gender dysphoria and distress resulting from an incongruence between one’s body and identity. The other opportunity was to develop internet-delivered mindfulness interventions to reduce HIV risk and promote mental and sexual health among young men who have sex with men (MSM).

Community Engaged Research

Discussant: Terrinieka Powell, Ph.D., (she/her), Associate Professor and Vice Chair for Inclusion, Diversity, Anti-Racism and Equity, Bloomberg School of Public Health, Johns Hopkins University
Moderator: Christopher Barnhart, Ph.D., (he/him and they/them), Sexual and Gender Minority Research Office, NIH

TransHealthGUIDE: Transforming Health for Gender Diverse Young Adults Using Interventions to Drive Equity

Sari Reisner, Sc.D., M.A., (he/him), School of Public Health, University of Michigan

Dr. Sari Reisner provided an overview of the community-engaged component of an intervention study that sought to address the significant mental health burden experienced by transgender and gender-diverse (TGD) young people. One of the study components was a free online course to improve provider competencies in addressing TGD youth mental health needs by enhancing their knowledge, attitudes, and communication skills. The second intervention component was an interactive digital platform that provided education on how to promote communication and strengthen relationships between TGD young people and their caregivers. Dr. Reisner and his team leveraged extensive community engagement throughout the research process, including an advisory board of TGD youth and their caregivers, an advisory board of caregivers and providers of SGM young people, and consultations with key stakeholders that served TGD young people. These community members helped assess needs, develop content, and identify potential barriers and facilitators of success in the study.

The community engagement also included survey results from 104 TGD young people enrolled in the study and 33 in-depth interviews with TGD young people, caregivers, and providers. The survey showed that 42 percent of TGD young people screened positive for elevated depressive symptoms. Low family support was the strongest correlate with depression, with a 70 percent higher prevalence of depression among TGD young people with low family support than those with high family support. The survey also indicated that TGD young people preferred information about gender and health primarily from trans peers, with a little more than half seeking information from medical professionals. TGD youth also preferred information from YouTube and Reddit, followed by Twitter, TikTok, and Instagram.

The in-depth interviews with caregivers showed three main themes: 1) navigating relationships with self—in which caregivers expressed feelings of loss and worry about the young person’s changing identity, 2) negotiating relationships with others—which involved the process of disclosing their TGD young person’s identity to extended family and social networks, and 3) educating themselves and others through relationships—which highlighted the importance of connecting through personal narratives with other caregivers to help better support their TGD young person. The interviews also emphasized the importance of linking with other caregivers, educating themselves, and learning how to become an advocate.

The lessons learned from this community engagement informed the development of the intervention components, which incorporated interactive elements such as simulation videos and role-playing. Dr. Reisner underscored the importance of including community voices in research, particularly in light of the passage of several policies that limited healthcare access for TGD young people.

An Intersectional Community Engaged Approach to Conducting Mental Health Research with Latine/x LGBTQ+ Youth Communities

John P. Salerno, Ph.D., M.P.H., (he/him/él), School of Social Work, Columbia University

Dr. John P. Salerno highlighted the mental health disparities experienced by Latine/x LGBTQ+ youth communities. He began by presenting data from the Trevor Project, showing that Latine/x LGBTQ+ youth exhibit higher rates of depression and suicidal ideation compared to their LGBTQ+ peers despite a general decline in symptoms from 2021 to 2023. Dr. Salerno pointed out several challenges in addressing these mental health issues, including an overreliance on the health disparities framework, cultural explanations that mask structural factors, and a lack of community-engaged studies. He emphasized the importance of using an intersectionality framework to understand the complex experiences of Latine/x LGBTQ+ youth and to identify the structural factors driving mental health disparities.

Dr. Salerno advocated for community-engaged research, in which community members participated in various phases of the research process—from study development to dissemination of findings. He illustrated this approach through an example of the LGBTQ+ Students and Allies in Public Health student organization at the University of Maryland. This group conducted a national survey on minority stress and mental health among LGBTQ+ college students, actively involving students in all research phases. The study found significant associations between minority stressors such as internalized LGBTQ+ phobia, family rejection, victimization, and high levels of psychological distress, underscoring the need for interventions to reduce minority stress on college campuses.

The second study examined the impact of racist microaggressions and LGBTQ+ minority stressors on Latine/x LGBTQ+ college students. It found that racist microaggressions were significantly associated with psychological distress, highlighting the insufficiency of the sexual and gender minority stress framework alone to explain the mental health challenges faced by Latine/x LGBTQ+ youth. Dr. Salerno concluded by calling for new research frameworks and the use of community-engaged research methods to better understand and address the intersectional experiences of these populations, ultimately aiming for social justice outcomes tailored to the community’s specific needs.

Theory-to-Practice in Community-Engaged Research: Intersectional, Feminist, Womanist, and Liberatory Approaches

Annaliese Singh, Ph.D., L.P.C., (she/they), School of Social Work, Tulane University

Dr. Annaliese Singh highlighted the importance of cultural humility in research, particularly when working with queer and trans youth. She emphasized that researchers often overlooked the personal motivations behind their studies and the theoretical frameworks guiding them. Dr. Singh shared her experiences working with LGBTQIA+ youth, underscoring the transformative impact of engaging authentically with these communities. She advocated for recognizing the potential for liberation in research practices and stressed the importance of framing research in ways that genuinely reflect the voices and needs of young people.

Dr. Singh discussed three key projects: the Georgia Safe Schools Coalition, Project Affirm, and the Trans Resilience Project. The Georgia Safe Schools Coalition, founded in 2009, utilized intersectionality theory to address bullying and discrimination in schools. The project involved deep listening and dialogue with various school stakeholders, leading to the creation of authentic partnerships defined by the voices of queer and trans young people. Project Affirm, an NIH-funded longitudinal study, explored trans identity development and resilience using innovative methodologies like the lifeline protocol, for which participants mapped significant life events related to their gender identity. This approach highlighted the importance of involving participants as co-creators of theory and data.

In the Trans Resilience Project, Dr. Singh applied mutual aid theory to research, focusing on the socio-political context affecting queer and trans youth. This project aimed to put research findings directly into the hands of the communities being studied, ensuring that young people could influence and shape the research process. Dr. Singh concluded with a call for researchers to embrace liberatory and intersectional approaches, listen deeply to the communities they serve, and consider the broader implications of their work for societal change. This emphasis on community-engaged research aligned with the NIMH’s goals of promoting mental health and well-being for SGM youth.

Pride & Community Connection for Indigenous 2SLGBTQ+ Youth: the Intersectionality of Identity for Indigenous Adolescents in the US

Alessandra Angelino, M.D., M.P.H., F.A.A.P., Division of Adolescent and Young Adult Medicine, Center for Indigenous Health, Johns Hopkins University

Dr. Alessandra Angelino highlighted the unique challenges and strengths of Indigenous 2SLGBTQ+ youth. Dr. Angelino began by acknowledging the historical and ongoing systemic inequities faced by Indigenous peoples in the U.S., calling for reconciliation and greater inclusion of Indigenous youth in various efforts. She explained the term Two Spirit, a unifying identity for American Indian, Alaska Native, and First Nation individuals that transcended Western binary gender concepts and historically celebrated gender diversity in Indigenous communities.

The research focused on the impact of pride and community connection on health outcomes for Two Spirit and Indigenous 2SLGBTQ+ youth, who faced significant barriers to healthcare due to systemic inequities rooted in historical trauma and colonization. Dr. Angelino's team utilized a mixed-methods approach, combining quantitative data and in-depth qualitative interviews to explore youth experiences. The study, conducted with the Northwest Portland Area Indian Health Board, recruited participants through social media and text outreach. The results showed strong pride in Two Spirit and Indigenous identities, although gender-diverse individuals reported lower levels of community and family support—particularly among younger adolescents.

Key findings from the research highlighted the protective role of cultural connection and community support in promoting mental and physical wellness among Indigenous 2SLGBTQ+ youth. The research underscored the importance of culturally safe resources and traditional practices in supporting these individuals. Dr. Angelino emphasized the need for healthcare providers to recognize and incorporate Indigenous communities' historical context and cultural practices into their care. Recommendations included increasing the representation and involvement of Two Spirit individuals in research and policy development and leveraging community strengths to foster resilience and better health outcomes for Indigenous 2SLGBTQ+ youth.

Engaging SGM Youth in Clinical Trial Research: Advancing their Roles as Interventionists

José Arturo Bauermeister, Ph.D., M.P.H., F.S.B.M., (he/him), University of Pennsylvania

Dr. José Arturo Bauermeister focused on innovative approaches to involving SGM youth in clinical research. He highlighted the potential of these youth to serve as interventionists, drawing on their lived experiences and expertise to enhance the relevance and effectiveness of clinical trials. Dr. Bauermeister emphasized the importance of community engagement, using Arnstein's ladder of citizen participation to illustrate how involving youth in higher levels of partnership and control can lead to empowerment and more impactful research outcomes.

Dr. Bauermeister described an ongoing project called STARS, a suicide prevention intervention for SGM youth aged 18 to 24 in Philadelphia. This NIMH-funded implementation science trial aimed to reduce suicide by assigning participants to a safety plan intervention, supplemented by a web app and peer mentor support system. SGM youth peer mentors provided six weeks of mentorship, helping participants integrate safety plans into their lives, address negative self-talk, and build support systems. The study monitored fidelity and effectiveness through assessments and in-depth interviews, showing promising early results in encouraging participants to use their safety plans more frequently.

The talk underscored the necessity of leveraging young people's expertise in clinical trials, advocating for fair compensation and structured training for peer mentors. Dr. Bauermeister emphasized the importance of funding and structural support to enable youth to contribute as agents of change in scientific research. He called for a shift in how grants were structured to facilitate youth engagement and highlighted the need for scalable interventions that could benefit from the unique insights of SGM youth.

Discussion

Dr. Terrinieka Powell reflected on the panel presentations, noting that:

  • Community-engaged approaches were crucial for expanding our thinking and practices, allowing the field to address mental health challenges among minoritized and marginalized young people more effectively by incorporating a diverse range of theories and perspectives.
  • The presentations highlighted the significant mental health challenges faced by LGBTQ+, minoritized, and marginalized young people, emphasizing the urgency of addressing these issues through innovative research and intervention strategies.
  • There was a clear need for integrative theories and perspectives, including intersectionality, feminist, womanist, and critical race theories, to enhance the understanding and practices in addressing mental health challenges among these populations.
  • Community-engaged research offered diverse intervention options involving young people and community partners at all stages of research. It demonstrated that there was no single correct way to approach these challenges; instead, multiple effective methods existed.
  • Young people played a vital role in giving and receiving support, particularly through peer mentoring, which had proven to be highly effective when they were properly trained and enthusiastic about their involvement.
  • It was essential to continuously expand the conversation by including more voices, particularly those from historically marginalized groups, to enrich research findings and make them more relatable and easily disseminated.
  • Sharing best practices in accessible formats, such as webinars, was crucial, given the difficulty of staying current with scholarly articles. Platforms like those provided by NIMH were invaluable for learning and sharing effective strategies.
  • Reducing the time from research testing to widespread dissemination was critical, as young people cannot afford to wait for prolonged periods. Strategies to expedite the dissemination of effective interventions were therefore necessary.
  • As the field moved forward, there was a need to invite diverse participants into the conversation, consistently questioning who was missing, and remain committed to learning, adapting, and sharing effective strategies and practices to address the mental health needs of minoritized and marginalized youth.

Dr. Powell welcomed panelists to a Question and Answer session.

Question: What are some of the strategies used to recruit and retain partners, especially young people, on teams and keep them engaged?
Answers: Dr. Bauermeister emphasized the importance of structured pathways to employment and the value of building credible resumes through community-engaged research, which helped young people understand the significance of their contributions to science.

Dr. Angelino discussed using multimodal approaches, such as incorporating storytelling and artistic expressions, to engage Indigenous youth in research, emphasizing the importance of culturally relevant methods to foster engagement and mentorship.

Dr. Reisner highlighted the need to create jobs and offer insurance for community advisory board members, sharing an example of adjusting research methods based on youth feedback to ensure separate, dedicated spaces for youth and providers.

Dr. Singh stressed the importance of long-term relationship building, cultural humility, and providing reparative acts such as financial resources and mentorship to foster authentic engagement with queer and trans youth.

Dr. Salerno advocated for integrating social justice and advocacy into research to keep youth engaged, emphasizing co-collaboration and giving youth a sense of ownership over the projects to increase their investment and retention.

Question: The folks we start with are not always the folks we end up with. When we work with young people, who are harder to reach after they graduate high school. How is everybody handling these transitions and maintaining continuity of the research project and the partnerships?
Answers: Dr. Singh emphasized the emotional challenges of maintaining long-term relationships in research, highlighting the importance of using community agreements to clarify transitions and encourage ongoing connections through social media and direct messaging. Dr. Singh also noted that these tools helped sustain engagement despite personal or legislative challenges.

Dr. Reisner described the flexibility of their engagement strategies, acknowledging the dynamic nature of young people's lives. He shared an example from the "Light" project, which adapted its focus based on community feedback to address mortality rates, illustrating the need to honor participants' changing levels of engagement and life circumstances.

Dr. Bauermeister warned against a colonial mindset in research, advocating for respecting young people's evolving interests and careers. He recommended structured graduation principles, like those used by the Adolescent Trials Network, to facilitate smooth transitions and affirm participants' growth and changing goals.

Dr. Salerno reflected on the inevitability of transitions in research, stressing the value of positive impacts during active project phases. He emphasized the importance of accepting the natural end of certain projects while celebrating the achievements and moving forward with new initiatives.

Question: There has been a checkered, sometimes catastrophic, history that has given marginalized, minoritized communities reason to mistrust and distrust researchers. Do you have any thoughts on how you can overcome that legitimate mistrust and distrust to truly, authentically engage the community?
Answers: Dr. Singh emphasized the importance of owning past mistakes and practicing deep, meaningful listening, highlighting that acknowledging the truth and sincerely listening to the community could help build trust.

Dr. Salerno discussed the problem of "helicopter researching" and stressed the need for researchers to remain engaged with communities and ensure mutual benefits, thereby avoiding the perception of using communities for research and then abandoning them.

Dr. Reisner highlighted the varying strategies needed depending on the environment and emphasized addressing specific barriers, such as administrative challenges in compensation that could foster mistrust if not managed transparently.

Dr. Powell echoed the importance of acknowledging historical harm and actively working to build a different relationship by being transparent and diligent in addressing practical issues such as payment delays that could negatively impact community trust.

Risk & Resilience: Individual, Interpersonal, and Family-Level Factors

Discussant: Erika E. Forbes, Ph.D., (she/her), University of Pittsburgh
Moderator: Laura A. Thomas Ph.D., (she/her), Division of Translational Research, NIMH

Psychosocial Functioning in Transgender Youth After Two Years of Hormone Treatment

Diane Chen, Ph.D., (she/her), Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine

Dr. Diane Chen presented findings from the Trans Youth Care United States study, which focused on psychosocial functioning in transgender youth after two years of hormone treatment. This NIH-funded longitudinal observational study evaluated the physical and psychosocial outcomes of transgender youth starting puberty suppression or gender-affirming hormones. Dr. Chen's research aimed to address gaps in the existing literature by enrolling a larger, more diverse sample of 315 youth, primarily white and designated female at birth, and following them over a longer period. The study focused on changes in appearance congruence, depression, anxiety, positive affect, and life satisfaction.

The study found significant improvements in psychosocial outcomes over a two-year period. Youth reported increased appearance congruence and life satisfaction, alongside decreased depression and anxiety symptoms. These improvements were particularly pronounced in youth who had received early gender-affirming care, including those who had previously received pubertal suppression treatment or had started hormones early. The data indicated that these youth experienced higher baseline appearance congruence and better mental health outcomes. Dr. Chen highlighted the importance of early intervention and continuous support for enhancing psychosocial functioning in transgender youth.

In another study, Dr. Chen also explored the relationship between appearance congruence and mental health outcomes. This study revealed that increases in appearance congruence were significantly associated with concurrent decreases in depression and anxiety and increases in positive affect and life satisfaction. These findings suggested that appearance congruence may be a key mechanism driving the positive effects of hormone treatment on psychosocial functioning. Dr. Chen emphasized the need for further research to extend these findings and explore hormone treatment's long-term impacts beyond two years, particularly among more diverse and representative samples. The study's continuation aimed to provide deeper insights into the medical care needs of non-binary youth and those who may discontinue treatment.

Parental Support is Not Enough: Advancing LGBTQ+ Youth Family Research and Practice

Jessica Fish, Ph.D., (she/her), School of Public Health, University of Maryland

Dr. Jessica Fish highlighted the critical need for more comprehensive research into the family dynamics affecting LGBTQ+ youth. Dr. Fish emphasized that while the acceptance of LGBTQ+ youth by their families had generally improved, family interactions remained complex and multifaceted. Research indicated that both accepting and rejecting behaviors from parents can coexist, creating a nuanced environment for LGBTQ+ youth. This complexity challenged the traditional binary view of family acceptance versus rejection, urging a more sophisticated approach to understanding and supporting LGBTQ+ youth in their family contexts​​.

The LGBTQ Youth and Family Study (LYFS) explored how cisgender, heterosexual parents interacted with their LGBTQ+ adolescents. The study included 27 families from the mid-Atlantic region, involving separate interviews with both parents and youth. Initial findings identified seven categories of parental behaviors, both supportive and non-supportive, impacting their child's sexual minority identity development. These behaviors included actions that facilitated exploration and actions that inadvertently encouraged concealment. The research underscored the ongoing and iterative nature of parent-child interactions and the mixed messages youth often receive, which can simultaneously support and undermine their development​​.

Dr. Fish advocated radical revision of how LGBTQ+ family environments were conceptualized in research. She called for moving beyond the simple dichotomy of family acceptance versus rejection to a broader understanding of family processes and environments. This shift would allow for more effective measures, methods, and interventions that address the unique challenges faced by LGBTQ+ youth. Dr. Fish highlighted the importance of parents actively engaging in socialization practices to help their children navigate a world filled with stigma and discrimination, drawing parallels to racial and ethnic socialization strategies. She emphasized the need to better equip families to foster resilience and positive development in LGBTQ+ youth despite the ongoing societal challenges they faced.

Oppression-Based Stress, Mental Health, and Substance Use among QTBIPC Adolescents

Ethan Mereish, Ph.D., (he/him), University of Maryland, College Park

Dr. Ethan Mereish talked about the significant health disparities faced by Queer, Trans, Black, Indigenous, People of Color (QTBIPC) adolescents. Dr. Mereish emphasized that QTBIPC adolescents reported poorer mental health and higher substance use compared to their same-race, heterosexual, and cisgender peers, as well as their white SGM counterparts. He connected these health disparities to various forms of oppression, including racism, heterosexism, and cissexism, which intersect and compound to exacerbate stress and adverse health outcomes for these adolescents​.

Dr. Mereish gathered data from over 3,000 QTBIPC adolescents aged 13 to 17 from the 2017 LGBTQ National Teen Survey. This cross-sectional study found that nearly all participants experienced at least one intersectional stressor, such as microaggressions, which were linked to higher levels of depressive symptoms, lower self-esteem, and a diminished sense of mastery. Dr. Mereish also explored the impact of these stressors on substance use, finding that intersectional microaggressions were correlated with increased use of alcohol, cannabis, and nicotine. However, supportive factors did not sufficiently buffer the adverse effects of these stressors on substance use.

Dr. Mereish concluded with insights from a more recent study using the 2021 National Teen Survey, which corroborated previous findings and highlighted that drinking to cope mediated the relationship between microaggressions and hazardous alcohol use. He stressed the need for longitudinal research to understand how these stressors and health outcomes evolved and called for interventions targeting structural oppression. Additionally, Dr. Mereish emphasized the importance of empowering QTBIPC adolescents in advocacy and social change, noting their strong motivation for social justice despite the significant barriers they face.

Traversing the Liminality of Young Adulthood

Rachel Schmitz, Ph.D., (she/her/ella), Oklahoma State University

Dr. Rachel Schmitz focused on the challenges faced by LGBTQ+ youth experiencing homelessness and residential instability. Her research emphasized the intersectionality of identity, family dynamics, religion, and resilience in these young individuals' lives. Dr. Schmitz shared qualitative findings from in-depth interviews with LGBTQ+ youth, highlighting their struggles with economic precarity and the impact of being ostracized by their families. Understanding these young people's perspectives was crucial for developing effective support systems and policies that address their unique needs​.

Dr. Schmitz's research underscored the importance of person-centered language and approaches in working with homeless youth. She advocated for a shift from viewing them primarily as homeless youth to recognizing them as young people experiencing homelessness. This change in perspective helped them acknowledge their identities beyond their housing status. The research also highlighted the high representation of queer youth among the homeless population and the compounded difficulties they faced due to their marginalized sexual and gender identities. Structural and interpersonal oppressions further exacerbated their challenges, making it essential to listen to their lived experiences to improve services and policies​.

Dr. Schmitz's studies, which were conducted in Nebraska and Oklahoma, revealed that identity development, family relationships, and the role of companion animals were critical areas influencing the well-being of LGBTQ+ youth. She explored the connection between youth and their pets in Oklahoma, finding that pets often provide emotional support and stability. Her findings called for more inclusive mental health and housing services that considered the unique needs of LGBTQ+ youth, including those related to their companion animals. Dr. Schmitz concluded by recommending that policymakers and service providers adopt more LGBTQ+ inclusive practices and involve young people in the design and implementation of support systems​.

Eating Disorders in Sexual and Gender Minority Adolescents

Jason Nagata, M.D., M.Sc., (he/him), School of Medicine, University of California San Francisco

Dr. Jason Nagata discussed the intricate connections among gender identity, body image, and eating disorders in SGM adolescents. He reviewed a case study of a 16-year-old transgender boy experiencing distress due to his feminine body features and menstrual periods. His struggle with bullying and body dissatisfaction led him to engage in excessive weightlifting and severe calorie restriction, illustrating the complex interplay between muscle dysmorphia and eating disorders in transgender youth. Dr. Nagata emphasized that eating disorders, such as anorexia nervosa and bulimia nervosa, had severe physical and psychological consequences, characterized by behaviors such as fasting, meal skipping, and excessive exercise.

Dr. Nagata highlighted the higher prevalence of eating disorders among SGM adolescents compared to their heterosexual peers, citing data from the Pride Study. This study revealed that sexual minority adolescents had two to four times greater odds of an eating disorder diagnosis, while over 40 percent of transgender adolescents reported disordered eating behaviors. He discussed various theoretical models that could explain these high rates, including the tripartite influence model and minority stress theory. These models suggested that societal stigma, discrimination, and internalized homophobia or transphobia significantly contributed to poor body image and eating disorder vulnerability, particularly during adolescence.

Dr. Nagata also presented findings from the ABCD Study that linked higher screen time and problematic social media use to increased eating disorder symptoms among SGM adolescents. The study found that SGM adolescents reported significantly more screen time and problematic social media use, which was associated with higher odds of binge eating disorder and other eating disorder symptoms. Dr. Nagata emphasized the importance of positive identity feelings, family and social support, safe school environments, and access to gender-affirming care as protective factors against eating disorders. He advocated for interventions that maximized the benefits of social media while minimizing its risks and called for further research to better understand and support this vulnerable population.

LGBTQ Youth Mental Health Risk and Protective Factors

Myeshia Price, Ph.D., (she/they), School of Education, Kinsey Institute, Indiana University

Dr. Myeshia Price highlighted the increased risk of suicidality among LGBTQ+ youth with data from her tenure at The Trevor Project. Dr. Price emphasized that LGBTQ+ youth were more than four times as likely to attempt suicide than their peers, a statistic supported by CDC data. This risk was compounded when multiple marginalized identities, such as race and gender identity, intersected—introducing additional stressors such as racism and gender-based discrimination. Dr. Price presented data from the 2023 Trevor Project study, which surveyed 28,000 LGBTQ+ youth aged 13-24, revealing that 14 percent had attempted suicide in the past year, with rates higher among transgender and non-binary youth.

Dr. Price also discussed protective factors that can mitigate these risks. They stressed the importance of supportive and affirming environments, noting that better treatment and affirmation could lead to more positive mental health outcomes. For instance, simple acts such as respecting young people's pronouns and creating affirming spaces at home, school, and in the community could significantly reduce the risk of mental health issues. Research showed that young LGBTQ+ individuals who experienced support and acceptance reported lower rates of anxiety and depression. This underscored the critical need for inclusive and supportive policies and practices in various societal institutions.

Dr. Price concluded with a call to action for systemic changes to support LGBTQ+ youth. They advocated for incorporating community assets and peer support in mental health interventions. Dr. Price highlighted the Trevor Project's focus on safe identification and coordinated mental health referrals as effective strategies to improve outcomes. They emphasized that while LGBTQ+ youth demonstrated resilience, there was a pressing need for research and policies that recognized and addressed the unique challenges faced by this population to foster an environment where they can thrive.

Discussion

Dr. Erika E. Forbes reflected on the panel presentations, noting that:

  • There was a need to explore neural mechanisms and mental health disparities, particularly focusing on mental health disparities among SGM youth.
  • Sexual minority youth with a lower response in the temporal junction area of the brain were more prone to higher suicidal ideation, depression, and victimization. These tendencies might contribute to increased mental health risks due to factors such as disengagement from social feedback, which could stem from past victimization experiences.
  • There was a higher left caudate response to social support interactions coupled with negative responses to real-life social threats that correlated with higher suicidal ideation.
  • Sensitivity to social information and threats could have both protective and risk implications for mental health, emphasizing the need to understand these mechanisms at both individual and group levels.
  • It was important to consider intersectional oppression, diverse sexual orientations, and gender identities in research to capture the full extent of experiences and risks.
  • Socioeconomic contexts were also critical in understanding mental health disparities and outcomes.
  • The effects of social media use depended on context and individual circumstances.
  • Developmental timing was a critical factor in interventions and understanding risks and resilience in SGM youth.
  • There was a need to build interventions based on findings about processes and mechanisms and translate these into practical policies and interventions.

Dr. Forbes welcomed panelists to a Question and Answer session.

Question: How can we understand and integrate varying risk and protective factors into our hypotheses, research formulations, findings interpretations, and policy or intervention translations, considering intersectionality, sexual orientation, gender identity, and socioeconomic contexts?
Answers: Dr. Chen highlighted the significant variability in mental health outcomes among youth receiving gender-affirming hormone treatments, emphasizing the need to consider individual risk profiles and contextual factors such as minority stress and family support to address the holistic mental health needs of trans youth.

Dr. Forbes mentioned the importance of considering multi-level vulnerability factors, including stress and structural issues, for SGM youth, suggesting a broader ecologically valid perspective in research.

Dr. Schmitz agreed with the holistic approach and discussed the role of companion animals as sources of support for marginalized groups, emphasizing the need to address not just basic needs but also personalized supports for mental health and resilience, as well as varying economic stability.

Question: What are the next steps for interventions or guidance?
Answer: Dr. Nagata emphasized the need for updated, non-binary growth charts and clinical guidelines for gender minority adolescents, highlighting the lack of data on normal growth rates and health metrics for non-binary individuals. He advocated for more comprehensive guidance and data to support transgender youth across general and specialty pediatrics.

Question: What about in our conceptual models? Does anyone have ideas about how to incorporate many different factors, such as intersectional identities and other risk and contextual factors?
Answers: Dr. Fish highlighted the importance of considering family dynamics and parenting practices in understanding youth interactions and their impact on sexual orientation and gender identity development. She emphasized the need for research on specific family processes, especially in racially and ethnically minoritized communities, to leverage resilience and support for LGBTQ+ youth.

Dr. Price focused on the protective role of cultural socialization in Black families and how these existing tools can be adapted to support LGBTQ+ youth. They also underscored the significance of addressing socioeconomic factors, as they play a critical role in resilience and the ability to meet basic needs, which in turn impacted mental health outcomes.

Question: How do you tailor your research or research questions to the age and developmental stage of the participants that that you're focusing on, or how are you taking that into account?
Answers: Dr. Nagata highlighted the importance of considering age, developmental stage, pubertal status, and level of parental support in adolescent research. He emphasized the wide developmental range from ages 10 to 24 and noted how family-based therapy was more common for minors. In contrast, cognitive behavioral therapy was preferred for more independent young adults. He stressed the necessity of adapting treatment modalities based on the individual's age and developmental independence.

Dr. Mereish emphasized the inclusion of a teen advisory board in his research, ensuring that measures, surveys, and materials were appropriate for the 13- to 17-year-old age group. He found that teenagers could provide valuable feedback on language and content, making the research more relevant and effective for their age group.

Dr. Schmitz incorporated feedback mechanisms into her qualitative interview-based studies, asking participants how they found the interview and what they would like the study to achieve. This approach allowed for real-time adjustments to research methods and ensured that findings were applied to benefit the youth involved.

Research on Services, Intervention, and Prevention

Discussant: Dorothy Espelage, Ph.D., (she/her), School of Education, University of North Carolina at Chapel Hill
Moderators: Mary Acri, Ph.D., (she/her), Division of Services and Intervention Research, NIMH

LGBTQ-Affirmative Mental Health Care: From Theory to Trials to Implementation

John Pachankis, Ph.D., (he/him), School of Public Health, Yale University

Dr. John Pachankis presented an overview of evidence-based mental health treatments specifically designed for SGM individuals. He highlighted the need for such treatments due to the unique challenges faced by LGBTQ+ populations, including the prevalence of harmful alternatives such as conversion therapies. He justified the development of LGBTQ-affirmative treatments as essential to countering minority stress, which was often not adequately addressed by general evidence-based therapies. Dr. Pachankis emphasized that tailored treatments could provide scientific insights into the impact of minority stress on mental health and serve as a professional guideline, as called for by the American Psychological Association.

Dr. Pachankis detailed the development process of a cognitive-behavioral therapy (CBT) manual specifically adapted for LGBTQ+ individuals. This process involved extensive consultations with mental health professionals and LGBTQ+ individuals experiencing mental health issues. The adapted CBT addressed minority stress by helping individuals acknowledge and challenge stigma, internalized negative beliefs, and social withdrawal tendencies. Initial randomized controlled trials with young gay and bisexual men, as well as young sexual minority women, demonstrated significant improvements in depression, anxiety, and substance use—validating the efficacy of the treatment. These studies highlighted the treatment's ability to address multiple co-occurring outcomes, such as reducing comorbidity in depression, anxiety, and hazardous behaviors.

Dr. Pachankis talked about the implementation of LGBTQ-affirmative CBT in community settings. His team surveyed LGBTQ community centers' capacity to adopt this treatment, collaborating with Centerlink, which coordinates these centers across the U.S. The positive responses led to training programs for over 700 mental health providers across 90 centers. These programs significantly improved providers' cultural competence and knowledge of minority stress and CBT skills. Dr. Pachankis advocated for the integration of implementation science to ensure widespread adoption of evidence-based LGBTQ+-affirmative treatments, stressing the importance of rapid dissemination and adaptation to various community contexts to meet the mental health needs of LGBTQ+ populations.

Targeting multilevel transphobia through a multilevel intervention

Maggi A. Price, Ph.D., (she/her), School of Social Work, Boston College

Dr. Maggi A. Price presented her research on targeting multilevel transphobia through a multilevel intervention, emphasizing the importance of addressing stigma at various levels. She began by defining stigma and its different forms: internalized, interpersonal, and structural. Internalized stigma involved adopting negative societal beliefs about oneself, interpersonal stigma included discrimination and identity-based bullying, and structural stigma comprised societal attitudes and policies that hinder the well-being of marginalized groups. Dr. Price highlighted that both interpersonal and internalized stigma were strongly linked to mental health issues such as depression and anxiety among LGBTQ+ youth, while preliminary research on structural stigma showed similar detrimental effects.

Dr. Price detailed a study focused on improving mental health care for transgender youth through a multilevel intervention. This intervention was designed to address internalized stigma at the client level through therapy, interpersonal stigma at the provider level through training, and structural stigma at the clinic level through policy and practice changes. The research team collaborated closely with transgender and non-binary youth, their parents, and experienced providers to develop the intervention components. These components included gender-affirming psychotherapy training for therapists, which was interactive and self-paced, and modifications to clinic policies and environments to be more inclusive and affirming for transgender clients.

Preliminary results from this study indicated significant improvements in therapists' attitudes, knowledge, and confidence, as well as behavioral changes in providing more affirming care. The pilot clinic began offering gender-affirming groups for youth and their parents, demonstrating the intervention's positive impact. These studies underscored the necessity of community engagement and evidence-based strategies in developing effective interventions to combat multilevel transphobia and improve mental health outcomes for transgender youth​.

“You Kind of Forget About It”: Latinx and Non-Latin White Sexual Minority Youth Drinkers’ Experiences with Discrimination, Affect, and Drinking

Robert Rosales, Ph.D., L.C.S.W., (he/him/él), Center for Alcohol and Addiction Studies, School of Public Health, Brown University

Dr. Robert Rosales emphasized the prevalence of underage drinking and its reciprocal effect on mental health, highlighting that sexual minority youth were at higher risk for alcohol use. His study aimed to explore the experiences of Latinx and non-Latin white sexual minority youth with alcohol, focusing on how discrimination affected their drinking behaviors. Dr. Rosales recruited and conducted interviews via Zoom to gather with twenty 15- to 19-year-old participants who had consumed alcohol in the past thirty days and faced discrimination.

The study revealed distinct differences in drinking behaviors between Latinx and non-Latin white participants. Latinx youth often cited cultural and social reasons for drinking, such as social norms in their communities, while non-Latin white youth mentioned drinking for enjoyment and socialization. Additionally, Latinx participants frequently expressed concerns about legal repercussions, such as losing their student visas, which influenced their decisions to abstain from drinking. The study also highlighted that sexual minority youth used alcohol to cope with stress and negative emotions stemming from racism and heterosexism, although this sometimes exacerbated their mental health issues.

Dr. Rosales recommended that treatment programs for sexual minority youth address the specific stressors of racism and heterosexism. He noted the potential for culturally adapted interventions, which have shown success in reducing alcohol use and improving mental health among Latinx adults. He emphasized the need for these interventions to be tailored to the developmental stages of youth, considering their unique cultural contexts and stressors. Despite the study's limitations, including its small sample size and age range, the outcomes highlighted the importance of understanding and addressing the complex factors influencing alcohol use among Latinx and non-Latin white sexual minority youth.

Prevention and Treatment of Intimate Partner Violence (IPV) for Sexual and Gender Minority Youth (SGMY)

Katie Edwards, Ph.D., (she/her), University of Nebraska-Lincoln

Dr. Katie M. Edwards talked about her research on the prevention and treatment of intimate partner violence (IPV) among sexual and gender minority youth (SGMY), indicating that these groups experienced higher rates of IPV compared to their heterosexual and cisgender counterparts. Her research, which included a diverse sample of over 300 SGMY, found significant rates of both perpetration and victimization of teen dating violence within a three-month period. The study highlighted the exceptionally high vulnerability of queer youth of color and trans and gender-diverse youth, emphasizing the necessity of understanding these dynamics through an intersectional lens. Additionally, the findings indicated that SGMY survivors of IPV often face worse outcomes due to compounded minority stressors.

Dr. Edwards emphasized the importance of primary prevention of IPV, using a social-ecological model to address universal risk and protective factors and those specific to SGMY. Her work identified internalized homophobia, biphobia, transphobia, and identity concealment as significant risk factors, whereas a strong sense of the LGBTQ+ community was found to be a protective factor. She noted that existing universal prevention programs lacked effectiveness for SGMY, due to their heteronormative frameworks and lack of relevance to the lived experiences of SGMY. Her team's efforts include adapting these programs to incorporate theories of minority stress and resiliency, making them more applicable and impactful for SGMY.

Dr. Edwards reviewed PRISM (Promoting Resilient Youth with Strong Hearts and Minds), which was an online intervention program designed to reduce IPV and alcohol use among SGMY. This program, co-developed with a queer youth advisory board, featured nine 45-minute sessions facilitated by SGM adults. Preliminary results from their randomized controlled trial involving 304 youth showed that participants in the PRISM condition experienced reduced alcohol use and teen dating violence, as well as increased LGBTQ+ community sense and improved sexual communication self-efficacy. These outcomes were sustained at a three-month follow-up, demonstrating the program's effectiveness and acceptability among the youth. Dr. Edwards highlighted the need for trauma-informed, affirming responses to disclosures of IPV and the importance of dismantling systemic oppressions that exacerbate these issues.

Single-Session Interventions to Promote Mental Health in SGM Youth

Jessica Schleider, Ph.D., (she/her), Feinberg School of Medicine, Northwestern University

Dr. Jessica Schleider highlighted the critical need for single-session interventions (SSIs) to address the mental health disparities faced by SGM youth. She emphasized that traditional, multi-session mental health interventions were often inaccessible to SGM youth due to systemic barriers and provider shortages. Dr. Schleider proposed that SSIs were a scalable, immediate solution to provide effective mental health support. These interventions, intentionally designed for single encounters, had shown significant benefits in various studies, demonstrating efficacy comparable to multi-session therapies in many cases. Her meta-review revealed that SSIs significantly improved mental health outcomes across multiple issues with an overall effect size of approximately 0.25.

Dr. Schleider discussed the design and implementation of SSIs tailored specifically for SGM youth. Her lab's interventions, developed in collaboration with youth, were accessible online and did not require parental consent, making them particularly suitable for this population. One notable program, Project Rise, was a digital, self-guided intervention focusing on minority stress theory and coping strategies. A pilot randomized controlled trial with 538 adolescents recruited via Instagram showed that Project Rise effectively decreased internalized stigma and increased identity pride and self-acceptance. The intervention achieved a high completion rate of 90 percent, indicating its acceptability and feasibility for SGM youth.

These findings underscored the importance of SSIs in bridging gaps in mental health care for SGM youth. The SSIs had reached more than 30,000 SGM youths, highlighting the potential for broad impact. She advocated for integrating SSIs within and outside formal healthcare settings to ensure sustainable access. Additionally, she stressed the need for policy changes to address structural barriers, such as parental consent requirements, which hindered SGM youth from accessing necessary mental health care. Her ongoing collaborations aim to develop tools and dashboards to streamline advocacy for these policy changes, ensuring that all youth can self-refer to mental health care regardless of their familial environment.

Using the Dynamic Adaptation Process to Advance LGBTQ+ Health Equity in High Schools

Cathleen E. Willging, Ph.D., (she/her), Pacific Institute for Research and Evaluation

Dr. Cathleen E. Willging reviewed a study that aimed to address health disparities among LGBTQ+ youth in high schools using the Dynamic Adaptation Process (DAP). The study was conducted across 42 high schools in New Mexico, a rural state with a significant population of Latinx and Indigenous people. The research focused on implementing six evidence-informed practices to enhance the well-being of LGBTQ+ students. These practices included establishing safe spaces such as Gay-Straight Alliances (GSAs); prohibiting harassment and bullying; and providing inclusive health education, staff development, and access to experienced medical and behavioral health providers. The study employed a randomized design with schools either using the DAP immediately or after a delay. This process involved multiple implementation strategies such as assessment, mobilizing champions, coaching, and monitoring to support schools in adopting these practices​.

The DAP was guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, and relied on data from semi-structured interviews, focus groups, and collaborative assessments. These assessments helped in action planning and were crucial in understanding the contextual factors affecting implementation, such as political climates, knowledge gaps, and pragmatic concerns (e.g., time and turnover). The study emphasized the importance of community-academic partnerships involving school officials, professionals, and local LGBTQ+ organizations. These partnerships facilitated training and technical assistance, and they were pivotal in setting up GSAs, establishing supportive policies, and responding to crises. The iterative nature of the DAP allowed schools to adopt practices thoughtfully and responsively, enhancing the overall implementation​.

The results showed significant improvements in the adoption of the six practices. Initially, schools had implemented about 43 percent of the practice elements, which increased to approximately 80 percent by the end of the study period, with these changes being statistically significant. This success was attributed to the structured collaborative assessments, which helped schools create effective action plans, and the supportive role of implementation resource teams. These teams, comprising various school personnel and sometimes students and parents, were essential in building capacity and confidence in action planning and facilitating collaboration. The study demonstrated that the DAP not only advanced LGBTQ+ health equity but also had the potential to support other innovations addressing health disparities in school settings​.

Discussion

Dr. Dorothy Espelage reflected on the panel presentations, noting that:

  • Despite structural stigma, there was hope due to ongoing efforts to support SGM youth, particularly in underserved contexts.
  • NIH funding has enabled rigorous program and intervention development, focusing on implementation science beyond just randomized controlled trials.
  • The adaptation of CBT treatment manuals to address minority stress was particularly helpful for SGM youth.
  • The extension of multi-level stigma frameworks from clinical settings to schools was critical, as teachers' attitudes significantly impacted SGM youth.
  • Research on Latinx sexual minority youth highlighted the complexity of substance use behaviors and underscored the need NIH and CDC to continuously track trends.
  • Single-session interventions were effective and challenged the belief that longer sessions were always better. It was important to disseminate this work through popular media channels.
  • Waivers of parent and guardian consent for research with youth were vital, especially given the pushback from Institutional Review Boards.
  • Structural stigma was increasing, and policies played a critical role in shaping the experiences of SGM youth. However, social media could serve as a protective factor.
  • Implementation science in schools was challenging but essential, and required iterative processes and commitment, as shown in successful school-based interventions.
  • Strong theoretical frameworks, such as theories of change and logic models, were essential for systematic research and understanding proximal to distal impacts.
  • Policies at state and district levels significantly impacted the well-being of SGM youth, highlighting the importance of queer-friendly environments.
  • It was important to continue focusing on reducing structural stigma and fostering supportive policies to improve the mental health and safety of SGM youth.

Dr. Acri welcomed panelists to a Question and Answer session.

Question: Have you experienced any barriers related to coverage of services by private or public health insurance in your work developing gender affirming interventions or prevention programs?
Answers: Dr. Schleider highlighted that there were no insurance infrastructures to reimburse for SSIs, disproportionately affecting SGM youth who often had limited access to care. Her team was working with state mental health agencies to secure Medicaid waivers and conduct pilot studies to demonstrate cost-effectiveness, emphasizing the need for innovative access pathways.

Dr. Price added that her training intervention included modules to help transgender youth access services, providing resources like letter templates and referral processes for gender-affirming services. These measures aimed to overcome barriers to care in regions where such services were available.

Dr. Pachankis emphasized the significant role of LGBTQ+ community centers in offering services to under- or uninsured individuals. He suggested that these centers’ methods of providing support groups and peer counseling should be studied and credited, as they filled critical gaps in mental health care left by larger systems.

Question: How do we sustain, adopt, sustain and scale up mental health interventions for these populations in a contentious political climate?
Answers: Dr. Willging emphasized the importance of developing an implementation support infrastructure at district and state levels to sustain mental health interventions, noting that school personnel turnover was a significant challenge.

Dr. Schleider recommended increasing access to mental health support for all youth, advocating for broad programs that allowed for individualized support based on specific needs and highlighting the necessity of policy changes at the state level to ensure consistency and reduce legal liabilities.

Dr. Edwards discussed the use of waivers of guardian consent in studies to protect youth who were not out to their families, stressing the importance of creating safe online spaces for these youth to access support and affirming care.

Reflections on Meeting Highlights, Common Themes, Future Directions

Christina P.C. Borba, Ph.D., M.P.H., (she/her), Director, Office for Disparities Research and Workforce Diversity, NIMH

Dr. Christina Borba reflected on the two-day conference, expressing enthusiasm and gratitude and highlighting several critical themes and future directions for the NIMH. One major focus was the measurement of gender identity and sexual orientation, noting the progression towards more accurate and inclusive data collection methods. Despite these advancements, there was a need for continued work to improve the quality of data and reduce confusion in responses. This aligned with NIMH’s commitment to refining measurement tools and expanding understanding.

Another significant theme was the importance of adopting an intersectionality lens in research and practice, recognizing how intersecting identities impact mental health outcomes. Dr. Borba stressed that stigma remained a prevalent issue at multiple levels—from interpersonal to structural—with a particular gap in research on structural stigma. The conference also highlighted the strengths of LGBTQ+ youth, suggesting that future interventions should leverage these strengths and involve youth as peer mentors, thereby fostering community engagement and empowerment.

The role of social media in mental health was also discussed, acknowledging its potential for delivering evidence-based interventions and providing a positive impact on queer youth. This perspective encouraged NIMH to consider the dual nature of social media in both supporting and challenging mental health. Additionally, the importance of community and creating safe spaces for youth was underscored, advocating for solidarity within and between communities to support LGBTQ+ youth.

Finally, Dr. Borba highlighted the critical role of implementation science in ensuring the scalability and sustainability of evidence-based treatments. She outlined future directions for NIMH, emphasizing the need for research on structural factors affecting mental health, development of structural interventions, and true community-engaged research. Dr. Borba also called for improved dissemination practices to ensure research findings reach and benefit the communities involved. She emphasized NIMH’s commitment to advancing the mental health and well-being of LGBTQ+ youth through continued research and inclusive practices.

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