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

Transcript

EVENT PRODUCER: Okay.  Let's get started. 

Welcome, everybody, and thank you for joining us today for Promoting Mental Health for Sexuality and Gender Minority Youth:  Evidence‑Based Development Perspectives. 

Just a few housekeeping notes and reminders.  Participants, again, have entered listen‐only mode, cameras off, and mics are muted. 

Please submit your questions via the Q&A box at any time during the webinar.  Questions will be answered during the discussion session of the workshop. 

If you have any technical difficulties hearing or viewing the webinar, please note these in the Q&A box and our technicians will work to fix the problem.  You can also send an email to NIMH Events.  That's nimh@mn‑e.com. 

And with that, I will now pass it over to Dr. Stacia Friedman-Hill. 

STACIA FRIEDMAN-HILL:  Thank you.  Good morning.  I am Stacia Friedman-Hill.  My pronouns are she/they.  And I am a program director at the National Institute of Mental Health. 

On behalf of the planning committee, I'm pleased to welcome you to our workshop, Promoting Mental Health for Sexual and Gender Minority Youth:  Evidence‑Based Developmental Perspectives. 

This workshop represents the collective efforts of seven NIH institutes, centers, and offices, and I think this underscores the broad impact and importance of this topic. 

And I want to share that the most common response we heard when we reached out to invite speakers and discussants was "this workshop is so needed" followed by "how else can I help you." 

Before we get started on the fantastic program we've put together, we have several welcoming remarks to share with you. 

It is my great honor to be able to introduce a message from the U.S. Assistant Secretary of Health and the head of the U.S. Public Health Service Commissioned Corps, Admiral Rachel L. Levine.  Before serving as a state and federal official, Dr. Levine's training and academic appointments were concentrated in pediatrics and adolescent medicine. 

And now, let's hear from Admiral Levine. 

We're having some technical difficulties.  Can we pause the video and get the audio to start?  We're seeing Admiral Levine but can’t hear her words. 

If you can restart from the beginning, that would be great. 

I'm sorry.  We still can't hear the audio as the panelists or the audience.  

EVENT PRODUCER:  My apologies.  My mic was muted.  So sorry about that.  I will restart the video.  

RACHEL LEVINE:  Thank you so much for inviting me to join you today.  I'm sorry I cannot be there in‑person, but I am honored to be a part of this event. 

I am Admiral Rachel Levine, and I am proud to serve as the Assistant Secretary for Health at the United States Department of Health and Human Services.  I'm also proud that I am the first transgender Senate‑confirmed federal official and the first transgender four‑star admiral in the United States Public Health Service Commission Corps. 

Adverse childhood experiences, or ACEs, can change the way children's brains and bodies develop and function.  They contribute to increased risk of poor mental health, substance use, suicidal behaviors, chronic diseases, and other poor health and well‑being outcomes into adulthood. 

Research shows that experiencing discrimination, including discrimination due to identifying or being perceived as LGBTQI+ is itself an adverse childhood event.  People who identify as LGBTQI+ are more likely to experience many different types of ACEs, including child abuse, neglect, and other household challenges compared to people who identify as heterosexual and whose gender matches their sex at birth. 

Young people who identify as LGBTQ+ or who have same‑sex sexual contacts are also more likely to experience other childhood adversities such as bullying, sexual violence, teen dating violence, witnessing violence in their community, unstable housing or homelessness, and food insecurity. 

New data from the Centers for Disease Control and Prevention collected among U.S. teens from six states in 2021 indicate that 26.1% of high school students, more than a quarter of the entire national high school population, have experienced interpersonal discrimination due to their sexual identity. 

Positive experiences in childhood wire the brain to thrive.  It can help to counterbalance the effects of adverse experiences. 

Preventing ACEs and promoting positive childhood experiences, or PCE, can improve health and well‑being for all children, including those who identify as LGBTQI+.  Making sure that PCEs are common and widespread is critical to improving health. 

No single sector can achieve this alone.  We must work together to build a strong overall foundation for childhood well‑being.  Examples of PCEs can include having nurturing relationships with parents, friends, or other adults, living in caring and supportive neighborhoods, having feelings of belonging at school or in the community, being able to engage in after‑school activities, including cultural or other traditions. 

Now, June is Pride Month.  This is an especially good time to reach out to LGBTQI+ organizations, leaders, healthcare providers, and even individuals in your own circles to share more information about the particular challenges queer young people face in our country today and how we can help them thrive in the face of those challenges. 

I believe that we are not doing better unless we are all doing better.  That includes our LGBTQI+ youth who we know are facing politically and ideologically motivated attacks in communities around the country.  We must do better.  We can do better.  And with your help, we will do better. 

Thank you, and have a great session today, and happy Pride. 

STACIA FRIEDMAN-HILL:  Wow.  I am so grateful to Dr. Levine for taking time out of her packed schedule to prepare such an inspiring introduction for us. 

We will also hear from the Deputy Director of the National Institute of Mental Health, Dr. Shelli Avenevoli. 

Prior to joining NIMH, Dr. Avenevoli received her Ph.D. in developmental psychology from Temple University and completed a post‑doctoral fellowship in psychiatric epidemiology at Yale University School of Medicine. 

Dr. Avenevoli initially came to NIMH as a staff scientist in the intramural program and eventually moved to extramural research administration, serving as a program officer and branch chief and then deputy director.  And I will let Dr. Avenevoli share her own update about her newest duties during her remarks. 

Over to you, Dr. Avenevoli.  

SHELLI AVENEVOLI:  Good morning, everyone.  Thanks so much, Stacia.  So, I'm Shelli Avenevoli, my pronouns are she/her, and I'm currently the Deputy Director of NIMH, as Stacia noted. 

As some of you also may know, our current NIMH director, 
Dr. Joshua Gordon, will be stepping down this Friday from his position as director.  So, in the interim, while NIH conducts a national search for the next permanent director of NIMH, I will serve as the acting NIMH director. 

It's really my pleasure and my honor to welcome you to our workshop today.  The workshop is focused, as you know, on promoting mental health for sexual and gender minority youth. 

In the last few years, we've seen an increase in incidents of mental illness symptoms reported by children, adolescents and young adults. 

According to the 2021 Youth Risk Behavior Survey, high school students who are female, identify as lesbian, gay, bisexual or questioning or had any same‑sex partners were more likely than their peers to experience poor mental health and suicidal thoughts and behaviors.  Nearly 60% of female’s students and nearly 70% of students who identify as lesbian, gay, bisexual, or questioning experience persistent feelings of sadness or hopelessness.  And 10% of female students and more than 20% of students who identify as lesbian, gay, bisexual, or questioning attempted suicide.

Furthermore, sexual and gender minority youth often experience disparities in the prevalence of mental illness, access to healthcare, quality of that care, and experiences of trauma and adversity, as well as inequities in social determinants such as education or quality of housing. 

Youth with more than one marginalized identity such as those who are transgender and live in rural communities or are part of a marginalized racial or ethnic group may experience even greater disparities.  Stigma, minority stress, school and social climate, experiences of discrimination, harassment and bullying and lack of access to sexual and gender‑affirming services, they all contribute to these increased reports of symptoms of mental illness, as well as increased risk overall for mental illness. 

Identifying strategies that can improve mental health care for sexual and gender minority youth is of great importance to NIMH.  Staff in the NIMH Office of Disparities Research and Workforce Diversity, as well as other researchers across our institute, work closely with those at other NIH institutes, centers, and offices to support research that can improve our understanding of the complex factors impacting the well‑being and mental health needs of sexual and gender minority individuals and to reduce the mental health disparities experienced by many in this community. 

In particular, NIMH is supporting research that aims to expand the knowledge base of sexual and gender minority mental health and well‑being, remove barriers to planning, conducting, and reporting NIMH‑sponsored research on sexual and gender minority mental health and well‑being, and strengthen the community of researchers who conduct mental health research relevant to sexual and gender minority populations. 

NIMH research efforts in this area align with our institute's strategic plan for research, as well as for the NIMH strategic framework for addressing youth mental health disparities. 

The strategic framework was developed in collaboration with several other NIH institutes, including several of those participating in today's workshops, as well as with multiple other partners across NIH, HHS, and the federal government, and it was informed by researchers and care providers across the country. 

While critical statistics are concerning and many of the presentations during this workshop will focus on risk, we also aim to celebrate diversity, recognizing the incredible resilience, joy, and creativity that sexual and gender minority youth and their families and allies embody, and seek ways to build supportive environments in which sexual and gender minority youth can thrive. 

Before we move on to our next speaker, I'd like to thank very much the NIH Sexual and Gender Minority Research Office for co‑sponsoring today's workshop, and I also want to thank the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute on Drug Abuse, the National Institute on Minority Health and Health Disparities, the National Institute on Alcohol Abuse and Alcoholism, and the National Center for Complementary and Integrative Health for helping plan this workshop with NIMH. 

So, again, thank you so much for your participation today.  I'm looking forward very much to hearing your thoughts and sharing your perspectives and the outcomes of this workshop.  Thank you. 

STACIA FRIEDMAN-HILL:  Thank you, Dr. Avenevoli, for your welcoming statement and the support of NIMH for this workshop. 

It is also my honor to present Dr. Karen Parker, the director of the NIMH Sexual and Gender Minority Research Office, a co‑sponsor of this workshop. 

Dr. Parker was instrumental in the formation of that office in 2015 in response to an Institute of Medicine report, and she has served as director since 2016. 

Dr. Parker received her Master of Social Work from the University of Michigan and her Ph.D. from the University of Maryland School of Social Work.  Dr. Parker began her career at NIH in 2001 as a Presidential Management Fellow and subsequently served in several roles at the National Cancer Institute before leading the Sexual and Gender Minority Research Office. 

And now some remarks from Dr. Karen Parker.  

KAREN PARKER:  Welcome and thank you for joining us today for this critical workshop focused on expanding health research and identifying research opportunities for sexual and gender minority health. 

I'd like to thank NIMH for taking the lead on this critical workshop. 

As was mentioned, my name is Karen Parker, my pronouns are she and her, and I serve as Director of the Sexual and Gender Minority Research Office here at the National Institutes of Health. 

I'm so proud that our office is co‑sponsoring today's workshop, and I'm excited for what we will learn together. 

Our gathering today underscores a glaring truth.  There's an undeniable gap in our understanding of the health needs and disparities faced by sexual and gender minority youth.  While strides have been made in health research, we cannot ignore that there's limited data on the unique challenges and experiences of this population. 

To address this pressing issue, we must first address inadequacies in data collection on sexual orientation and gender identity.  The current landscape falls short in accurately capturing SOGI data from minors, hindering our ability to develop targeted interventions and policies that cater to the diverse needs of sexual and gender minority youth. 

Moreover, the limited research available often fails to capture the full spectrum of experiences within these communities, perpetuating misconceptions and overlooking critical health disparities. 

This workshop serves as a pivotal opportunity for us to challenge the status quo, to push boundaries, and to pave the way for more inclusive and comprehensive health research. 

It is my hope that today's workshop will identify research opportunities to advance this field of scientific inquiry, amplify the needs of sexual and gender minority youth, and drive meaningful change. 

Thank you again, and I'm so pleased to be here over the next couple of days.  

STACIA FRIEDMAN-HILL:  Thank you, Dr. Parker, for providing important context in how this workshop fits into the larger ecosphere of NIH research in sexual and gender minority individuals. 

I'm pleased now to introduce Dr. Monica Webb Hooper, Deputy Director at the National Institute on Minority Health and Health Disparities. 

Dr. Webb Hooper is an internationally recognized translational behavioral scientist and clinical health psychologist.  She's dedicated her career to the scientific study of minority health and racial and ethnic disparities, focusing on chronic illness prevention and health behavior change. 

Dr. Webb Hooper completed her doctorate in clinical psychology from the University of South Florida and an internship in Medical Psychology at the University of Florida Health Sciences Center. 

Before joining NIMHD, Dr. Webb Hooper was a professor of oncology, family medicine, and community health and psychological sciences at Case Western Reserve University. 

Dr. Hooper, we're ready to hear your introductory remarks.  

MONICA WEBB HOOPER:  Thank you so much.  Hello everybody, and welcome.  I am so pleased to join my colleagues and help open this really important meeting and to help draw attention to critical issues facing our society, the mental health of sexual and gender, or SGM, youth. 

This is not merely a topic that warrants attention.  It demands our empathy and, most importantly, our action. 

I'm here to underscore the profound commitment of the National Institute on Minority Health and Health Disparities, or NIMHD, to address the mental health needs of SGM adolescents. 

In October of 2016, a pivotal moment occurred at NIH when NIMHD, in collaboration with the Agency for Healthcare Research and Quality, officially designated sexual and gender minority groups as a population experiencing health disparities for research purposes. 

Now, while NIH already had a history of funding meritorious research on the health of sexual and gender minority groups, this designation marked enhanced focus on research initiatives, programs, and activities across NIH aimed at addressing the unique challenges faced by SGM individuals.  And it recognized the profound disparities in health and healthcare access experienced by these populations, highlighting the urgent need for research advancements to understand the complexities leading to disparate health outcomes among SGM individuals and strategies to address them. 

We are delighted at NIMHD to work closely with Dr. Parker's office, and we know that their office is the coordinating hub for SGM health and research‑related activities across NIH. 

I want to point to two efforts that recently NIMHD has undertaken to help advance this area of science. 

In March of 2023, NIMHD convened a workshop that complements this meeting focused on the leading causes of death and disability in the SGM population, methodological issues and social and structural drivers of disparities in SGM health.  And this workshop is available on the NIH Videocast.  It can also be accessed from the NIMHD website.  So, I encourage you to check that out. 

And then, as a next step to the workshop, NIMHD, along with nine participating institutes and offices, released a funding opportunity in December of 2023.  It's entitled Addressing Health and Healthcare Disparities Among Sexual and Gender Minority Populations, and it will be active until the fall of 2026.  And it aims to support innovative, observational and interventional research to identify and characterize pathways and mechanisms through which health and healthcare disparities occur among SGM populations, specifically of minoritized, racial and ethnic and socioeconomic status backgrounds. 

Now, we know that there are many needs.  And as we seek to address mental health concerns among SGM youth, three things that come to mind for me are interventions, intersectional approaches, and third, pathways to career development. 

So, first interventions. 

Much of the existing research is observational rather than interventional, so increased attention to prevention strategies and treatment interventions that include multilevel mechanisms driving mental health disparities are needed.  Of course, it's important that interventions also promote culturally and community‑competent as well as gender‑affirming and trauma‑informed healthcare. 

We also endorse highly community‑led research approaches that help ensure that community needs are prioritized, and further stigmatization is attenuated. 

Second, intersectionality, which Dr. Avenevoli mentioned.  Intersectionality plays a pivotal role in shaping mental health disparities and treatment access.  And while there have been initial strides in supporting the mental health of SGM youth through promising approaches such as peer support programs and culturally tailored interventions, significant gaps in research persist, and we see these particularly among SGM youth from racial and ethnic, minoritized, and lower socioeconomic status backgrounds.  So, I would also emphasize the need for more nuanced research and interventions that recognize heterogeneity by social status and position. 

And then third, and finally, workforce development. 

To accomplish these goals, we must have a well‑trained and diverse biomedical research workforce, including those with lived experience who bring a socio‑ecological approach to these issues.  And we know that there are challenges in pathways to career development in standard biomedical research among SGM people that need to be addressed as well. 

So, I'll just close with this.  Addressing the mental health needs of SGM youth is a priority.  It's a public health priority.  Positive movement requires collaboration and action through multisector commitments. 

NIMHD is here to support cutting‑edge and meaningful science in this domain, and together we can create a world where all young people, including sexual and gender‑diverse individuals, can thrive mentally, emotionally and physically. 

Thank you so much.

STACIA FRIEDMAN-HILL:  Thank you, Dr. Hooper, for your welcome and explaining how this workshop addresses important themes for health equity research. 

For our final welcoming remarks today, we will hear from Dr. Wilson Compton, the Deputy Director of the National Institute on Drug Abuse. 

Dr. Compton completed medical school and residency training in psychiatry at Washington University in St. Louis.  Before joining NIDA, Dr. Compton was a tenured faculty member in the Department of Psychiatry and director of the Masters in Psychiatric Epidemiology program at Washington University.  And before being appointed Deputy Director of NIDA, Dr. Compton served for more than a decade as the director of NIDA's Division of Epidemiology, Services, and Prevention Research. 

Dr. Compton has been recognized multiple times with the Health and Human Service Secretary's Distinguished Service Award, and he is a Distinguished Life Fellow of the American Psychiatric Association. 

Dr. Compton, thank you for joining us this morning.  

WILSON COMPTON:  Well, thank you very much, Stacia.  And I'm so glad to join my colleagues from across NIH to welcome everyone to this meeting on sexual and gender minority youth and the issues related to development. 

As I was listening to my colleagues, I'm going, all right, I don't have a lot to add, because I really think the key issues in terms of the developmental risks, the overrepresentation in terms of behavioral health concerns have been highlighted so importantly. 

What I hope you all will take away from this set of introductions is how much of a priority we at NIH put on being inclusive and comprehensive in our approach to addressing health issues for a population that's frequently been ignored in research and in science. 

And so certainly on behalf of the National Institute on Drug Abuse, it's my pleasure to help welcome you today. 

I want to highlight two members of the planning committee, Nick Johnston and Angela Lee‑Winn from NIDA, who have been involved since day one in helping to plan this event, which we're so grateful to our colleagues at NIMH in leading us here today. 

So why the National Institute on Drug Abuse?  You certainly heard a broad inclusion about the issues related to behavioral health, and we're part of that concern.  We certainly know that substance use, whether that's tobacco use, cannabis use, or other substances are more frequently seen in sexual and gender minority youth and sexual gender minority adults.  So, what explains this? 

We certainly already heard discussion about the important issues around adverse childhood experiences and how those being more frequent in this population and these persons may help us understand these trajectories. 

But, of course, it's never going to be that simple.  And it's not just one set of factors.  So I encourage you all to focus on not just the risk factors and the problems that persons face in this population and others but also focus on the resilience that we see in so many and the positive growth trajectories that we see more and more frequently represented as some of the hope we have for the future to do a better job of reaching those who continue to be at risk and who need science and behavioral health to address their concerns. 

As we've heard about the issues related to intersectionality from Dr. Webb Hooper, I want to highlight that as well.  We're focused on sexual and gender minority youth, and that's the purpose of this meeting.  I really hope we'll gain some new insights into how there may be overlapping risks for subpopulations and for those that face multiple issues of trauma and bias and discrimination during development. 

NIDA is very pleased to be able to support studies that can be used for secondary analysis or ongoing exploration to address some of these issues.  I highlight for you in particular the project Adolescent Brain and Cognitive Development study, which is supported by NIDA, NIMH, and multiple other NIH institutes as a key resource for understanding the development of adolescent brains as well as adolescent social and developmental trajectories as a key resource for you. 

I'll also point out to you that we think we need to do a better job in terms of standard collection of information about sexual and gender minority status for youth and adults.  And so, I'm excited as an epidemiologist to see population studies do a better job in recent years, but we still have a long way to go to enhancing the standard collection of data across all of our research programs so that all those participating today and others in the future can have a better opportunity to address this important research on sexual and gender minority youth development and outcomes. 

With that, I want to turn it back to Stacia, and I'm so excited to learn from this group about what we can do to have a better and more effective research portfolio going forward.  

STACIA FRIEDMAN-HILL:  Thank you, Dr. Compton, and to all that have provided us with an incredibly warm welcome for this workshop. 

I am so excited about the presentations we're going to hear for the next two days. 

And to get us started on our first panel, I'd like to give the floor to my NIH colleague, Dr. Parisa Parsafar.  

PARISA PARSAFAR:  Thank you, Stacia.  Can you hear me?  

STACIA FRIEDMAN-HILL:  Yes, we can hear you. 

PARISA PARSAFAR:  Great. 

Welcome, everyone, to the very first panel session.  My name is Parisa Parsafar.  I use her/her pronouns.  I'm a developmental psychologist and program officer with the Eunice Kennedy Shriver National Institute of Child Health and Human Development, or NICHD, in the Office of Health Equity.  And NICHD is very proud to be partnering with NIMH and our other NIH institutes on this important workshop. 

The first session today will focus on developmental trajectories of LGBTQ youth, epidemiological trends and measurement of sexual orientation and gender.  And the goals of this session are to promote a broader contextual understanding of the mental health related challenges and stressors that LGBTQ youth have faced historically and are still facing today, ways we can better identify, understand, and capture their experiences, and highlight opportunities to help support them as they grow and develop and manage all the biological, cognitive, and social changes that are happening across adolescents and during the transition into young adulthood. 

We're lucky to have Dr. Kathleen Ethier, Director at the Division of Adolescent and School Health at the U.S. Centers for Disease Control and Prevention, the CDC, serving as our discussant today. 

Among the presentations, you'll hear about historical and developmental discussions of mental health stressors experienced by LGBTQ youth by Dr. Ilan Meyer from the UCLA School of Law, challenges, best practices and opportunities regarding measurement of youth sexual and gender identity from Dr. Alexi Potter from the University of Vermont, and, later, Dr. Gregory Phillips from Northwestern University. 

You'll hear about the latest national research on mental health outcomes and suicide risk among LGBTQ youth from Dr. Derrick Matthews with The Trevor Project, developmental research on the impact of gender‑affirming care from Dr. Johanna Olson‑Kennedy from Children's Hospital Los Angeles, and insights from research on the intersection of autism and gender diversity from Dr. John Strang at the George Washington University School of Medicine and Health Sciences. 

The presentations will be followed by commentary from our discussant, a group discussion, and we'll have time for audience questions through the Q&A feature. 

Dr. Meyer, the floor is yours.  Please start us off.  

ILAN MEYER:  Thank you, Parisa.  And thank you to NIH and for the participating institutes and centers and for the planning committee for putting together this very humbly titled workshop.  I would call it something more like a conference. 

And I'm very, very pleased to be participating in it but also to see it happening.  And, really, my only recommendation is we need this as an annual regular conference.  And I'm sure the planning committee is excited to be over this, but maybe it's time to plan the next one. 

But with that, I would move to my presentation. 

So, we've been talking about how it's going to get better, and I think at this point is enough time for us to begin to look at has it gotten better.  And I'm going to focus on has it gotten better for young people but really for all LGBT people as well. 

It is important to remember that stigma, homophobia, and transphobia are deeply rooted in our culture. 

This image is called "The Shameful End of Bishop Atherton and his Proctor John Childe", hanged for sodomy in 1641 in Dublin. 

Today, 400 years later, almost 400 years later, we're still confronting similar prejudice, even if not hanging.  But this is the backdrop for everything we do and everything we're talking about today, I believe. 

Many of you may be familiar with the minority stress model that is the basis for my thinking about these issues.  I think that the important thing that I want to point out for today is that circumstances in the environment, in particular disadvantaged statuses which are intersectional, as everybody ‑‑ as people mentioned already, and I'm particularly concerned with sexual orientation, gender identity and gender in my work, those lead to different types of stressors but including special stressors or added stressors that are related to prejudices and stigma. 

And those include external distal stressors that come from perpetrators outside but also proximal internalized stressors that come from social culture and history going as far back as I just noted. 

It's also important to note that coping and social support are important moderators of distress and may ameliorate some of the negative effects of stress. 

But what is important really to show here is that minority stress is really a moderator of the relationship between social structure, social status and health outcomes.  And in that, society takes a major causal role in everything that I do and everything that I think we should be concerned about. 

I'm going to report on two studies that were funded by the NIH, and those two studies have somewhat different aims, as I will show you in a minute, but you can read more about them on the websites that are listed at the bottom.  And they have a lot more information, they have publications, and they also have some information about how to access the data.  If anybody is interested in this data, the data is publicly available. 

For the generation study we separated our sample into three distinct age groups which we defined as related to the discourse around LGBT people at the time where the people in these cohorts were around 10 years old.  And we defined three groups. 

The first one, the older people, were 52 to 59 in 2016 when we began the study, and this group was characterized, and we called it Pride or Identity Formation Generation in that those were main themes around the time.  The first Gay Pride March and removal of homosexuality from the DSM were characteristic of that era. 

The second group were 34 to 41 years old in 2016.  And that was a time where AIDS was very much at the center of news, which led to greater visibility as well as institutional advancements for LGBT communities, in particular, to the establishment of health centers and through various, as I said, greater visibility.  Much of it was negative and stereotyping but still led to some changes, including through political activism. 

And the youngest age group which I would focus as a kind of center today for this part of the presentation were people who were 18 to 25 in 2016, and we call them the Equality Generation in that the discourse around them was a lot about demanding equality.  In particular, marriage equality was a major topic around those times. 

And in the generation study, we wanted to basically see something very simple:  Has all the changes that we know occurred in American society over the past 60 years led to better social environments, less minority stress and, therefore, better health outcomes?  This is basically ‑‑ the minority stress prediction would be as things improve, stress is reduced, and health is improved. 

We also wanted to see the sense of community identity and LGBT identity of the people because there's been so much increase in the use of labels that some people suggested made LGBT identity itself already obsolete to some extent. 

So going back to the model, these are some of the ways we measure things. 

So, in terms of stressors, we looked at physical assault.  We also looked at what we called everyday discrimination or, in stress lingo, minor events, such as being insulted.  We looked at the internalized levels of stress like internalized homophobia and transphobia.  And we also looked at identity, as I mentioned; to what extent people are connected with the identity as an LGBT person, whatever identity level they have, and with the LGBT community as a whole. 

There are some articles that you can read that address some of the issues that I cover now.  And, as I said, the websites that I showed before also have a lot of those publications. 

So, what we found.  There were very significant differences between the three age groups. 

The diamond with the dark blue represents the younger age group.  And as you see, they're much younger in all of the coming‑out events, or coming‑out milestones, as they are called.  In particular, if you look at the last line, they're almost 10 years younger when they come out as LGB. 

And for all the groups, by the way, sex with a partner comes after people identify as LGB.  So that is one very distinct difference between the older and younger age groups. 

But when it comes to other types of experiences like stressors ‑‑ this is the experience of conversion therapy ‑‑ we don't see any significant differences, and certainly we don't see a reduction. 

In this slide ‑‑ unfortunately the colors changed a little bit.  So, Equality is what we call gold at UCLA, the yellow, and the Visibility and Pride, which are the older age groups, are in blue.  And you see here that there's not a lot of difference over these many, many decades in terms of how many people are exposed to conversion therapy. 

In terms of exposure‑to‑violence events, if you just look briefly at the color code that I used, the red indicates a higher level.  And without looking at significance level, which many of them are, we see that the Equality or the younger cohort has more experiences of violence compared to the other two cohorts.  And certainly, thinking about our hypothesis, there are definitely not less of them.  And they're more likely to experience everyday discrimination, being verbally insulted, and also more likely to experience stigma and internalized homophobia.  This is the LGB sample. 

Finally, in terms of psychological distress, we have higher levels of distress ‑‑ that is, depression and anxiety symptoms ‑‑ higher levels of suicide attempts ‑‑ again, this is the younger group ‑‑ and we also looked at the connection between suicide attempt and the age of coming out.  And we see for each age group that suicide attempts come after coming out, after realizing that I am gay, lesbian, bisexual. 

In terms of resources, we did see that strength of gay identity and connection with LGBT community are also strong, which was a little surprising because, as I said, people said, well, now these days people are not identifying with LGBT terms.  And we specifically used the term "LGBT community," not queer, not other terms that people might use as individual identity, and show there is still a strong association, which is important because people ‑‑ because all of our efforts to LGBT health interventions come from LGBT community. 

In terms of the transgender population, we didn't have the same hypothesis that there will be lesser ‑‑ lesser stress in the younger generations because we haven't seen a great reduction in attitude towards transgender people.  But we did see that in all of the measures that we used, they are much more likely than cisgender straight people to have experienced stress, and they're also much more likely ‑‑ sorry ‑‑ to experience mental and physical health outcomes.  And, again, those studies are available for you to review if you're interested. 

Finally, we also found challenges in healthcare outcome and healthcare access. 

And I know my time is up now, but I look forward to talking about it more later as we discuss these issues.  Thank you.  

PARISA PARSAFAR:  Thank you so much, Dr. Meyer. 

And now we'll pass it over to Dr. Alexi Potter.  

ALEXI POTTER:  Hello, everybody.  It is just a pleasure to be here today. 

Let me grab my slides up here.  They did not appear.  Hold on just a moment.  Here we go. 

I'm really excited to be here.  Thank you for ‑‑ to everyone who has organized this and is attending this workshop.  It really is an exciting event. 

What I'm going to talk to you today about is really about a resource, and that resource is something Dr. Compton already mentioned, which is the Adolescent Brain Cognitive Development Study.  And I think it's a unique resource that we can use to understand wellness in GSM youth. 

Just disclosures of funding there. 

And I will try to do a heroic thing, which is to tell you about the ABCD study in, like, one or two minutes.  Please go to the website.  If you're interested, it's on the next slide. 

But for people who don't know, ABCD is a longitudinal neuroimaging study, enrolled 11,878 youths in 2015.  All youths were nine or ten when they were enrolled.  They're at 21 sites across the country.  And the idea is to follow them longitudinally to assess and characterize typical development trajectories and factors that influence development. 

The demographics of ABCD matched the ACS, when we recruited, of nine‑ and ten‑year‑olds.  And the study right now in the bottom of the slide here is the timeline of the ABCD study, and the red arrow is where we are now.  Now, of course it spans a little bit, but we're finishing up six‑year follow‑ups and we're running eight‑year follow‑ups.  So, we're kind of in this spot. 

And the most important thing about ABCD is it's done with a full open science model, so there are annual data releases of all of the data. 

ABCD is a very broad assessment battery.  So, you can see that we are assessing all types of things.  And in blue is what I'm going to be talking about, which is our measures of gender identity and sexual health. 

Each of these domains are overseen in a workgroup structure, so there's a workgroup ‑‑ there are workgroup chairs and then people with domain expertise.  We also have members of the consortia research staff there.  And ABCD is done under a U mechanism, so there's also NIH representation as well. 

Once the workgroup has come up with a proposed battery, it goes to all of the investigators and then, finally, voted on by a steering committee. 

And so, I'm going to tell you a little bit about the work we're doing in the gender identity and sexual health workgroup.  This workgroup is a partnership with the CDC.  They approached ABCD and said the Division of Adolescent and School Health at CDC would really like to partner with you to improve measurement of gender and sexuality.  And so that has really been a huge benefit here. 

So, the charge of this workgroup is to recommend developmentally sensitive assessments of gender and sexuality and to provide ongoing QC and monitoring of these data. 

I'm going to take a quick break and just want to always talk a little bit about definitions, so you know what I mean.  And as I'm talking through my slides, I always show the gender unicorn because I think it really perfectly helps us understand that these things are ‑‑ that these constructs are dimensional and that everybody belongs on every line in this chart at some point.  We'll be talking ‑‑ as I show you ABCD data, we're talking about gender identity, gender diversity, and about sexual orientation. 

So how do we measure gender in ABCD?  So, we're taking a few approaches. 

When the study started, we didn't actually have the gender identity and sexual health workgroup.  It was formed after the study started.  So, at the baseline visit, the only question about gender as to the youth was "Are your transgender" with answers of "Yes," "Maybe," "No," "I don't understand this question" and "Refuse." 

Once the GISH workgroup joined, we met with community partners and decided to measure felt gender.  So, beginning at the one‑year follow‑up and asked every year since, all youth are asked "How much do you feel like a boy" and "How much do you feel like a girl" so that ‑‑ and the order of those is determined so the gender that is typical of your sex appears first. 

It's important to mention that felt gender is not gender identity.  Gender identity is an internal thing where you're claiming a gender or choosing a term to use.  So, this is not that.  But we wondered, at this young age, if people could report on their gender and let us get ‑‑ would that maybe be a precursor to identity. 

Starting at the three‑year follow‑up we have moved to the gold standard, keeping the other measures as well, but that's the two‑step gender identity question where we ask, "What was your sex assigned at birth" and "What is your current gender identity."  We've published the results of that recently, showing that that is very understandable to youth in the ABCD study and can be really useful for identifying SGM youth. 

I want to pause for a minute and tell you about the felt gender results because I think this is really exciting. 

So, this is at ages 10 and 11, the first year that we did this.  And the way that this works is across the top are people's ratings of how much they feel like the gender associated with their sex assigned at birth typically, and down the column here is how much people feel like the gender that's not typically associated with their sex assigned at birth. 

The most important things to notice are, first, there are numbers in every single cell.  When you give youth the opportunity to have a dimensional response for these options, they use them.  Also, 1% ‑‑ a little over 1% of youth declined to answer one or both items.  So very high acceptance and understanding by the youth. 

Next, when we look at the numbers, in this top left corner you'll see that 80% of kids respond in a way that's really typical of the binary, feeling totally like they're in line with the gender associated with sex assigned at birth and not at all like the opposite gender.  And then as you move out, you can see the percentages change. 

We ‑‑ this 1‑step, 2‑step and gender minority is just a rubric we've placed on there to understand this better.  It doesn't ‑‑ people can analyze this data any way they want, and there's a lot of information in here.  And I'll just show you briefly what this looks like three years later when youth are 14 and 15.

And what we see is, again, every cell has numbers in it, and our "totally" group, "totally," "not at all," kind of binary gender group is still at around 80%. 

But the real change has happened that people are responding in the 1‑step, 2‑step and gender minority more evenly distributed.  So, I'm just going to go back to show you that here we had 9% in this 1‑step, so close, feeling mostly like their sex assigned at birth and not at all like the opposite or feeling a little like the sex not assigned at birth but totally like their sex assigned at birth.  So, we had nine and then five and four.  And then two years later we have a much more even distribution here. 

We did an initial look at does felt gender have a signal, is it representing something?  And what we see is that even at that 1‑step level, so feeling very aligned with your sex assigned at birth but not entirely anchored, there are measurable differences in mental health problems rated by parents.  And that goes along with that continuum. 

And finally, ‑‑ so if you're interested in using this data, here are the response rates up through the four‑year follow‑up.  So, the "Are your transgender" is the only thing we had at baseline, and you can see that at the four‑year follow‑up, about 3% of youth are saying either yes or maybe. 

The 2‑step gender identity, which wasn't added until three years but is available for those ‑‑ for three‑ and four‑year shows the rates there at four years, about 5% of the sample.  And the way that we identified SGM youth at that point is described here at the bottom.  So, we took anyone who said they were another gender, for example, nonbinary, plus any responses ‑‑ any boy or girl responses that were not typical of the sex assigned at birth. 

And, finally, using that felt gender, if you look at people just in the pink on those graphs I showed before at the farthest away step, we have about 8% of youth. 

So, what we see is that youth are really identifying with gender as a dimensional construct.  And I think that gives us a really unique opportunity to study the development of gender among a large typically developing cohort that is not enhanced or recruited for gender diversity. 

Finally, I'm going to move to the measures of sexual orientation here.  And so, again, at baseline we have the item from the KSADS background, which is "Are you guy or bisexual," single item, with "Yes," "Maybe," "No," "I don't understand" and "Refuse to answer."  Starting at ‑‑ after that we've added the sexual orientation questions.  So, we asked "Which of these bests describe you."  The preamble is "People vary in their sexual attraction to other people.  Which of this best describes you?"  And the answers there are "Gay or Lesbian," "Bisexual," "Unsure," "I use another term," "I don't understand the question" and "Decline to 
answer." 

And, finally, the kind of equivalent or we think could be related to that felt gender for picking up those early attraction, we asked three separate questions.  So, everybody answers, "I'm attracted to girls" from "Not at all," "A little," "A lot", "I don't know," and "Decline to answer."  Same question for "I'm attracted to boys" and "I'm attracted to people who are another gender," for example, nonbinary. 

When we look to see the prevalence rate in ABCD, we see that the method that you use to assess it doesn't seem to matter as much.  So, if I start at the right‑hand side at this five‑year mark, the item from the KSADS identified 25% of youth.  The more kind of gold standard option of which of these describes you is identifying 28% of the youth with 12% identifying as bisexual, 4% as gay or lesbian. 

And, finally, if you look at attraction ‑‑ and the way we were looking at that is including as sexual minority people who have ‑‑ who endorse attraction to people who are another gender ‑‑ for example, nonbinary ‑‑ plus people who have answers that are greater than none for the gender that's not associated with a heterosexual attraction. 

And I just want to give a thank you to all of my team at UVM ‑‑ we are in Vermont, so we make tie‑dyes ‑‑ and to everyone involved.  I'm happy to provide any more information if people want to get in touch. 

And I will stop now and introduce you to Dr. Matthews.

DERRICK MATTHEWS:  Thank you so much.  Let me pull up my slides. 

Happy Pride Month and thank you to the NIMH for the opportunity to speak at this meeting today about the research that we do at The Trevor Project, mental health and suicide with LGBTQ+ young people. 

And so today I'd like for us to just briefly make sure we're all aware of what The Trevor Project does and kind of why we do research, the National Survey on Mental Health, I'll go over some key findings and results and then talk about some of the methodological advances of large data analysis that we do. 

But before we get going, I want to do a quick kind of introduction.  I won't read all these, but I do think it's just important that we acknowledge and kind of ‑‑ that we bring ourselves to this work in a full way.  And I was really encouraged to hear from Dr. Webb Hooper about the idea that we really need to invest in training and diverse workforce. 

And so, for me it's important that I acknowledge that my positionality in this work as a Black, gay, cisgender man, you know, this work is very important to me, and I think it's also critical for how we all collectively humanize this research and humanize the voices of LGBTQ+ young people that we seek to represent and serve with our science. 

And so, The Trevor Project, our goal is really ‑‑ we're the leading suicide prevention organization for LGBTQ+ young people, and the goal is to really just make sure that everyone can see a bright future for themselves. 

And so, we're probably best known for our very important crisis services, which really are aimed at helping anyone in distress or crisis.  So, this is our ‑‑ folks can call in or text or reach out through mobile or the web to speak to a trained counselor and support.  But we also have a lot of activities that are geared towards suicide prevention, and that's the orientation in which all of our research activities are based.  So, our goal is to really make sure not only that folks have an avenue for when they are in crisis, but we do those things that are required to really reduce the risk of folks needing to use our services in the first place. 

And in terms of our research mission, we broadly kind of think about this in three buckets.  The first is our knowledge acquisition, and this is where we are really dedicated with everything, we do from our monthly research briefs to writing reports to peer‑reviewed manuscripts, and we really want to help do our part in advancing the scientific knowledge related to the mental health of LGBTQ+ young people. 

The second is internal knowledge sharing.  And this what makes sure our research actually also supports the activities that go on in our organization so that everything from our crisis services to our advocacy is also data‑driven and informed by research. 

And then, lastly, external knowledge sharing.  So, we want to make sure that what we're learning in our research activities is accessible to folks outside of Trevor and anyone who wants to really kind of take our work and support their own work in supporting the health and wellness of LGBTQ+ young people. 

And so today I'm going to really just go over our key findings in the most recent national survey that we did, the 2024 U.S. National Survey on Mental Health of LGBTQ+ Young People, and you can access all of these online at any time through the 
trevorproject.org.  And we also have ‑‑ we maintain all of the previous year's results as well.  So, if that's ever anything folks are interested in, please feel free to kind of check that out at your own convenience. 

And just as a brief overview of our methodology, we ‑‑ all of our study participants respond online, and so we recruit for a few months.  This year it was from September through December of 2023 via targeted ads on social media.  And so, we also made sure that we engaged in targeted recruitment so that we could really try to do our best and make sure that we have a sufficient sample size with respect to a variety of characteristics; specifically, geography, gender identity, and race and ethnicity. 

This year we were able to end up with a final sample of over 18,000 LGBTQ+ young people who were between the ages of 13 to 24 who live in the United States. 

And so, folks who kind of are eligible and complete ‑‑ they complete a survey, and this includes about 134 sub questions.  And so, this is not a quick survey, but ‑‑ which is why we realize the importance of ‑‑ that we really kind of disseminate what we learn and that we're really appreciative of all the young people who kind of really took the time to complete the survey.  And the survey is offered every year in English and Spanish as well. 

Again, you can see our more detailed methodology on our website.  And know that everything was approved by an independent institutional review board. 

And, also, when I start sharing results, just to be clear, so we're using kind of the umbrella term "transgender and nonbinary" to really help us identify quickly any non‑cisgendered young people in our survey.  And so, this includes other labels that folks have identified, including gender queer, agender, gender fluid, and et cetera. 

And I think kind of the top‑line planning that's really hard to hear but is also really important that I think we keep saying, so nearly four in ten LGBTQ+ young people in our survey say that they seriously considered attempting suicide in the past year, and that 12% of LGBTQ+ young people said that they have attempted suicide the past year.  And I think it's easy to agree that these numbers are just far too high, and we all know that a huge reason for this is the sort of adverse experiences that the young people in the survey face due to their LGBTQ+ identity. 

And so, I'm going to quickly go through some of the demographic differences just so we can kind of get a sense of what's happening. 

And so, we see that it's really the younger folks in our sample, those less than 18, that are the ones that are more likely to consider and attempt suicide in the last year.  So those are really the folks that are often not represented in research because they may be harder to access, but we can see here that they're the ones who really are in need of our services and efforts. 

And we also see some important differences by sexual orientation.  Specifically, I want to highlight that folk who identified as queer, pansexual, or questioning were the ones that really had the average highest rates of considering and attempting suicide. 

And so, as we think about our research agenda moving forward, it's really important that we do a good job in making sure we capture diverse sexual orientation because the ones that we maybe have historically not done a great job of assessing may be the very folks who are kind of at the highest risk and, again, need services. 

Again, by gender identity we're seeing, unfortunately, that transgender and nonbinary, queer, and questioning young people were the ones who had the highest rates of considering suicide and attempting suicide in the last year. 

And by race and ethnicity, we definitely see kind of some patterns here, specifically where the Native and Indigenous LGBTQ+ young folks in our sample had overwhelmingly the highest rates of considering suicide and attempting suicide in the past year, and also those who identify as multiracial.  So, these were certainly the two groups that kind of stood out in terms of race and ethnicity. 

And then, lastly, we also see that a majority of LGBTQ+ young people in our sample had reported experiences of anxiety and that a little over half, 53%, had also reported experiences, recent symptoms of depression.  And for these we used the GAD‑2 and the PHQ‑2 validated instruments to assess this.  And so understanding that the rates of these are so high may also help us understand kind of increased rates that we see in suicide consideration and attempts. 

I also wanted to take a moment to acknowledge that it can be really easy for us to kind of forget, especially when we're communicating to other audiences, that this isn't about kind of individual ‑‑ anything is wrong with folks, but oftentimes these are antagonistic policies driving this. 

And so, a lot of folks said their well‑being is negatively impacted by politics and that folks would consider leaving the state. 

And so, one advantage of using this data is we have the ability for increased statistical power to detect differences.  Because we don't include cisgender straight respondents, we can ask questions that are more specific to queer experiences that might not be practical for larger surveys and that, again, we can disentangle experiences of different diverse subgroups. 

And so, here's just a brief breakdown of some of our demographics.  And I just want to point this out because it just shows that we have the capacity to really look at subgroups without having to worry that we may not have sufficient sample size to do analyses. 

And this is particularly important for me in terms of 
race/ethnicity given what we know about intersectionality and its consequences for health. 

And so, for example, while we have less than 1% of our sample who identify as Middle Eastern or North African, it still gives us enough sample size to be able to do a kind of focused analysis on groups that may not have historically been considered a lot in LGBTQ+ health research. 

And, again, depending on our sort of research questions, we can use this large data set to allow for a lot of different types of analyses.  Control variables and regression models are typical, but we're looking also now at interacting with other variables, stratification, and intergroup analysis. 

And despite all of these advantages, we do realize that large cross‑sectional data is not kind of the end‑all and be‑all of research, so we'll be actually moving from doing this study every year to every other year, and we're excited that now we're going to be engaging in several different studies such as longitudinal research, qualitative research, and also disentangling all of our results at a state‑by‑state level, and then we'll be doing our next survey the following year in 2026. 

And so, I want to thank you all for your time, looking forward to the discussion later, and I'll pass it on to Dr. Olson‑Kennedy.

JOHANNA OLSON‑KENNEDY:  Thank you so much.  I really appreciate the opportunity to be here this morning. 

I'm going to share my slides.  I hope that people can see these.  Okay. 

So, I'm going to talk today about a few things.  Just for recognition, my name is Johanna Olson‑Kennedy.  I am the medical director of the Center for Trans Youth, Health and Development at Children's Hospital, Los Angeles, I use she/her pronouns, I've been doing gender work for the past 18 years, and then I want to talk about a few things that we've discovered in our research. 

But I want to start out by talking about some of the challenges related to research involving trans and nonbinary youth because this is coming up a lot, I think for me in court cases, but has been kind of a common thing that I've heard. 

And the first issue is that the numbers of youth that are accessing services are very small.  This was a study ‑‑ these are numbers from a study that was commissioned by Reuters, done by Komodo Health, looking at the numbers of people who started puberty blockers in the U.S. between 2017 and 2021.  These were considered the first five years of the real increase in the numbers of people accessing services; but, even so, you can see that these numbers are quite small.  Less than 5,000 people, possibly a few more from years earlier than that, but not a lot more. 

Young people who started getting gender‑affirming hormones is around 14,000.  There's some overlap because some of those individuals were getting both puberty blockers and hormone therapy. 

I think it's important to understand this research endeavor identified just over 120,000 young people had received a diagnosis of gender dysphoria in these years, and we're talking about less than ‑‑ around 10% of them getting access to services, which is a really small number.  So, trying to create ‑‑ trying to create large longitudinal datasets is really difficult, and it necessitates multi‑site studies, and those studies are very expensive. 

So, there are some other issues related to research in this population.  Longitudinal data is ‑‑ beyond about five to seven years is not going to be available for a while because especially the utilization of puberty blockers in trans and nonbinary young people is relatively new, especially in the numbers that we need to collect this data, and so we rely on extrapolation from other populations to answer some of our questions. 

The use of puberty blockers as monotherapies ‑‑ so young people who only use puberty blockers ‑‑ it is a small amount of time, relative, so you're not going to necessarily get a lot of information about puberty blockers alone. 

Youth who are progressing to going to hormones are going to age out of pediatric and adolescent care, which also challenges collection of longitudinal data. 

I think probably people know this, but randomized control trials are an untreated control arm ‑‑ or unrealistic and unethical in the population of trans and nonbinary young people, because the interventions exist.  There've been a lot of data about the benefit of these interventions, and so it's very unlikely that people are gonna participate in a potentially untreated control arm of a study.  The current bans on youth care have diminished our opportunities for research in a lot of sections of the country.  The other thing is there's a strong commitment from anti‑trans groups to misinterpret findings.  So, it kind of curtails or certainly puts a limitation on the kinds of data and it creates a lot of distress in thinking about how to talk about the results in a way that isn't going to be misinterpreted.  
The trans youth care United States study thankfully funded by the NIH that started in 2015 is the largest prospective cohort of trans and nonbinary youth.  It is an observational study looking at the physiologic, anthropometric and psychological impact of medical interventions on youth who are new to gender‑affirming hormones and youth who are new to GnRH analogs or puberty blockers.  You can see the Forsyth here, Benioff Children's Hospital in San Francisco, our site in Los Angeles, Ann and Robert H. Lurie Children's Hospital in Chicago, and the Boston Children's Hospital in Boston.  The cohorts consist of 94 young people who initiated GnRH analogs for puberty suppression and the parents and guardians of each of those young people and 315 young people who are starting gender‑affirming hormones.  We've completed visits actually through your forum and are now starting to collect eight‑year data on some of our original participants.   Today, I'm going to be showing you data from the youth who initiated GnRH analogs and our observations about their mental health over time.  I think it's really important to tell everyone who is on this webinar that these are unpublished data.  They have not been peer‑reviewed yet, but I did want to share some of our preliminary findings related to two‑year data after initiating puberty blockers.  Here are the demographics of that cohort.  We used designated sex at birth, because there are multiple identity labels that people use, but it is impossible to do analysis with all of those different labels, which is unfortunate.  I have issues and thoughts about anchoring to designated sex at birth, but for the purposes of analysis, especially in a smaller cohort such as this, we really have to lean into that.  What is important about this cohort, I think, is really relevant for us to think about.  I've heard a few of my co‑presenters talk about this, that the majority of people who were in this particular study are non‑Hispanic or non‑Latino white and this is related to and mirrors what we see across clinical sites as well.  And this is really important for all of us to be thinking about, because it is our job collectively as clinicians and researchers to understand why this phenomenon is happening and increase access for youth from communities of color to this very critical intervention for people.  

We use a lot of data collection measures, but I wanted to talk about the things that folks are maybe more familiar with.  The CBCL ‑‑ so remember this parental report of youth, and across the board you can see that the only clinically significant change was a decrease in rule‑breaking behavior.  I'm going to caveat this by saying, however, that these measures right here are the separate subdomains of the CBCL.  The green area on the graph is representational of non‑clinically concerning ranges.  So, while we may see a small increase in some of these things and a small decrease in some of these things, the young people who are starting out on puberty blockers are in the non‑clinically concerning range at the baseline and they are at the non‑clinically concerning range at 24 months.  Everything in red is the clinically concerning range.  I think this is one of those things I'm delighted to talk about, because the young people in this study are starting out in really good shape and they are 24 months later in really good shape.  

Okay, here is ‑‑ I thought it was important also to talk about the youth reporting on themselves.  The NIH Emotional Health Toolbox is really important for determining specific things such as friendship and perceived rejection, perceived hostility, self‑esteem, loneliness, emotional support.  All of those are in that upper cluster and then BDIY, or measures of depression, are that last line.  And again, just to reiterate the importance of these findings, emotional support, self‑efficacy and friendship all are clinically concerning as some of these T scores are lower than 40, and you can see that in this group, you see improvement in ‑‑ none of these are statistically significant either, or all of these measures are in a non‑clinically concerning range.  And the same is true for loneliness, perceived rejection and perceived hostility ‑‑ again, no significant changes, but beginning below concerning range and remaining at below concerning range.  These are really important findings.  I moved the BDIY into T scores, so people could take a look at this as well.  70 plus is extremely elevated; 60 to 69, moderately elevated; 55 to 59, mildly elevated, and 55 or less is the average score.  

So, these young people who are getting the opportunity to get blockers are doing really well, but I think it also would be remiss not to talk about the fact that if young people have access to blockers in early puberty, which this cohort did, they also have parental support that is a proxy.  When people have access to puberty blockers, they are much more likely to have parental support just because of the fact that they're younger and someone needs to be listening and hearing them about their gender and accessing medical care.  We know that this is a very small number of people who have this opportunity, but this opportunity is a complete trajectory changer for people, specifically for trans‑feminine people, because we know that if they go through a testosterone‑dominant puberty, there are things that they're not gonna be able to walk back.  

Thank you very much.  I appreciate this opportunity to talk about this and want to leave you with, while the use of puberty blockers has been fundamentally attacked and the source of so much distress in the media, especially right‑wing media, it is really important that we maintain this opportunity for people.  And I am pleased to hand the mic over to Dr. Gregory Phillips. 

GREGORY PHILLIPS:  Thank you.  

Okay.  So, thank you for having me.  I'm excited to be on this panel to talk a bit about some of the work that my team and I have been doing in the measurement space.  So as has already been highlighted a bit earlier, although we know adolescence and young adult is a critical time for development of sexual orientation and gender identity, we know that few systems are really well‑equipped to capture accurate and useful data.  A lot of my work focuses on the Youth Risk Behavior Survey.  I'm happy to have heard people talk a bit about YRBS and I'm happy that we have someone from DASH here to be the discussant for this panel, because I think YRBS is one of the fundamental datasets we use to understand SGM trends in youth.  

So, for those who don't know, YRBS is a CDC‑funded biennial study that assesses health behaviors among high school‑aged youth in the United States.  There are two different versions of it, the national YRBS survey created by the CDC and then there's a jurisdictional or local version that states and cities can alter some questions or administer their own versions.  So YRBS covers a bunch of topics, from basic demographic information to violence, victimization, substance use, sexual health.  In 2015 sexual orientation questions were first added to the national YRBS, and then in 2017 the transgender identity or gender modality question was piloted in a subset of jurisdictions.   So, one of the things that my team and I focused a lot on and has been a source of confusion for many of us is this "not sure" category in the YRBS. 

So, in 2019, 3.2 percent of high school students said that they were not sure in response to the sexual orientation question, and this is confusing because it could be interpreted as the students were questioning their sexual orientation; they didn't understand what the question meant, or they didn't know how to respond since none of the available categories are accurate.  So thankfully YRBS updated this question in 2021 that will help reduce interpretation.  We recently published a note on this in JAMA Pediatrics.  So here you can see what the sexual identity question was prior to 2021.  There were four options ‑‑ heterosexual (straight), gay or lesbian, bisexual, or not sure.  In 2021, "not sure" was broken out into three new categories ‑‑ "I describe my sexual identity some other way; I'm not sure about my sexual identity or questioning; and I do not know what this question is asking."  So, this lets us understand more what goes into this "not sure" category.  

And I don't expect you to read all of this or anything.  What I really want you to focus on is really the bottom three lines, which is where what was originally "not sure" is broken out, and you can see how much of a difference there is in each of these categories.  Back in 2019, a total of 4 percent of youth said that they were not sure.  When we get to 2021, this number goes up really high.  We have 5 percent who identify as questioning; 3.5 percent who describe their sexual identity some other way, and a smaller number, about 1.8 percent, who don't know what the question is asking.  And as we all know, there are a lot of differences by sex.  So, numbers are smaller among males than among females, and this is really the first time we're able to see what this "not sure" category actually means.  

The other thing that YRBS asks about, as I mentioned, was gender identity.  So here you can see the transgender question that was piloted in 2017.  "Some people describe themselves as transgender when their sex at birth does not match the way they think or feel about their gender.  Are your transgender?"  This question is fairly typical.  The issue, however, is once we pair it with the sex question.  So YRBS asks, "What is your sex, male or female?"  And while the transgender question lets us identify who transgender is, we can't really say if somebody is trans‑male or trans‑female and it's hard to distinguish who nonbinary or other gender is‑diverse identities.  And it gets really complicated especially when you're submitting papers for review when people are trying to insist that sex is assigned at birth, which we can't really assume in this space.  So YRBS is a great dataset for understanding more population trends.  I was funded during the COVID‑19 pandemic through the RADx‑UP initiative to really study the impact of COVID‑19 on youth and young adults, focused primarily on multiply‑minoritized individuals ‑‑ so sexual and gender minority individuals, racial and ethnic minority individuals ‑‑ and we conducted a study with 1,055 youth ages 14 to 24 throughout the United States.  

So, again, not wanting you to read everything, but some best practices or recommendations we have for collecting measures.  So sexual orientation, we have a "choose all that apply" option.  We use "not listed" instead of "other."  We also know that for epidemiologists, for anyone who works with quantitative data, it can be really hard to quantify who falls into a category if they respond to multiple options.  So, we give them this follow‑up question also, "If you were forced to pick one term, which would you pick?"  So, we give them the option to identify as both, so that we're able to capture that.  So, we ask about sexual orientation this way.  We also ask about sex assigned at birth, pretty standard.  We actually make sure it's mentioned as birth certificate.  

We include intersex identity.  We know that intersex questions are often left off surveys.  So, it's really important to make sure we're asking people if they identify as intersex, and this question we have adapted from our work with Interact.  And then gender identity, we ask about what their current gender identity is.  Again, we have the "choose all that apply," but then we give them the option to select only one.  If they choose more than one, then we ask about gender modality.  So, we're able to put gender ‑‑ sex assigned at birth.  People don't need to say what their sex assigned at birth is, so we are able to use the gender modality paired with their gender identity to figure out what they would identify as.  

And just some overall breakdown of our cohort.  We had pretty high diversity across all of these questions.  So, about a quarter of our 1,055 were transgender.  We had 16% who identified as nonbinary.  A third were trans or gender diverse.  We had a wide array of different identities.  More than a third were bi or pansexual, five percent were asexual or Ace spectrum, 14 percent were queer.  

We also did a qualitative substudy of the work to figure out how the COVID‑19 pandemic impacted youth and young adults, knowing that people were impacted differently depending on what their identities were, where they lived, and we interviewed 34 individuals from 18 states in 2021.  So, we found some differential impacts, but there's a lot of focus on transition.  So, shifts in time, shifts in living situations, shifts in community support systems, and shifts in climate, both political and social.  So, unsurprisingly, the pandemic exacerbated existing stigmatization and introduced new forms of social and policy control, which helped to further isolate LGBTQ+ youth.  This loss of autonomy and increased stigmatization was linked to poor mental health outcomes.  So, the need to protect a person's mental health and safety often overshadowed opportunities for identity exploration and development, and the pandemic unsurprisingly disrupted typical developmental processes, such as identity formation, autonomy seeking, and community in general that people would normally have in‑person, which could have and likely has had long‑term mental health consequences for these youth.  

So, we think that a lot of the pandemic had negative impacts on youth, and we were right about that.  We also found some positives.  So, the two quotes on the left were supportive findings.  So, both of these people were able to find some positive out of the pandemic.  The first person talked about going on Reddit to find people like themselves, to help find a community, to have people to fall back to, to help really develop their identity.  That's also what comes out with the bottom one.  The person was able to really solidify their identity and they were able to take the opportunity to come out to their relatives.  Whereas the ones on the right had a very different experience.  So, people had to go home, they moved in with their parents, they moved to less accepting areas.  People had to go back into the closet.  People had to go into hospitals to deal with mental health challenges, and this was a challenge for a lot of people.   So, what can we do with all of this?  Make the most of existing data.  So YRBS is a great dataset.  There are some issues, but there are issues with any dataset.  So, we tried to make the most of it.  We were able to find trends, we were able to talk about data.  I use it all the time.  I think it's a great dataset and I think it's one of the best places to really find where the critical points are that are impacting youth.  Advocate for all systems to use an expansive list of sexual orientation and gender identity questions.  So, you've heard this earlier; I'm sure you're gonna hear it throughout the workshop, but really giving autonomy and power to the youth to pick multiple terms and to self‑identify with terms that really reflect who they are, recognizing that identity can change over time.  I see so many systems that are only built to collect data at one time point, and we want to make sure that we can collect data over time.  And prioritize qualitative and mixed‑method approaches to contextualize our findings. 

So, thank you for your time and your attention.  I 
want to thank my team for their help in putting together this presentation, and I will turn it over to Dr. Strang for our final presentation. 

JOHN STRANG:  Great, thank you.  I'm John Strang.  I use he/him pronouns, and I'm the director of the gender and autism program at Children's National.  I'm also a research director for our gender development program.  And here are my disclosures.  

So, this final talk for the first panel is dedicated to the common intersection of autism and gender diversity.  So why a talk dedicated specifically to autistic transgender and gender‑diverse people?  Well, since as long as about 20 years ago, gender‑supporting clinicians have been discussing their observations that a substantial subset of gender‑diverse and transgender individuals are autistic or have notable autistic traits.  As of 2024, there are more than 50 studies reporting on the common overlap of autism and gender diversity.  Kelatonaki and Williams' 2023 meta-analysis estimated that across studies, 11 percent of gender‑diverse people have been diagnosed autistic.  This is in contrast to estimates of autism in the general population.  The current estimate is that about 2.3 percent of the general population is autistic.  

Now, the intersection between autism and gender diversity appears to exist at the trait level as well in the non‑clinical general population.  A series of studies in youth and adults have reported significant relationships between autistic traits and gender diversity traits among people who are not diagnosed autistic and who do not identify as gender‑diverse or transgender.  As many of you probably know, we are learning that autism can present quite differently based on assigned sex and gender.  For example, autism may be more easily missed or late‑diagnosed in cisgender girls and women.  Late diagnosis of autism appears to be a particularly common feature among gender‑diverse and transgender people.  A recently published study presented here identifies a four to six‑year timing disparity in the age of autism diagnosis when comparing gender‑diverse and cisgender youth and adults.  In the left panel, we see the autism diagnostic ages for a clinical sample of 1,550 autistic youth.  The red circle highlights the approximate six‑year age difference in autism diagnostic age between cisgender and gender‑diverse young people.  The right panel shows a community‑based replication sample of 244 individuals diagnosed autistic.  Here, we see about a four‑year gap in autism diagnostic timing between cisgender and gender‑diverse groups.  Importantly, in both samples retrospective autism diagnostic dates were obtained, as some individuals are diagnosed autistic before they come to know that they are transgender.  Now, autism diagnostic timing disparities are concerning and especially in transgender youth, who may already face a range of gender minority stressors.  This is because late autism diagnosis means missed opportunities for critical early neurodiversity‑related accommodations and supports.  Also, late autism diagnosis is associated with greater mental health burden and poorer adult quality of life.  

Several reasons have been hypothesized for late autism identification and diagnosis in gender‑diverse individuals.  First, social and developmental differences in transgender youth may be attributed to gender minority stress.  It is not uncommon for transgender kids to be late‑referred for autism‑related supports, because families, schools and providers may at first assume that the young person's social challenges are related to the stress of fitting in as a transgender child.  Another hypothesis for late autism diagnosis in gender‑diverse people is related to cognitive ability.  Emerging evidence suggests that higher verbal IQ is associated with later autism diagnosis.  Interestingly, Thomas and colleagues, as well as collaboration with our group, recently published a study of polygenic profiles across cisgender and gender‑diverse individuals and identified that the polygenic propensity for higher cognitive ability was related to aspects of self‑reported gender diversity.  

It is also important to note that autism presentations other than the traditional well‑known cisgender male profile are often later diagnosed, and this is in part because of the signs of autism in people of other genders, which are less well‑recognized by clinicians, schools, families, and providers.  And, finally, there is a clinical phenomenon described by gender care providers of a substantial subset of transgender youth appearing to be right at the edge or margin of an autism diagnosis.  Being at the margin of autism may lead to a late diagnosis, as notable challenges may appear for a young person only when social demands increase in middle childhood or adolescence.  

In this work presented here, we were interested in this full range of autism presentations among transgender youth, with a particular focus on the many transgender youth who appear to be at the edge of an autism diagnosis.  We used an enriched autism recruitment approach, and through comprehensive autism‑related assessment, we classified the transgender young people into one of three groups ‑‑ those who met full criteria for autism, those who were at the margin of an autism diagnosis, called here slightly subclinical autism, and those who were not autistic.  This was a functional MRI study and we focused on default mode functional connectivity.  Connectivity with a default mode network has in previous studies demonstrated to differentiate autistic versus non‑autistic individuals.  Pictured in the five panels on the right are connectivity findings across five neural regions, showing differences between autistic and non‑autistic transgender youth.  You'll notice in the panels this type of stair‑stepping pattern between the three groups, with the non‑autistic group pictured in the lightest gray showing the least amount of functional connectivity: the slightly subclinical group showing somewhat greater functional connectivity ‑‑ that's in the medium gray ‑‑ and the full criteria autistic group showing the most extreme functional connectivity, and that's in the dark gray.  These patterns align with existing literature on autistic functional connectivity patterns in youth of similar age.  

There are two key conclusions from this work.  First, gold standard autism assessments with transgender youth, such as used in this study, may well be identifying true autism in these kids because neural patterns previously associated with autism are observed in those transgender youth who are diagnosed autistic with gold standard measures.  Second, the observation of a slightly subclinical autistic group of transgender youth may be accurate.  This group showed neural patterns that fall in between the autistic and non‑autistic youth, and the presence of this almost‑autistic group does make sense conceptually given that autism traits and gender diversity traits appear related in the general population.  So, autism at multiple levels may be enriched in gender‑diverse populations.  So, this brings us to a possible classification system for autism among gender‑diverse individuals.  Clearly, the majority of gender‑diverse individuals are not autistic.  Then there is a subset of transgender people who have clear autistic traits, and we might call this the broad autism phenotype, but there is no functional or clinical impact.  We also identify a subgroup who are at the margin of an autism diagnosis.  Early research with this subgroup reports notable mental health burden for these individuals; yet they may fall through the cracks in terms of diagnostics, accommodations, and supports.  And finally, we have the sizable minority who are diagnosed autistic.   Over the years, there has been a great deal of philosophizing about the nature of this autism and gender diversity co‑occurrence.  Two primary theories have emerged.  First, some have suggested a deep biological link, such as specific prenatal hormone levels that may increase the likelihood of both autism and gender diversity.  There has been work studying prenatal hormone levels and later diagnosis of autism, but to study this in the intersection of autism and gender diversity would be very difficult given the required timelines and sample size.  Another theory, which in part comes from the autistic transgender community itself, is that autistic people may be less driven by or moored to social gender norms and this greater distance from social gender expectation may result in broader gender expressions and identities.  

However, there is community concern with asking questions about etiology.  Some advocates in the autistic transgender community have spoken about a double standard put on autistic transgender people.  For example, is there research into the, quote, etiology of being gay?  Do providers need to understand the, quote, cause of being gay in order to provide appropriate care?  Probably not.  Autistic transgender advocates have said that the same approach should apply to the autism and gender diversity intersection, that there should be no research focused on the cause, but instead that we should acknowledge that this intersection is a common feature of human diversity and that the focus of research should be on the needs of autistic transgender people.  And there has been some early work to understand the experiences and needs of autistic transgender people.  Here is our first mixed‑method study of autistic transgender youth which identified several clinical themes, and of those themes, one of them was the impact of neurodiversity.  

I'm going to share with you the words of an autistic transgender young man talking about the impact of neurodiversity as a trans man.  He said, "It is a paradox of self‑awareness, because autism, I think, makes you less aware of your emotions, and to know that you are trans means that you have to be incredibly cognizant of your own mental state and your identity.  So, it's difficult for that reason and it's difficult to plan for all the sort of details and process of being trans, like getting appropriate treatment, changing documents, talking to people about getting accommodations ‑‑ like getting the bathroom at school ‑‑ is more difficult if you're on the autism spectrum."  

I'm going to finish today with some big‑picture ideas of why it may be important for those of us doing clinical and research work with gender‑diverse communities to think about the proportional overrepresentation of autism among gender‑diverse populations.  First, it is important to personalize care given emerging evidence of unique clinical needs of autistic transgender people.  Second, it is important to characterize and account for the proportional overrepresentation of autism and autistic traits in our studies of transgender populations, as autism may explain important variability in outcomes, and this could very much impact the interpretation of study findings.  And finally, it may be important to consider the common intersection in light of the current social and political context.  Specifically, autistic transgender people are increasingly mentioned in transgender limiting legislation, either as a group that is intentionally restricted or as a justification for restricting care for all youth, as seen in the Georgia law.  Yet, neither of the two studies investigating shifts in gender‑related medical requests in autistic versus non‑autistic individuals reported autistic gender‑diverse individuals as significantly more likely to experience shifts or regret.  Clearly, more research is needed on the longitudinal gender trajectories and needs of autistic gender‑diverse people and a critical part of this work will be consideration of how ableism may be driving assumptions about this population.  

Thank you.  

PARISA PARSAFAR:  Thank you so much, Dr. Strang.  And now I'll invite all the speakers to turn on your cameras and unmute your mics to engage in the discussion, and we have Dr. Kathleen Ethier leading the discussion today. 

KATHLEEN ETHIER:  Good afternoon, I'm Kathleen Ethier.  I use her/her pronouns.  I am the director of the Division of Adolescent and School Health at the Centers for Disease Control and Prevention.  I'm really so excited to be with you today and to have gotten a chance to get a little bit of a preview of the presentations today and the opportunity to just say a few words and also really welcome presenters to join in the conversation.  The first thing I wrote down as the session started was, is it getting better?  And I know the question was, is it getting better for LGBTQI young people and certainly want to address that question, but I also want to step back and just talk about the question, is the work getting better?  And from the vantage point of the number of years I've been in this field and have watched the arc of research and the surveillance and other kinds of data questions, it is absolutely getting better.  It is the quality of the research that ‑‑ and I know that what we've been talking about today is the tip of the iceberg, but the quality of the research, the quality of the data, the different types of data that we have available to us that we did not have even 10 years ago, I think is just so substantial and I think can only benefit the young people in the country, which is really the goal of all of this.  

I do want to follow up with Dr. Phillips to say that we did for the first time include our transgender identity question in the 2023 data collection for YRBS.  So that data will be reported when we release the 2023 data starting in August.  So, I'm sure that many of you are waiting with bated breath for that data.  We are as well, and I think to be able for the first time using the national data to use the full LGBTQ+, I think, is really exciting.  I do agree that we do need to start to explore how to add the I.  I think that's probably the next frontier for us, but I think as many of you know, surveillance systems like YRBS don't change easily, don't change quickly, and are designed not to change quickly or easily.  The CDC actually doesn't determine what goes on in the YRBS survey.  So, the standard survey, which is the basis for both the national survey and all of the state and local surveys, is decided on through a balloting process that includes the YRBS coordinators in all of the states and locals who conduct the survey.  So, when we want to make a change in that way, we go to the YRBS coordinators and ballot those changes, and those changes get voted on.  

What that does ‑‑ I think to speak to some of the other issues that have been raised here ‑‑ is that it protects the survey from undue sometimes political but sometimes other types of interference.  So, it remains difficult to easily change a question, take questions off, add questions on.  And so, it kind of protects the system.  On the other hand, it does make it really difficult, as we seem to be a number of steps behind kind of both how young people identify themselves and new and emerging issues that might arise.  So that's something that we always battle with.  
I think that there's real value ‑‑ we're so excited about the data that Trevor Project and other organizations are collecting, because I think what it does is it allows us to go deeper.  You know, YRBS and other kinds of national surveys are about an inch deep and a mile wide.  We collect so many outcomes and it is meant to kind of provide that for the country, but I think the ability to be able to go down more deeply at the survey level is incredibly useful.  And I think one of the things that I would love to see us do, moving forward, is to figure out how to be more collaborative in terms of what ‑‑ from government surveys, what we decide to include on them and then what our partners can include in some of the non‑governmental surveys.  I think that would be really helpful to be able to kind of offset each other in important ways.  

We are so excited to be able ‑‑ and have been since the beginning of the ABCD study, to be able to support the inclusion of sexual and gender questions and so excited to see some of the results as they come out, because I think that that's giving us just a really rich sense of the ‑‑ from very early ages, kind of the progression and the development.  And I think Dr. Strang's research as well is telling us more about the kind of developmental processes.  One of the things that I think that does is it points to some really important directions that Dr. Meyer raised about are things getting better from a societal standpoint.  We know from both YRBS data and from other datasets, like data collected by The Trevor Project, that from a mental and behavioral standpoint, what young people are experiencing is not optimal.  We are seeing much too high levels of emotional distress, anxiety, depression and suicidal thoughts and behaviors among LGBTQI young people, and that suggests to us that even as we are seeing improvements in some of the policy environment broadly, in our own work, the fact that those of us across such a wide swath of investigators, including government agencies, are able to do this work and to have workshops like these two days suggest that there have been changes, but they don't seem to, as yet, be getting to the point where we're seeing positive changes more broadly in the mental and behavioral outcomes for young people.  And I think what I would love to have us discuss are ways in which we can look at the relationship, whether that's kind of looking at individual states that have policies and practices in place that are not supportive of LGBTQ young people or are and being able to track those to differences in the outcomes for young people.  

I want to get to discussion.  I had two slides, one pointing out the disparities in YRBS ‑‑ you all know those well ‑‑ but one other slide that I had that I'm not gonna take the time to pull up is a paper that we wrote ‑‑ thank you.  Go to the next one, this one here.  This is really where I would love to see us more nationally take a look.  So, this is looking at policies and practices that schools have to support LGBTQ young people in districts where we worked.  And what we looked at was ‑‑ we have another system called the School Health Profile System that looks at a whole host of school health policies and practices, and we looked at these four specifically; whether a school has a gender sexuality alliance, whether the school identifies safe spaces for LGBTQ young people, whether harassment is prohibited and whether those anti‑harassment policies are enforced, and providing professional development for educators on the importance of inclusivity in schools.  And what we did was, we looked at whether or not the school had those policies and practices in place in the YRBS data collected in those schools versus schools that did not have these policies and practices in place, what did we see for the young people.  And what we saw was that in the schools that put these policies and practices in place, we saw decreases in depressive symptoms, suicidal thoughts and behaviors, and suicide attempts.  We not only saw that for the young people who identified as lesbian, gay or bisexual, we also saw that among the young people who identified as heterosexual.  And so, what we saw in this particular study is that not only are policies and practices that support LGBTQ young people beneficial for the young people who are targeted by those policies and practices, but they were good for all of the young people at a population level in schools.  

And so this is just one small example of when we look at ‑‑ and you can take the slides down, thank you ‑‑ when we look at the relationship between the policies that are put in place and things that either a community or a state, in this case a school, are doing, does it have an impact on the health and well‑being of young people?  And I would really love for us to be able to look more closely at the impact of a number of things, as several people have mentioned.  When we put anti‑transgender youth policies in place, what impact does it have not only for the young people who identify as transgender but young people more generally?  And I think that can tell us a lot about ‑‑ back to the original question ‑‑ is it getting better?  So, I would welcome any conversation both about those ideas and any others you might have.  I'm happy to now turn it over to see if there's any questions from the audience on any of the presentations that we presented here today.  

PARISA PARSAFAR:  Would any of the panelists want to answer the question before we move to some of the questions from the chat? 

ALEXI POTTER:  I'd actually love to just share a little information.  Just fascinating what you found with the school data, and we did an analysis of the anti‑gender law policies across the state within ABCD.  So, we had about half the kids in protective states and about half the kids in states with negative state laws, and we found from paralleling your information that higher rates of interpersonal violence, bullying and harassment at school not only for gender‑diverse youth but actually for all youth in the sample.  So, a really interesting parallel, and we're actually working with the mass project now to get longitudinal data, so hopefully we can see how that has changed over time.  So, thanks for sharing that.  

KATHLEEN ETHIER:  I think it's a really important point in that folks who are arguing for or against some of these policies are kind of taking ‑‑ are picking a side, and what we are seeing in our data and it sounds like what you're seeing as well is that there is no side, that what is good for one group of young people is good for all young people, and that when you put things in place that target one group or are negative, whether that's intentional or not for a particular group of young people, it negatively impacts all young people.  And I think that speaks to the interconnected nature of young people, but also what that kind of targeting does for the environment in general.  

PARISA PARSAFAR:  And Dr. Olson‑Kennedy, it looked like you wanted to respond to that question as well. 

JOHANNA OLSON‑KENNEDY:  Yeah, I did want to respond to the question, is it getting better.  I think it's yes and no.  I think that our understanding and knowledge in some ways ‑‑ well, prior to all the bans coming into effect, access was really becoming much more available, but I think that the pushback on youth care specifically for trans and nonbinary youth has made the work considerably more difficult.  And I think just reflecting on our own RO1, multi‑site RO1, just the fact that we have experienced nine FOIA requests and these are things that take time, that we're not funded to do.  And I think another thing that's really interesting that people aren't talking about enough is that pediatric hospitals, where a lot of youth care clinics are embedded, are not used to taking on the challenges, political challenges related to their care.  I think that other segments of medicine are, but I don't think pediatric hospitals are.  And the final thing that I will say is that the gender clinics that do exist in safe states right now are having to absorb people coming from other states, and that's another thing that our capacity just doesn't allow us to do. 

PARISA PARSAFAR:  Thank you.  

Dr. Meyer?   

ILAN MEYER:  Yeah, I think ‑‑ I've been really troubled by my own findings and the findings we're all sharing in terms of ‑‑ on the one hand, things are getting better.  There are no doubt public attitudes are better.  Certainly, around sexual orientation there's been a split on transgender issues lately because of some of the attacks on the right that Dr. Olson‑Kennedy mentioned, but the lives of LGBT people are not necessarily getting better, even where things are getting better objectively.  And I think we need to begin to think about more microenvironment than the level of policy that we're thinking of, number one.  So, we interviewed people in part of my study, and we had a young guy who was born in San Francisco, who was talking about ‑‑ he was like 18 at the time, so 2016, and he was talking about things that are very familiar to me from my growing up, about hiding, about shame, about being shamed by his church.  So just imposing policy doesn't honestly penetrate it enough into everyday life of every person.  

The second part of it is religion.  We have to ‑‑ that is, to me, the most difficult area and there are a lot of religious organizations that are very supportive, but there are more religious organizations that make life very miserable for LGBT people.  And I don't know if I can still share, but I wanted to share this.  This kind of helped me, because I think there was a time where we thought things are just getting better and they're going to continue getting better, and I really like this quote from an interview with ‑‑ I borrowed it from his book apparently, but from the New York Times:  "Contrasting the arc of moral universe is long, but it bends towards justice.  History is not an arc bending towards justice but a war of dueling forces, racists and anti‑racists, and each escalate their response when the other advances."  And I think we all, as interventionists, need to take that in.  There was a certain optimism and euphoria at some point that we're all getting better.  Obama was elected president and racism is over, marriage equality was ruled, and homophobia is over, and we know better now.  I think we should remember that lesson.  

PARISA PARSAFAR:  Thank you.  

To build from this discussion of is it getting better and the different perspectives, in the chat we received a question of, how can clinicians and others who are working with LGBTQ youth use the research that you've shared today to help better support and incorporate it into their work?  So how can we translate the research into practice to help make improvements?  

DERRICK MATTHEWS:  I can speak about that briefly.  One of the first things is I think we are able to really assess a lot of the co‑occurring needs and challenges.  For example, we're able to rightly identify that housing insecurity was an issue for a lot of young LGBTQ+ folks.  So, I think being prepared ahead of time with the ability to refer folks to services that could support ‑‑ housing, as an example, is one thing.  And we're also able to see the challenges that a lot of young people face that I think are able to be addressed in kind of clinical encounters.  So, for example, we published ‑‑ a lot of young folks really said they couldn't even envision themselves living to 35 and that they didn't have a lot of purpose in their life.  So those are things that not only are associated with suicide attempts, but they're also kind of ways we can engage folks in conversation that might be easier for young people to do than to just give a clinical assessment and have a much more like cold interaction that way.   

So, I think there's a lot of things there.  There's also we know a lot about individual and community‑level resiliency that folks find that are really helpful and I think learning from that, those are the things that I think we can kind of use and leverage when we're talking with young folks. 

PARISA PARSAFAR:  Thanks.  

Dr. Strang?  

JOHN STRANG:  I just wanted to add that whenever we talk about the application of research to clinical practice for LGBTQIA+ people, we have to acknowledge that in this country there's a huge disparity in access to clinicians, that we do not have enough clinical access for patients.  Wait lists of one to two years for patients who might be coming in for a gender consultation are pretty normal across the country, and that's in metropolitan areas.  So, for families a few hours out, these disparities are great.  So, it is a little bit of an idealistic conversation to talk about the application of research to clinical practice when we have such a crisis in the country for our youth. 

PARISA PARSAFAR:  Great points.  

And Dr. Olson‑Kennedy. 

JOHANNA OLSON‑KENNEDY:  Yes, I can't stress that enough.  And I will add that our access to mental health services, all of the things that we know come along with the experiences that we've seen so much of today are also desperately needed, and certainly we know there are service deserts, not just in specific states but even in the rural communities in safer states.  Especially for trans youth but for all youth, access to mental health care is in serious jeopardy with an increasing population of young people who have need for that.  

PARISA PARSAFAR:  Other questions in the chat are sort of surrounding the school environment and what we can do to promote more diverse activities in school environments that might be less supportive initially, and also how folks are thinking about these initiatives in schools that are more supportive of LGBTQ youth, how it's having an impact on the school environment more broadly, including the staff and personnel as well.  So, if anyone has thoughts about that from their work, or what can be done in schools. 

KATHLEEN ETHIER:  I will say that in our work with schools, we're making great progress and I think we've seen in the last two years or so a change in the arc of progress for LGBTQ youth.  I'm hoping that will start to change again.  I mean, I think when young people in the entire country are experiencing a mental health crisis and we start to be able to call attention to the fact that in the places where we are putting laws and policies and school‑based practices in place that are actually harmful for the full range of young people, then that school will start to see kind of a backing off of some of those anti‑LGBTQ policies and practices.  That is my hope.  We actually know very clearly from ‑‑ the slide kind of gives us a couple of them.  We know pretty clearly what schools that can do is helpful and supportive and works.  So those are things like having places for young people to gather where they can share identities, having safe adults easily accessible and identifiable, making sure that we are not ‑‑ that everyone knows that bullying and harassment is not allowed, and making sure we provide information to all of the people who look at schools and who work in schools as to why this is important.  
I mean, those are four kinds of really broad categories of things that are really effective.  When we do those things, I think we also see improvements in the health and well‑being of the LGBTQ staff who work in a school, and I think that ‑‑ we haven't studied that in as much depth, but we have heard that in the places where laws and policies have changed and teachers and school staff feel discriminated against or feel that there's stigma added or, in some cases, have lost their jobs because they have been out at work, making sure that we support not just the kids but also the adults in any system is really important. 

PARISA PARSAFAR:  Thank you so much.  

More questions more broadly in terms of the original question you posed.  In terms of whether or not things are getting better, do you think that there's shifting expectations of what constitutes well‑being in general?  For example, younger LGBTQ+ individuals might have higher expectations for understanding well‑being and how they should be treated, but these standards aren't necessarily being met yet.  

KATHLEEN ETHIER:  I think that's a great point.  I would love to hear what some of the other panelists might glean from the work they're doing. 

ILAN MEYER:  I think that is kind of turning around the problem to the young kids in some ways, like saying they have expectations, but I think we see from the data that it's not just about expectations, it's about very serious objective measures of health and well‑being that are not met by the education system.  You mentioned YRBS ‑‑ to me, that is kind of like a thermometer.  I always go when you publish results to look at the suicide data on LGBT youth, and every time so far, I've been terribly disappointed.  So, I think until we change those things, we can't really think that they are an expectation problem or expectation gap, but more of a delivery gap in terms of what they're receiving.  

PARISA PARSAFAR:  Any other thoughts?  Yeah, go ahead.  

JOHANNA OLSON‑KENNEDY:  I think we can't underestimate the value of social media in this regard.  I do think that young people absolutely connect around understanding and supporting other LGBTQ youth, and I think that's really exciting. 

And also, the algorithms, we always talk about them being bad, but I think they can be really valuable for young people looking for community but also around expectation‑setting, certainly around access to care, but also just equity in general. 

I just want to pop back to the school thing for a minute, which is if we continue to erase the progress that we've made in school, for example, like certain books and things that expose young people to all kinds of trajectories of human development, that's really problematic not just for LGBTQ+ youth but for all youth. 

And I think there's going to be ‑‑ what worries me is there's this rip where there's going to be a much bigger disparity in, ironically, the states that already were struggling to incorporate this. 

And I really appreciate ‑‑ I wish I could remember her name ‑‑ that said all of ‑‑ anti‑racism and a broadening of people's minds, it needs to be built in and not tacked on.  So, teachers in school systems can embed all of these things into the way that they teach.  I think that's really important. 

PARISA PARSAFAR:  Thank you so much for highlighting both the challenges that we still have to address as researchers and clinicians and those that are engaging with the youth as a society more broadly but also some of the structures and initiatives, we already have in place that can be expanded and built out to help support them. 

Thank you all for being here with us today.  These were wonderful presentations and discussion. 

We have a break now until 1:30, and then the fun will continue.  So, thank you, everyone, and have a great break. 

[ Break.]

CRYSTAL BARKSDALE:  Shall we start?  Okay.  I think we're at 1:31, so I think we will go ahead and get started. 

Good afternoon again, everyone.  My name is Crystal Barksdale, and I want to welcome you back to our conference.  I am a program director at the National Institute on Minority Health and Health Disparities, and I'm going to be your moderator for our next session entitled Social and Structural Determinants of Health:  Community, Culture and Policies. 

This session is going to highlight the translational and multilevel research on those community, social and structural‑level social determinants of health that are important and impact mental health outcomes among our sexual and gender minority youth. 

Today, this afternoon, we have featured several speakers which I'm excited about, and I hope you are too. 

First, we will hear from Dr. Skyler Jackson from Yale School of Public Health who will be talking with us about multilevel stigma and depression among Black and Latino LGBTQ+ adolescents. 

Then we will hear from Dr. Roberto Abreu from the Department of Psychology, University of Florida, who will talk with us about the importance of cultural values and traditions for LatinX LGBTQ youth, their families and communities. 

Next, we'll hear from Dr. Jane Hereth from University of Wisconsin, Milwaukee, who will discuss the mental health needs of LGBTQ+ youth involved in the juvenile justice system. 

And then we will hear from Dr. Dana Prince from Case Western University who will discuss the research and practice gaps and opportunities related to SGM youth involved in various public systems. 

Then we will hear from Dr. Kerith Conron from Williams Institute at UCLA School of Law who will discuss with us how state policies and school environments may converge to either reduce or exacerbate mental health inequities among LGBTQ youth. 

And then we'll hear, lastly, but not least, from Dr. Meg Paceley and Spencer Evans, both from University of Connecticut School of Social Work, who will talk about the impact of anti‑trans policies on the mental health of gender‑diverse youth. 

Our discussant, Brian Altman, who is the director of the National Mental Health and Substance Use Policy Laboratory at the Substance Abuse and Mental Health Services Administration, or SAMHSA, will then provide some comments and lead us in a discussion of this panel. 

So, I turn the virtual floor over to Dr. Jackson to lead us off.  Thank you. 

Dr. Jackson.  

SKYLER JACKSON:  Hello, you all.  Great to be here today. 

I'm going to go ahead and share my slides and make sure what you all are seeing. 

Oh, that's not what I want.  Let's see.  Let's try this again. There we go. 

So, it's my pleasure to kick off this discussion and this series of talks on this topic.

As was mentioned earlier, I'm going to be talking about a study where we attempted to look at stigma across multiple levels and also in various types or domains to understand depression among Black and LatinX LGBTQ adolescents.  So, let's go ahead and dive in. 

So as many of you are likely acutely aware, there's some major mental health disparities among LGBTQ people as compared to their heterosexual and cisgender counterparts.  This is one of the most persistent and enduring mental health disparities in psychiatric epidemiology.  And unfortunately, what we know is that adolescents are not immune to these sorts of mental health disparities.  In fact, by virtue of their dependent legal status and being in a sensitive developmental period, they may be disproportionately at risk of some of the health‑eroding forms of stigma known to drive these disparities. 

In fact, that idea that stigma is the real culprit that drives these disparities is something that we take to be true now but has not always been the case.  If we dial back 50 years, we know that the disparities that we see in mental health between LGBTQ folks, adult and youth, versus their heterosexual cisgender counterparts were mostly explained through pseudoscience, through myths, that somehow being a sexual or gender, quote, unquote, deviant somehow made you, in and of yourself, pathological, and that that made you more prone to psychopathology. 

Today, fortunately, we have science that gives us a better understanding of how stigma actually leads to downstream problems in health, and that allows us to put the blame where it really lies with an environment and context of stigma. 

So today we know that social stigma that LGBTQ people face is something that both drives and maintains mental health disparities as faced by LGBTQ youth as compared to their heterosexual and cisgender counterparts.  We have an accumulating body of literature that shows these effects pretty robustly across time and across subgroups. 

However, there are a couple of areas of gaps in the literature that we still need to advance the literature on.  And I want to talk about two. 

First is that we have uneven attention to how stigma manifests to drive mental health disparities across multiple levels.  So, what I mean by that is that, fortunately, we have a really robust body of that literature that looks at interpersonal everyday experiences of bias, discrimination, bullying, cyberbullying that LGBTQ adolescents might face.  We have also a pretty big, although slightly smaller, body of literature that looks at how the negative anti‑LGBTQ sentiments that exist in one's world can get internalized, leading towards internalized homophobia or biphobia or transphobia.  So that literature base we have as well. 

But the smallest of the levels, data sources and empirical basis is that for structural level stigma.  We have very little research, comparatively, that looks at how structural‑level factors actually get under the skin to cause downstream problems with mental health, particularly for LGBTQ adolescents. 

This is something many of us are thinking more about these days because we know that we are in unprecedented times when LGBTQ individuals' dignity and rights are being debated and legislated at the state and federal levels on an ongoing basis.  As you can see, even as of just last week, the ACLU is tracking over 500 anti‑LGBTQ bills in the U.S. 

But it's really important to remember that when I'm talking about structural‑level factors, unjust laws are only one part of the broader picture.  So, in addition to that, we have to think about things like anti‑LGBTQ discriminatory policies.  This can occur in one's school, at one's place of work, within the healthcare setting, et cetera. 

We also want to be thinking about the broader fabric of oppressive social norms.  So, this can be at the community, state, or even societal level where we see that norms that embody an anti‑LGBTQ stance can actually represent something more structural as opposed to thinking about them only as individual factors. 

And, lastly, we want to be thinking about unequal access to resources, particularly resources, whether they're in terms of people, people‑based resources, but also things like access to spaces that affirm one's identity.  We can think, for example, in terms of the availability of safe and affirming bathrooms for trans‑identified individuals. 

All right.  So, with those gaps in mind ‑‑ with that gap in mind, I want to talk about a second one, which is that we have inadequate attention to stigma and its multiple forms.  So, we know that LGBTQ adolescents, because they are sexual minorities and/or gender minorities, are at risk for at least one or two forms of stigma, but that doesn't make them immune to potentially facing other forms of discrimination, bias, and stigma. 

For example, the populations I'm focusing on today, Black and/or LatinX LGBTQ adolescents, are at high risk for facing things like racism and xenophobia in addition to anti‑LGBTQ sentiments. 

We have intersectionality, which comes from Black feminist activism and has been discussed in the academy within legal studies in critical race theory, and it aims to understand people's individual risks and resiliencies as they navigate multiple systems of power. 

Scholars of intersectionality argue that one's experience of oppression is really greater than the sum of their parts, and that if we want to understand that interlocking nature and study it, that it's best to do so in a way that studies them simultaneously in an integrated manner.  This is something that we see increasingly but still relatively rarely as most minority health disparity research focuses on one aspect of minority status and isolation from others. 

That said, we do have research that's looking at how anti‑LGBTQ stigma and racial/ethnic stigma might land in the lives of LGBTQ people of color and, in particular, how it affects depression. 

So, at the interpersonal level, there's a lot of research ‑‑ I'm just giving a couple of examples ‑‑ that show that both anti‑LGBTQ stigma and racial ethnic stigma are associated with depression and, in fact, research showing that they may have a multiplicative effect on depressive symptoms among sexual minority adolescents of color. 

Although much smaller, there's some research at the structural level.  I'll give one quick example of a study by English, et al., in 2022 that showed that when looking at depression, anti‑LGBTQ structural stigma and racial ethnic structural stigma are both associated with depression among Black sexual minority adolescent males but not among White sexual minority adolescent males, telling us that there's something intersectional in how these forces of oppression might land in the lives of these individuals based on their racial positionality. 

All right.  So, considering those gaps, I want to talk about a research study briefly where we tried to address some of these challenges. 

So, the present study wanted to look at various forms of stigma.  And there's sort of two ways we varied the way we looked at it.  So across multiple domains, so including race/ethnicity but also sexual orientation and gender identity, but also different levels, so looking not just at interpersonal everyday experiences of stigma and bias but also structural‑level factors and to look at how those different forms of stigma, together and separately, might be associated with depression among a highly stigmatized population, Black and LatinX LGBTQ adolescents. 

In order to facilitate this, and as something to share with science, we wanted to develop and test the new composite index of state‑level adolescent‑focused LGBTQ structural stigma to look at how that relates to depression as well. 

The data source for this study is the national LGBTQ+ adolescent teen survey.  It was conducted in collaboration with the Human Rights Campaign, The Trevor Project, and Planned Parenthood.  There were over 2500 young people in the study, ages 13 to 17.  They all lived in the U.S. but across various states. 

This is a snapshot of their gender identity, sexual orientation, and race and ethnicity, but please know that these statistics are not ‑‑ these counts are not mutually exclusive, meaning somebody could have identified as both Black and LatinX in the present study. 

Our outcome of interest is recent depressive symptoms, and that was measured using 10 items from the Kutcher Adolescent Depression Scale. 

So, the first series of results I want to share are just some basic things that corroborate things that we already see pretty robustly in literature, and that is that different domains of stigma, in this case racial/ethnic bullying, was how we looked at interpersonal stigma, and also sexual‑orientation‑based bullying, how these two forms of bullying might jointly or independently and uniquely predict depression.  So, in this study, as expected, we did find that both those who endorse racial/ethnic bullying and those who endorsed sexual orientation bullying, that those were both associated with greater odds of recent depression. 

We looked at these things to see if these had effects above and beyond one another.  So even after controlling sexual orientation bullying, racial ethnic bullying still predicts recent depressive symptoms.  And the same is true for sexual orientation bullying, that even after controlling racial/ethnic bullying, we see a unique association in terms of greater odds of recent depression. 

The last thing we looked at was some interactions.  I won't go through every result, but we'll talk about the most interesting one because it sorts of grapples with some intersectionality; and that is that as compared to those that endorsed neither 
racial/ethnic or sexual orientation bullying, those that endorsed both forms, we saw nearly 2.5 times greater odds of recent depression.  So, keep those in mind.  We're going to come back to some of these variables in a moment. 

The next thing we wanted to look was this development of an adolescent‑focused structural stigma index for LGBTQ issues.  We looked in every state, and we looked at domains where we could find pretty broad state‑level data across the country in almost every state.  And we looked at seven different areas that we considered to be possibly protective for LGBTQ adolescents and two that we would think would be harmful, such as the presence of "Don't Say Gay" legislation or really negative implicit attitudes measured through the implicit association test averages in that state. 

As you can see, we looked at various domains, again, in every state to see whether they had anti‑bullying legislation, whether they had state conversion therapy bans, and we tried to have some diversity, although this is heavy in laws and legislation, to even look at things like social attitudes and sort of access to people‑based resources as well. 

So, on a state‑by‑state basis, we found pretty pronounced support that, for example, youth living in states with more LGBTQ+ public officials or with a greater density of GSAs or with anti‑bullying legislation, so on and so forth, almost across the board had lower rates of recent depression. 

And the opposite was true with the harmful effects.  I will say that the "Don't Say Gay" legislation row you see is non‑significant.  That trend was in the expected direction, meaning the youth in those states did report worse depressive symptoms, but it was not significant, and that is because this data was actually collected at a time when "Don't Say Gay" legislation was actually relatively rare and new.  That comes from data collected in 2015, and we needed to use data that old because we wanted to ‑‑ the data collected from the adolescents in the study was in 2017. 

So next up, and in some ways more excitingly, we used these various areas of protectiveness and harmfulness to create a composite index.  And what that means is that for ‑‑ in a given state, for every protective factor that they had, we gave them a negative 1 and for every harmful factor they had they got a plus 1.  If you do that math, that means every state got a number between 2 and negative 7, and this represents how the states with the most anti‑LGBTQ structural stigma got a 2 all the way down to those with the least anti‑LGBTQ structural stigma got a negative 7. 

This is the map that came from it.  Again, I want to note that this map is already outdated because there's been so much movement, the most glaring of which to many of you all might be Florida, which I imagine, based on changes in legislation over the past six to seven years, might be red, but on here at this time, based on the indicators we used, was actually more towards the middle. 

And we did find a dose‑dependent relationship between youth living in the states with the highest structural stigma versus the least.  I'll give you just one statistic, which is compared to the Black and LatinX adolescents who lived in the states with the least structural stigma, those who lived in the states with the most structural stigma had 32% greater odds of recent depression.  

CRYSTAL BARKSDALE:  Dr. Jackson, I'm so sorry.  You just have a few more minutes.  Just one more minute.  

SKYLER JACKSON:  This is my last statistic, so right on time.  

CRYSTAL BARKSDALE:  Thank you.  

SKYLER JACKSON:  Of course.  Thanks for the time check.  
So, the last thing I want to share is that our last thing was to look at whether anti‑LGBTQ structural stigma still predicted depressive episodes, depressive symptoms, above and beyond 
racial/ethnic and sexual orientation bullying, and indeed we found that it did. 

So, you can read more about this in the published study that came out in 2023.  I'm not going to go over this, but these are things you might look for are some of the ways that structural stigma actually might be predicting depression among these young people.  And we also talk about some key limitations, for example, the lack of a structural stigma index for racism in the study, as well as opportunities for intervention. 

I want to thank folks who were involved, from coauthors to folks that contributed to the data collection and many funding sources, including NIMH. 

And that's all I've got.  So, I'll stop sharing my screen here, and I look forward to hearing from the rest of the presenters.  Thanks for your time.  

ROBERTO ABREU:  All right.  I think I'm on next.  I'm going to go ahead and share my slides. 

All right.  Hello, everyone.  Thank you so much for being here.  Thank you, Dr. Jackson, for the wonderful presentation.  I look forward to the rest of our time together. 

Once again, my name is Roberto Abreu.  Pronouns are he/him and el.  I am at the University of Florida Psychology Department, and I'm the PI of the Collective Healing and Empowering Voices Through Research and Engagement, or the Chevere Lab, and I'm excited to talk to you today about LatinX LGBTQ youth and their families and communities.  And specifically, what I want to focus on is patterns and things that I have observed throughout the years in my research with LatinX LGBTQ individuals and their families and the importance of cultural values and traditions and the importance of not seeing all LGBTQ folks as one big group and really taking into consideration those cultural pieces. 

Again, I will just touch briefly about some of the research that I do and then focus mostly on those LatinX cultural pieces, my research with LatinX LGBTQ youth and their families.  I'll talk a little bit about implications for next steps and ‑‑ yeah ‑‑ and I think that will be our time. 

All righties.  So, broadly speaking, my research looks at ‑‑ I'm really interested in looking at how LGBTQ people and specifically LGBTQ youth and their families and communities interact with each other.  Right. 

So, what that really means is that I look at LatinX LGBTQ youth and their families' mental health outcomes not just for the LGBTQ person but also for their parents, families, and what is most important, the role of culture in these relationships, in these interactions.  I also look at trans youth and their parents and, more broadly, the interaction between LGBTQ individuals across lifespan within their communities. 

Because we only have a short time today, I want to focus today specifically on LatinX LGBTQ youth and their families. 

All right.  So, before we even get there, right ‑‑ so what do we know about research about the experiences of LGBTQ youth and their parents, right?  So, generally speaking, when a parent accepts and supports their child, right, we see positive outcomes on the LGBTQ person; for example, higher positive identity development, higher self‑esteem, better mental health outcomes.  Right. 

And the opposite is also true.  When LGBTQ youth report more rejection or less acceptance, we see higher substance use, sexual risk‑taking behaviors, internalized stigma. 

Now, something to note from this research is that it generally looks at the experiences of LGBTQ individuals themselves or that of their parents and family members.  Very few research actually looks at the (inaudible) experiences.  Also, most research really looks at the experiences of LGBTQ individuals and their White mothers.  Right. 

So, we know a lot about how is it that LGBTQ folks are interacting with their mothers, specifically White mothers.  Right?  We know very little about fathers.  So, we know very little ‑‑ we know less about the experience of LGBTQ individuals of color and their parents and family members. 

So, another way to look at this is minority stress has a direct relationship with mental health outcomes for both LGBTQ youth and their parents and family members.  Right?  Family relations both, one, have a direct relationship to mental health outcomes, such as rejection of one's LGBTQ child, and two, it also serves as a buffer in the well‑being of LGBTQ youth.  Right. 

Again, another limitation of this research is that it assumes that all LGBTQ youth are having the same experience regardless of race, ethnicity, culture, background overall.  Well, certainly there are studies that compare the experiences of White versus BIPOC LGBTQ youth in the context of their experiences of being accepted or rejected by their parents and family members. 

Most of the time ‑‑ and it's not done intentionally, but a lot of times it promotes a more racist narrative.  What I mean by "racist narrative" ‑‑ what I mean by this is that most of the studies often kind of compare LGBTQ youth of color to their White counterparts.  It often concludes that LGBTQ people of color have less support, right?  And a lot of conclusions are made as to why that is the case.  Right. 

And it really leaves this big void, right, for researchers to fill, and many of these conclusions fail to capture culture, right, traditions, histories that is cultural, that different cultural groups have. 

So, I think this narrative ‑‑ so this narrative could be particularly harmful because it often implies that communities of color are both more homophobic, more transphobic, more biphobic and otherwise more exclusionary of their LGBTQ members. 

Now, I think we can all agree the systems of oppression that affect LGBTQ youth are not exclusive to a particular group, including communities of color.  Right?  But when we use the only lens to interpret parent‑child relationships, we create this universal kind of narrative about what is happening in this relationship between LGBTQ youth and their parents and family members, right, that really presents White communities and White parents are safer than parents and communities of color to LGBTQ folks.  Right. 

And that's kind of where my work comes in, the work that I've been doing the last few years, specifically with LatinX families and LatinX individuals.  Right?  I've been trying to understand what cultural values and beliefs and traditions are at play here, right, in the absence of their White counterparts.  I really want to understand, right, what is happening, how the parents and family members are thinking about their interaction with their LGBTQ youth member, right, what the LGBTQ youth are telling us are happening within their community with their parents. 

So certainly, some of the studies that we have done with LatinX LGBTQ youth, right, with microagressions and the effect of microaggression on depression, sexual harassment and depression, and the role that parents have. 

What we've learned is that, yep, parents' acceptance actually serves as a very strong buffer in these relationships.  Right?  We've also conducted qualitative studies.  All this work has been qualitative and also quantitative.  We've also conducted qualitative studies and asked, like, so what specifically culturally is happening in these relationships?  Right.  

So, we've learned a ton about specifically what is happening with LatinX LGBTQ folks but also with their parents and families from a cultural lens, right, in trying to understand what is happening in this relationship. 

But we've also conducted other studies with LatinX parents and family members and asked them about their relationship with their child.  Right?  We've talked to fathers of trans youth.  We have talked to fathers of sexual minority folks. 

But even when we do studies, they're not ‑‑ we do not necessarily ask about relationship with parents and family members.  Right?  For example, we've done a series of studies with trans LatinX folks and asked them about their other experiences with healthcare providers, their experiences seeking jobs, their experiences just within their communities. 

These cultural pieces and how they relate to the relationship with their parents, with family members, are often very salient.  So, what we have been able to see in our research is that how is it that this ‑‑ the LatinX cultural values, beliefs and traditions are at the core of this family community experience when it comes to LGBTQ folks and their communities and their families.  Right? 

And, therefore, we really ‑‑ I really posed the call that, you know, that research questions, analysis and findings must be conceptualized from, at the very least, keeping in mind very specific cultural pieces in order to truly understand what is happening in this relationship. 

Some of this, what I'm going to present to you, is kind of like themes that we have seen throughout the years of how is it that the different cultural pieces, the LatinX cultural pieces, are at play here. 

So, some of those are family and community support, although there are some studies that have specifically looked at family support, for example.  What we have learned specifically through our qualitative work is that it is more nuanced than just family support.  Right? 

Gender norms are also extremely important, some marianismo, or the role of Latino women within the culture, or machismo, or more like hypermasculine type of interactions, a more aggressive type of behavior, right?  Or caballerismo.  I will go into more detail in the next few slides.  And religion and spirituality, right?  So, these have been kind of like core cultural pieces that have shown up in our work. 

So, when it comes to family and community, what we have seen is that it's a lot more nuanced.  Right?  So often LGBTQ youth, but also their family members, talk about receiving support from family members during the process of accepting their child.  Right?  They often talk about navigating family dynamics, so balancing family members' different reactions to LGBTQ people and issues, right?  Maintaining harmony in the family unit is a big one that often shows up in our work and seeking support from other LatinX family members specifically. 

So, when it comes to gender norms, referring to machismo, so coping and reframing within the cultural context in order to accept family members, caballerismo, emphasis on Latino, sense of loyalty, family and emotional connections.  Right?  Marianismo, emphasis on the roles of Latina women within the culture to help these family’s kind of understand and accept their LGBTQ child better. 

Respeto.  It's more than just respect.  It's more kind of like this cultural piece of how to interact with elders but also this aspect of, like, people deserving dignity often shows up in our work as well. 

And religion and spirituality, either embracing religion and spirituality, rejecting ‑‑ it is oftentimes reframing religious messages ‑‑ often shows up, and it often shows up throughout all of our work.  And I just kind of, like, went through them really quickly. 

So, some main takeaways are parental acceptance and family acceptance of LGBTQ is not universal.  And specifically, when working with LatinX LGBTQ folks, I think cultural values, traditions and ‑‑ they play a significant role in this relationship, and the interventions must be culturally specific to this community, taking into consideration these cultural pieces in order to actually see outcomes. 

So ‑‑ and this is kind of the first slide ‑‑ one of the first slides I showed you.  I guess one of my biggest takeaways is, like, we cannot understand really what is happening here if we do not understand the cultural pieces.  And I will take it a step further and say that further research, really what we need to spend time looking is not just at the cultural values and traditions but how is it that those are interacting specifically within specific systems of oppression as well. 

And here's a shout‑out or ‑‑ to collaborators with whom I do this work throughout the United States, Dr. Aldo Barrita, Russell Toomey, Drs. Gattamorta, Gonzalez and Perez‑Brena. 

And I think this takes me to my time.  I look forward to questions and answers.  

JANE HERETH:  Hi, everyone.  I hope you can hear me, okay.  Just bear with me for a moment.  Okay.  And hopefully you can all see those slides. 

So, thank you all for attending and taking the time to be here today.  Thanks also to the organizers of this event, and happy Pride Month to everyone. 

My name is Jane Hereth, I use she or they pronouns, and I'm an assistant professor of social work at the University of Wisconsin Milwaukee. 

Today I'm going to be talking about mental health needs of LGBTQ+ youth involved in the criminal legal system.  I'm going to begin by sharing some data regarding the overrepresentation of LGBTQ+ youth in the criminal legal system and mental health impacts of system involvement, then I'll share some of my own research regarding pathways by which youth enter the system, and finally I'll identify some points along those pathways where we could better intervene to prevent further involvement and to support mental health. 

So, estimates indicate that roughly 7 to 9% of youth in the U.S. identify as LGBTQ+, yet research indicates that about 20% of youth within juvenile facilities identify as LGBTQ+.  And 85% of LGBTQ+ and gender nonconforming youth within the juvenile justice system are youth of color, indicating the increased vulnerability to criminal legal system involvement experienced by LGBTQ+ youth of color. 

Once inside the system, youth experience a range of adverse outcomes and traumatic experiences.  Youth experience discrimination and bias in many forms all along the pathway leading up to criminal legal system involvement.  It shapes how they are interacting with and treated by the police, lawyers, judges, facility staff and other youth, resulting in increased surveillance, harsher sentences and punishments, and worse treatment; and then that, in turn, shapes the rest of the experiences listed here. 

So, for example, youth are often housed according to sex assigned at birth within juvenile justice facilities, so transgender and nonbinary youth are not able to express or have their identities affirmed.  They're often hyper‑visible and outed, sometimes placed into segregated or isolated housing, often for the stated purpose of protecting them, but we know that that also has adverse mental health outcomes. 

Youth are routinely denied access to LGBTQ+ affirming medical and mental health care, including gender‑affirming care, and LGBTQ+ youth are at increased risk of experiencing victimization by other youth and by staff. 

So, for example, data from the national survey of youth in custody found that 10.3% of youth who identify as non‑heterosexual reported being sexually victimized compared to 1.5% of heterosexual youth in custody. 

And directly related to all these forms of trauma and discrimination and compounded by trauma and discrimination experienced before even entering the criminal legal system, LGBTQ+ youth report a range of adverse mental health outcomes, including high rates of suicidal ideation and attempts, self‑harm, depression, anxiety, and PTSD. 

So, I want to turn now to examining a few of the pathways by which youth come into contact with the criminal legal system in the first place in order to contextualize this overrepresentation and the adverse experiences of youth inside but also to highlight some opportunities for prevention and intervention. 

So, I'll just talk about three pathways from my own research today:  The criminalization of LGBTQ+ identities, the school‑to‑prison pipeline, and a pathway that begins often with family rejection and then leads to homelessness and poverty, followed by forms of criminalized survival.  These are by no means the only pathways into the system. 

For each pathway I'll share some quotes from participants in my own research studies.  These quotes are from life history interviews I conducted with young transgender women in their late teens, twenties, and early thirties.  I interviewed 21 women in Chicago with and without a history of arrest about their pathways into or away from the criminal legal system, their perceptions about the police and other key life events and moments.  And while these data are from interviews with transgender women, many of these themes apply broadly to LGBTQ+ youth. 

So, the first pathway I want to highlight is the historic and current criminalization of LGBTQ+ identities and the crisis of mass incarceration. 

So, bias and stigma against LGBTQ+ individuals contribute to perceptions of LGBTQ+ individuals as deviant.  The intersection of white supremacy and hetero‑cis patriarchy leaves LGBTQ+ people of color particularly vulnerable to perceptions about deviance and criminality.  These perceptions have been then codified into laws targeting LGBTQ+ communities. 

So many of the other panelists have already discussed and noted that we are witnessing an exponential increase in laws targeting LGBTQ+ identities.  This is continuing a long historical legacy of laws criminalizing aspects of LGBTQ+ identity. 

So, some of these current laws, as I'm sure you all know, as we've already discussed today, include laws banning schools from including content on LGBTQ+ identities, making it difficult or even criminal for youth to access gender‑affirming care or for their parents to help them to do so, drag bans, bathroom bills and just so many other current bills.  
So, the perception of LGBTQ+ individuals as deviant also shapes how law enforcement officials then interact with LGBTQ+ individuals and often contributes to increased surveillance, contact, arrest, and then further and ongoing involvement in the system. 

So, for example, a participant in my study, Cinnamon, a 20‑year‑old Black woman, stated that she'd been arrested at least 10 times, beginning as a teenager, but she thought that most of those arrests were unjustified and were a result of police harassment and discrimination due to her transgender identity. 

As a side note, all of the names that are shared here are pseudonyms selected by participants, and identities are how participants describe themselves in their own words. 

So, Cinnamon stated, "Most of the time they were arresting me it wasn't justified.  And most of the time they were harassing me.  Like I go to court, and the case is thrown out because they don't have evidence or because the police don't come.  Most of the time I get arrested because they're either harassing me or just because I'm trans.  I could be walking outside to the school, I could be going to the store, or I could be doing things and just like, hey, what are you doing, or, hey, let me run your name.  Police here are terrible, terrible, terrible." 

So, Cinnamon's experience of being targeted by police because of her identity or walking while trans illustrates the impact of policies and practices that permit police to stop and question individuals when they are suspected of being engaged in criminalized behavior. 

And as you can expect, this negatively impacts how transgender women and LGBTQ+ youth broadly feel about the police.  It's also dehumanizing and negatively impacts mental health. 

So Aerial, a 22‑year‑old African‑American woman, described how her interactions with the police made her feel less than human, stating, "It's just like being trans and dealing with cops and lawyers and things, especially the police.  I don't think they really care about us.  I don't think the police think we're human, or we don't have hearts." 

These perceptions about the police also negatively impact help‑seeking, which then further perpetuates experiences of violence and trauma.  So given these negative experiences with police, it's unsurprising that many participants in my research expressed cynicism about the criminal legal system and its ability to help to protect them from victimization. 

During the time period in which I was conducting interviews, two young Black transgender women were murdered in Chicago, and a number of participants talked about this in interviews.  They talked about feeling like the police were not doing enough to investigate the murders of trans women. 

Discussing the murder of one of her friends, Sasha stated, "I just hope the police and the detectives don't sweep her murder under a rug like any other trans murders:  Well, she probably tricked a guy, or, well, she was probably deviant, she was probably doing her prostitution.  No, you won't know until you investigate her murder.  Most police officers here in Chicago, they're not going to spend too much time investigating a trans murder because they're just going to assume they know what happened." 

So as Sasha was discussing here, transgender women, particularly transgender women of color, experience disproportionately high rates of violence and murder.  And as Sasha suggests, police cynicism is a direct result of transgender women's experiences of victimization by the police and their experiences of the police failing to respond to the murders of transgender women. 

The feelings of helplessness then compound experiences of vicarious trauma and trauma also caused by direct experiences of victimization. 

The second pathway I want to highlight is the school‑to‑prison pipeline, which is a term that's used to describe the direct and indirect impact of policies that push students out of schools into the criminal legal system. 

So, while schools have implemented a range of policies in the name of keeping students safe such as zero‑tolerance policies or having police in schools, we know from the growing body of research that many of these contribute to disproportionate rates of detention, suspension, and expulsion among minoritized students, particularly LGBTQ+ students of color. 

So, before she stopped going to school, and even before she became involved in the child welfare system, Angela had an altercation with police officers stationed in her school that led to her arrest when she was 17.  She and a friend would often sneak out of school. 

She stated, "We would have a book bag with our girl clothes in it.  We would go to the front door and leave out the back door and actually come up north to boy’s town and just walk around and be us.  Towards the time that school was supposed to be out, we would hurry up and dress back in our uniforms and go back." 

So, one day police officers stationed at her school caught her as she was trying to sneak out.  They were looking through her bag, saw her girl clothes.  They were asking her about it loudly.  She felt embarrassed and panicked.  She tried to leave.  The officers tried to stop her. 

She stated, "I don't remember exactly what happened, but I think I had two charges of battery to a police officer for that.  I didn't even hit them.  Resisting arrest maybe." 

So this led to not wanting to go to school, which led to conflicts with parents, involvement in the child welfare system, running away from a residential program and then, ultimately, homelessness. 

So, I just wanted to finally talk about a pathway that often ends in LGBTQ+ youth engaging in forms of criminalized survival like theft, panhandling, sex work in order to survive. 

Reliance on criminalized survival is part of a complex web of family rejection, homelessness, unemployment, poverty, bias, discrimination, heightened police surveillance; more complicated and nuanced than I have time to really delve into today.  But I just want to illustrate one story that sort of includes some of the components of this pathway from Mya. 

So, she described being unhoused at 16 after being kicked out by her mother when she came out as trans.  At 21 she met a group of young women who asked if she wanted to commit robbery.  Describing her thought process, she stated, "Well, I don't know.  I'm not particularly sure about that.  But I'm thinking to myself, okay, I don't know where else to go.  I don't have any money.  I don't know where my next meal is going to come from.  I don't even have a toothbrush.  I have nothing to take care of my body.  It sounded like a good idea.  I end up getting arrested."

She went on to serve several years in a men's facility, experiencing violence, lack of access to hormones, but since her release she'd gone back to school and was planning to move out of Chicago with her partner to start a family.  And I just wanted to note that to highlight that despite many adverse experiences, LGBTQ+ youth are incredibly resilient; but we know, of course, that these experiences take a toll.  And while youth can overcome many of these things, they just shouldn't have to. 

So lastly, to close, as I'm out of time already, I just wanted to highlight some points along these pathways where we could intervene to prevent LGBTQ+ youth from becoming involved in the system in the first place. 

So, of course, increasing LGBTQ+ affirmative practice and services in all contexts:  mental health services, antiviolence services, schools, resources for families, increasing family support, the child welfare system.  We already have existing models for LGBTQ+‑affirming clinical services and should be ensuring that these are implemented everywhere that youth are coming into contact.  We need to hold the criminal legal system accountable for bias and victimization. 

And then going back to that first pathway, I think it's critically important, as we've discussed already, that we all do whatever we can to resist anti‑LGBTQ+ policies, whether that be in our local school districts, in our communities, in our states, and nationwide.  And, of course, we can do that in our professional roles as experts in youth health and wellness, and we can also do it in our other roles as voters, for those of us who have that privilege, community members, parents, family members, et cetera. 

So, I'll leave it there and pass it off to Dr. Dana Prince.  Thank you all again so much.  

DANA PRINCE:  Hey, hi, everyone.  My name is Dana Prince.  I use her/her pronouns.  I am a White disabled neurodivergent queer fem.  I have been out since 1995, working on behalf of my community, and I'm here today to talk more about systems involvement and gaps and opportunities, so this talk flows very nicely from the last one. 

To begin, though, I would like to knowledge the ancestral, traditional, and contemporary lands of the Lenape, Shawnee, Wyandot Miami, Ottawa, Potawatomi, and other Great Lakes tribes.  This is the land upon which I do my research and work in collaboration with community.    

I'd also like to recognize the myriads of partners who have collaborated with me, co‑conspired with me, and also funded my research here in Cuyahoga County and Cleveland greater area for the last eight years. 

So as others have already laid out before us, we know that sexual and gender minority youth are at heightened risk for a range of negative mental health outcomes.  I am focusing today specifically on suicide, self‑injurious thoughts and behaviors. 

And many folks on this virtual convening probably already know that suicide is the second leading cause of death for all adolescents and young adults and also that our kids, our sexual gender minority youth, are at increased risk across the lifetime of ideation and attempt, and substantial research has already identified some of the key risk factors for suicidality among sexual gender minority youth, and those have been discussed previously as well.  Caregiver and family rejection, abuse and neglect, typically from biological family or kinship networks because of one's sexual orientation, gender identity or expression, peer bullying and victimization, and then also the internalization of queer/homo/transphobia. 

My work is at the nexus of systems.  In terms of the child welfare system, we know that youth with diverse SOGIE ‑‑ that's Sexual Orientation Gender Identity Expression ‑‑ are disproportionately more likely than heterosexual and cisgender peers to experience a variety of negative outcomes, including health challenges, more likely to enter the child welfare system, typically have more placements within an episode of care and more episodes of care ‑‑ that means more times having been removed from home ‑‑ and then placements within that care could be as up to ‑‑ I've worked with youth who have 25 different placements within a two‑year episode of care, for example.  They also are more likely to experience adverse outcomes exiting care and have lower reunification rates with their families of origin. 

Many of our speakers have spoken to this today, but I'm going to go over it again. 

In terms of child welfare and juvenile court involvement, if we're just looking at youth involved in systems, okay, regardless of their sexual orientation or gender identity, if you are or have been involved in foster care or juvenile court, there's ‑‑ a quarter of these young people report lifetime ideation, 25%.  That's double that of non‑involved peers. 

Youth involved in systems, again, regardless of sexual orientation or gender identity or expression are at three times greater risk for suicide ideation, for planning, attempt, and also for completion.  One study using population data in California compared young people with a history of child welfare involvement to those without and found that youth with a foster care history were five times more likely to die from suicide compared to youth with no foster care history. 

We've had speakers today talk about the importance of culture and also intersectional stigma.  There's been an alarming trend over the past two decades, a linear trend, of an increase in suicide attempts among Black boys, and the fastest increase among suicide behaviors is among Black girls compared to any other racial or ethnic group. 

And, finally, we know that our sexual gender minority youth are also at disproportionate risk for ideation and planning, attempt, et cetera. 

So, some research has looked at this intersection of being LGBTQ and being involved in child welfare or juvenile court, like our last presenter and our next presenter as well.  And county‑based estimates typically, which started in L.A. County, we replicated that in Cuyahoga and some others, some national data, have found between 16 to 32% of youth within public child welfare or within a juvenile justice, juvenile court system, are identifying as a sexual gender minority, and that's too compared to 2.8% in the general adolescent population. 

We've also had a few studies look at different kinds of mental health types of issues and found, for example, that depression and self‑injurious thoughts and behaviors, also hospitalizations, psychiatric issues, are higher among the sexual gender minority youth involved in child welfare compared to the cisgender heterosexual peers. 

Other research looks at overrepresentation in systems involvement and our Black indigenous LatinX youth. 

And, finally, researchers are focusing more on this issue of sort of double minority status or intersectional stigma and also culture.  And there's mixed results in this regard as well. 

There are studies that have found, for example, that being Black is protective against homophobia, which is counterintuitive to what Dr. Abreu pointed out, this sort of racist narrative of communities of color always being more homophobic or more transphobic, and we do need a lot more research in that area to look at culture and context as well as structural stigma. 

And, finally, my work sits at the nexus of all three of these intersecting types of populations where suicide is disproportionately overrepresented. 

The work that I do focuses on complex systems, and I use system dynamics and community‑based system dynamics as a way to help visualize and understand the complexity of these types of issues.  You know, as our previous presenter pointed out, there's multiple pathways, but these pathways are happening simultaneously. 

So, some of our work is looking at the conceptual understanding of simultaneous factors that are impacting overrepresentation of SGM youth in systems and disproportionate mental health comorbidities. 

So, in this image what you'll see on the right‑hand side are three direct drivers:  Harmful policy and practice ‑‑ in this case I'm looking at child welfare ‑‑ abuse and neglect because of one's sexual orientation or gender identity expression, familial rejection.  Each of those can be a direct pathway to foster care involvement. 

The next thing I want to point out is for our kids, once they become foster‑care involved, first of all, they are more likely to be put immediately into a restrictive‑care placement.  That means they are more likely to be put into congregate care, a group home, a residential treatment facility.  Right? 

If they exit, if they step down into lower care levels ‑‑ for example, a foster home placement ‑‑ they are more likely to disrupt, they are more likely to have that placement say we can't handle you or we don't want you, and that leads back to going into a restrictive placement setting.

This is a reinforcing loop called R1.  It's called hard to place.  This is an actual label that we give to kids in child welfare when we have a hard time finding a stable place for them to be, safe place for them to be. 

And the thing about systems is that systems are full of reinforcing loops.  All right?  And complex thinking, complex systems thinking, lets us identify where those reinforcing loops are, as well as pointed intervention.  I'm not going to go over the entire model here, but I will direct you to the manuscript, the paper, if you want to think more about the simultaneous factors that are impacting youth outcomes for young people.  And we lay them out as structural, institutional, interpersonal and intrapersonal factors which map onto minority stress theory and also extend it. 

So, what are we doing?  All right.  So, Cuyahoga County was one of four locations that was selected for a national demonstration project funded by the Administration for Children and Families.  This is a four‑year demonstration project to transform child welfare, the organizational culture to enhance stability, well‑being, permanency, and safety for youth with diverse SOGI.  I served as the local site evaluator for this four‑year project and the funder was ‑‑ the receiver of the grant was the University of Maryland.  So, what we learned from this in terms of the child welfare component is safe identification, so a policy‑level thing.  If we're not asking the appropriate questions of a young person, if we're not finding out about their sexual orientation and gender expression, then no other decisions are being made that include this key information.  When we input safe identification, we move from identifying 3 percent of adolescents entering child welfare to 20 percent identifying as sexual gender minorities.  There are some other components to this, but I believe there will be other speakers speaking on this later.  I'm gonna move forward, because I know we are a little short on time.  I see you there, Crystal.  I'm doing my best.  

So, I'm gonna talk really quick about these three drivers again.  We have biased policies within systems.  Remember, a biased policy can appear neutral.  Neutral policies still have bias inside of them.  Without safe identification procedures, we have systems failing to identify a key factor that's related to young people's self‑interests, thoughts or behaviors, and then we can't refer to them.  We also have young people who have been traumatized and re‑traumatized inside of public welfare systems, inside of behavioral health systems, and this is very real for SGM populations actually across the life course, that then we avoid care, we don't engage in care, and these things are problematic in terms of treatment.  

So, the two gaps we are now working on here in Cuyahoga County amongst these partners, because we continued to work together after the grants.  The funding ends, but the partnership and the learning collaborative continues.  We want system‑level safe identification of sexual/gender minority youth at risk of suicide.  We want coordinated referral to affirming peer support ‑‑ I'll say why peer support in a moment ‑‑ and we lack specifically affirming peer support that's embedded in our current crisis response system, where our youth are overrepresented and underserved.  So, this is the learning collaborative; it's many of the same partners.  We've been working together now for eight years.  

Now, the learning collaborative approach is directed by community.  It is not me, Dana, sitting in my office thinking, "Oh, I think I should research this."  It's what does the community say is an issue and is it being echoed across different parts of the community?  So, we have the LGBT Center, we have Youth Voices as very much a part of this work.  Across the board, folks saying we don't have enough resources for youth when they're in crisis or on suicide for our queer and trans youth; we don't have them.  And across the board, especially coming from the queer and trans community, we want to use our own community assets and resources as intervention.  That's why peer support, okay.  We know that persons with lived experience play a unique role in mental and behavioral healthcare delivery.  We know they're under‑utilized in youth populations and in SGM populations, and so that's what we are currently developing together with our systems partners, with our community partners, and with our community activist partners.  These are very different groups of people, but we come together with this common vision. 

So, the basic idea ‑‑ and I've talked about these drivers ‑‑ is really building out identification and referral of sexual/gender minority youth at risk of suicide.  In juvenile court, that's a place where assessment happens.  In child welfare, that's a place where assessment happens; and in behavioral health, that's where assessment happens.  We need cross‑system identification and cross‑system talking to each other and also high awareness of the sensitivity of these data ‑‑ who can see the data, who can disclose the data, and always the youth owning their own data.  Because we know, again, that these youth have experienced being outed by other people in system settings.  If they're outed to the wrong person, it could have very harmful effects.  And the second piece of this is working across these systems, then, to embed affirming peer support specialists inside the behavioral and mental health delivery system; that when we identify a young person to child welfare who is LGBT, who is screaming cautionary or critical on a suicide assessment, that we can track them and map them onto a peer support specialist.  That's someone that has shared lived experience, that someone is gonna be queer or trans, that person is gonna be BIPOC.  That person is gonna have overcome suicide themselves and is gonna walk alongside that youth and ensure that they're able to stay connected to their other types of treatment that are being offered.  You know, is it a paraprofessional role?  And also, to reduce self‑injuring behaviors, and to do that, we capitalize on lived experience.  There's research showing that LGBTQ folks, in general, want to support others in their journeys.  We have a history of creating our chosen families and our chosen networks of support.  We have a history of taking care of one another, and this is another place where we can do that.  

So, I know that we're really short of time and this is a lot, but I'm gonna go ahead and end there, so we can have our other presenters have some of their time as well.  And I thank you all very much. 

CRYSTAL BARKSDALE:  Thank you.  

Dr. Conron.  

KERITH CONRON:  Thank you so much.  It's an honor to be in such good company with this crowd.  My talk, I think, will be a bit shorter, and in many ways, I think it could be called a call to action.  Things are bad and they're getting worse, and what can we do to make sure that we're studying the effects of public policies on the well‑being of youth moving forward. 

So, there is a large and growing population of LGBTQ high school youth.  From 2015 at 8 percent to about 15 percent in 2021.  There are an estimated two and a half million LGBTQ high school students.  Now, the reason I decided to focus my talk today on high school students versus folks who are accessing higher education, which has been the subject of some of my own work the last few years, is because of the vulnerability that Skyler laid out earlier.  Folks are earlier in the life course, dependent on parents, required to be in school, and that also places them at greater vulnerability.  When we asked college people who had been in college if they had ever wanted to live in a different state or a city to find a more supportive climate, we found that almost one out of five LGBTQ people who were going to a four‑year college picked a different place to live to have a more supportive environment.  They were four times more likely than their non‑LGBTQ peers to report that decision.  And when we asked folks if they'd ever picked a school or university in another place to get away from their family, a third of LGBTQ people who went to four‑year colleges reported that decision, compared to about half as many of their non‑LGBTQ peers.  So that information tells me that when people have choices, they move to more supportive places, and when they don't, we have an even greater responsibility to make sure that their environments are safe, and particularly in school settings, to make sure that people have the opportunity to learn.  

Inequities in mental health along the lines of sexual orientation and gender identity and known risks for poor mental health, including school‑based harassment, violence and child maltreatment, as other presenters have said, have been observed for quite some time, in fact, for over a decade.  And here in Massachusetts where I've lived a lot of my life, we have seen this pattern of inequity and school‑based bullying for over a decade.  Which leads some of us to say what the heck is going on and what are we doing about this and what can we do to change these patterns.  I would also add that state policies and school climates have the potential to reduce or exacerbate observed inequities.  And because there's been a lot of change, as many other presenters have said, in laws over time, both protective laws that confer protections for LGBTQ youth as well as harmful laws, there's an opportunity and a need to study the effects of these laws on youth, including the extent to which their effects are mediated through school environments.  

So, on the positive side, 21 states prohibit bullying on the basis of sexual orientation and gender identity, plus another two that confer enumerated protections along the lines of one characteristic or the other.  We've seen in research by Ilan Meyer and others that enumerated inclusive anti‑bullying laws are good for young people, whether they're LGBTQ or not, in terms of lowering risk for suicide attempts and feeling safe at school.  
On the hazardous side, we've seen that many states, seven in particular, have banned discussions about LGBTQ people and issues across school curricula, and other states have restrictions on LGBTQ curricula in some form or another.  Some states are banning the use of gender identity‑based pronouns.  Eight states have passed parental notification laws that would out trans youth to their families.  

So now I'm gonna share with you a little bit of data from a study that we did with the Point Foundation in 2021 called the Access to Higher Ed Survey.  It was a cross‑sectional survey that we fielded in the beginning of the year with the Ipsos Knowledge Panel.  We had a sample of over a thousand people.  They were adults 18 to 40.  By design, half the sample was LGBTQ‑identified and 20% of the participants ended up being ages 18 to 24.  We asked folks to tell us about their experiences in high school, community college, college, graduate school, all across the life course.  We developed sampling weights that allowed us to present findings that reflect U.S. adults in those specific age groups.  

So, here's some findings from our 18 to 24‑year‑olds.  More LGBTQ than non‑LGBTQ participants reported diagnoses of depression from healthcare providers, anxiety than their non‑LGBTQ counterparts.  Why am I saying this?  I've been looking at YRBS data now for decades, and while I think sadness and suicidal ideation and attempts are incredibly important, I would like us to start collecting more data about anxiety, perhaps even using the GAD‑2 on the YRBS.  I think it is associated with exposure to violence and harassment.  I'm gonna share with you a little bit of data about experiences that people reported in school climates, in part because I find the word bullying to really cloud the extent to which people are experiencing violence and harassment of different forms, in some ways presented as a normal experience of adolescence, when we know in fact that it's quite hazardous and also preventable.  

So, here's some of the experiences that people reported in high school, at least a few times a year when they were in school.  In‑person bullying much more common among LGBTQ than non‑LGBTQ folks.  Other bullying or electronic bullying is much more common, including texts, negative messages left at your locker, property damage also occurred.  Sexual harassment occurred at school more commonly among LGBTQ folks than non‑LGBTQ folks.  Importantly ‑‑ and I don't think this shows up often enough on surveys like the YRBS ‑‑ LGBTQ people reported experiences of sexual assault at school more often than non‑LGBTQ participants.  It's important to remember that most of us when we're looking at data on lifetime sexual assault and sexual abuse, we see that it has a very powerful association with increased risk for adverse mental health, substance use, all kinds of negative outcomes.  We don't often collect data about perpetrators or context.  Some work that we've seen from David Finkel and others shows us that about a third of sexual abuse is peer‑perpetrated.  Looking at some of my data, I can see that some of it is happening at school, and this is something that we need to start monitoring more carefully and not just the experiences themselves, but who are the perpetrators and what is the context and thinking about how to make school safe.  

As you would expect, fewer LGBTQ than non‑LGBTQ people reported a sense of belonging in high school.  So, we collected some data ‑‑ this is retrospective ‑‑ about high school climates and what kinds of indicators of LGBTQ inclusion were present in high schools.  About just over a quarter of people reported the presence of an LGBTQ student organization, like a GSA.  That was the most common indicator of inclusion, and you can see that very few people were reporting any other indicator of inclusion.  These items reflect the LGBTQ campus climate index, an informal version.  And when we asked similar questions about other kinds of educational settings, we saw similar patterns, although higher elevation for folks in four‑year college settings are much more likely to report the presence of multiple indicators of inclusion.  Community college environments look much sparser and look much more like the high school climate that we're looking at here.  I'm presenting this because one of my suggestions is going to be that we monitor high school climates more robustly than we have been doing previously, particularly in large population‑based datasets, which is needed if we're gonna study the effects of public policies on the well‑being of adolescents.  

When we look at the indicators of inclusion ‑‑ and again, these are 18 to 24‑year‑olds; they are reporting about their high school environments in 2015 to 2021.  So, this is retrospective, but half were in an environment with no indicators of inclusion, not even a GSA alliance, and only a quarter were in a place that had two or more.  Had I had a better distribution, of course I would've shown you the whole spectrum, but all to say this is at least preliminary evidence that school climates are not particularly inclusive of LGBTQ people, and these are malleable factors and something that could be surveyed and efforts could be made to promote inclusion.  Of course, perhaps not in places that ban LGBT inclusion and curricula.  So, what we have is a series of policies that seem to counter what we know is helpful for LGBTQ young people, at least in terms of feeling a sense of safety and belonging.  And this of course we saw in our data.  This is an adjusted odds ratio.  Folks who were in high schools in places with two or more indicators of LGBT inclusion were much more likely to report a sense of belonging than folks who attended schools with no indicators. 

So that's the school environment, but youth don't inhabit only one environment, as Dana showed us.  They inhabit multiple environments simultaneously.  So school, we can see, is not safe for many young people, but what about home?  Well, home isn't always safe for LGBTQ people.  This is sort of using some of the ACE’s questions about experiences of psychological abuse, frequent psychological abuse, emotional abuse, feeling unsafe, and also physical abuse, and we can see that it's higher for LGBTQ 
18 to 24‑year‑olds than non‑LGBTQ folks, although a difference in physical abuse isn't statistically significant.  In part, that's a sample size issue.  I'm excited to see that there are some ACEs questions included in the 2023 national YRBS, which is amazing, but I would really like to see those questions included in the state core survey, so that we can look at the effects of policy environments on youth.  

So, in terms of future research, I'd love to see more studies looking at the impact of policy environments and the differences in school climates, in school‑based victimization, mental health, and other indicators of well‑being.  We've had lots of great work over the last 10 to 15 years.  Steve Raphelson, amazing work, and lots of other folks, Mark Hatzeneur, but we want to see some bigger studies, like difference in designs ideally to look at the effects of policies on health.  State policies that require schools to out trans youth or other LGBTQs to their parents are likely to increase risk of child maltreatment.  Research on the consequences and costs of these policies is needed.  I would also say that, more generally, research in creating effective anti‑bullying climates is also needed, particularly strategies that look at promoting social‑emotional competency and supporting youth and having positive peer relationships. 

Thank you. 

SPENCER EVANS:  Meg, I think you're on mute. 

MEG PACELEY:  Thank you.  It was bound to be somebody and today it was me.  So, apologies, everyone.  

Good afternoon.  I'm Meg Paceley.  My pronouns are they and them, and I'm here with Spencer Evans, who is a wonderful Ph.D. student who works with me at UConn, and she will be co‑presenting with me.  We will be sharing the state of the literature on state‑level legislation rooted in cis‑sexism and hetero‑sexism, as well as a rapid research study that provides some contextual understanding of how these anti‑trans and anti‑LGBTQ+ policies impact gender‑diverse youth.  

So, Spencer, I'm gonna turn it over to you to share some background. 

SPENCER EVANS:  Awesome.  Thank you, Meg.  

So, in the last three and a half years, we have witnessed a quickly increasing onslaught of anti‑trans legislation in states across the U.S.  The first big wave of proposed legislation happened in 2021 with 125 proposed state policies that aimed to limit access to affirming recreational, school, and healthcare supports for transgender and LGBTQ+ youth more broadly.  By the first half of 2024, we have seen nearly 600 proposed bills in 42 states across the U.S.  These proposed bills affect nearly 300,000 young people across the country, a majority of whom are located in the Midwest and southern portions of the U.S.  

Here we have the risk assessment map, which includes the most at‑risk states for gender‑diverse youth designated in the red color.  These states have enacted bans on gender‑affirming care for trans youth, and many also mandate detransition for those who had already begun to take hormone blockers or gender‑affirming hormones.  The darker blue states represent the safest states with laws or sanctuary protections in place for protecting and affirming gender‑diverse youth, but Florida is the only state to receive a do‑not‑travel designation, due to laws that allow for the arrest of transgender people who use bathrooms associated with their gender identity and not associated with their sex assigned at birth.  

Most of the legislative aims of the anti‑trans policies focus on restricting access to gender‑affirming care for minors ‑‑ name and gender marker changes, the use of bathroom and gender‑ specific spaces, LGBTQ inclusive education, and sports involvement on gendered teams.  Some of the legislation also aims to require public institutions to inform parents of youth's pronoun or name changes at school and mandates misgendering of youth via name or pronouns assigned at birth.  Anti‑trans legislation includes the rhetoric surrounding the legislation.  This may be stigmatizing, as well as the actual implications of policies when passed.  Research on the structural stigma includes the impact of state‑level policies on the mental health of trans and LGBTQ people and indicates that discriminatory state‑level policies are associated with poor mental health outcomes, including depression, anxiety, stress, and suicidality, as well as things like discrimination and misgendering, which are also associated with poor mental health.  

MEG PACELEY:  Thanks, Spencer.  

So, importantly, there's only a few studies that have explored the mental health impacts of the current onslaught of anti‑trans legislation: so, since around 2020 or 2021.  This rapidly changing sociopolitical climate, as we've heard from other speakers today, is becoming more and more hostile toward LGBTQ communities and really most specifically transgender youth.  So, this really warrants critical attention in the literature.  As you can see here, we only located four peer‑reviewed studies that examined the mental health impacts of the current anti‑trans legislation on trans youth or on LGBTQ youth more broadly, understanding that research is very likely ongoing and just hasn't been published yet.  Only one of these studies, which we'll talk about in more detail, included youth perspectives.  Two included samples of parents and one included a sample of providers, and all collected data ‑‑ and all of these studies collected data in the early months or years of this current wave of anti‑trans legislation.  So, prior to the amount of bills increasing so dramatically in the past two years.  

Despite this, we can see the findings echo what Spencer shared about broader structural and state‑level stigma with perceived impacts of these policies, including depression, anxiety, increased gender dysphoria and suicidality.  We also heard earlier from The Trevor Project, who examined the impacts of state legislation on LGBTQ youth, and they found that LGBTQ youth reported significant impacts of legislation on their well‑being and that nearly half of trans youth reported their families considered moving to a different state in light of this legislation. 

So, I'm gonna talk briefly about a study that included a youth sample in early 2021, and this was the Trans Youth Speak Out study.  This study was a community‑based participatory research group of trans and non‑binary youth.  They had been meeting biweekly for over a year at the time of the study and engaged in trans‑related mental health research that was ongoing.  They were also initiating new ideas as a CBPR group.  Youth had an average age of 16.  Four identified as trans‑male or trans‑masculine and two identified as non‑binary, and four of the six were white.  
So, it was early 2021, and at the time more than about 50 anti‑trans bills had been proposed across the United States and two were pending in the state that the CBPR group was situated.  We were meeting biweekly.  The group was engaging in ongoing research, but their conversations began to shift more and more towards legislation and the sociopolitical climate.  

So as these conversations continued, the youth co‑researchers approached us about getting information out quickly about the impacts of this legislation and the rhetoric surrounding it, both in our state and across the United States.  So, the youth co‑designed this rapid research study.  They were an essential part of designing and carrying out the entire study, including dissemination.  So, discussions with our CBPR group were already covered as research and are approved by IRB protocol.  So, the youth elected to engage as participants rather than spend time recruiting new participants going through a new IRB, and this enabled us to engage in rapid data collection and dissemination of findings and to share findings at the state level, with the goal of impacting the ongoing legislation.  Youth participated in two online focus groups that were facilitated by me and a colleague.  We led the thematic analysis and the youth provided ongoing feedback of that process.  

We identified three themes in their focus group data.  These were focused on their perceived impacts on mental health, structural supports, and messages that they had for policymakers.  And I'm going to share a few quick quotes for each of these, just to bring their voices into this presentation.  So first, youth talked about increasing depression, fear and suicidality within themselves and their peers, other trans youth that they know.  One shared that just the fact that these bills exist is harmful to mental health.  Another said, "It makes me feel almost hopeless.  Them passing these bills will definitely make the suicide rate higher."  Another youth spoke of the fear they felt.  "You keep hearing all these people that don't want you to exist.  It's scary."  Youth also talked about two potential structural impacts on their health, including increased barriers to affirming healthcare and decreased access to safety.  One youth shared that having little to no gender‑affirming care will be really bad.  Another spoke to the sense of unsafety.  "It's just making fewer spaces that are genuinely safe, which is just horrific that we're going so far back in time."  Finally, youth had important messages to policymakers about these policies.  "When I hear people talking about trans‑youth and our bodies, it feels like it's going back to control.  They want to control what other people do, and the bottom line, you're going to kill people by passing the law." 

So just a brief discussion.  It's important to note that this study was a rapid research design.  It was not meant to generalize across context or youth.  It was really meant to provide point‑in‑time data in a really unprecedented and scary early onslaught of these policies.  The study was also limited in that there were few racially minoritized youth and no trans‑feminine youth, but this study is also the only one that we could find that has collected data in a peer‑reviewed journal since 2020 that includes youth as the sample and emphasizes the impacts of policies, even when they're not passed or when they're still in the proposal stage.  And I think this is a really key piece of this research, is that it's the policy and it's the impacts of policy, but it's also the rhetoric and the stigma associated with that rhetoric.  

So, I want to end with a brief discussion of the gaps in the literature and some future recommendations.  Some of the most striking gaps we noted are just a general lack of research in this area since 2020 and 2021, really in terms of collecting data since 2020 and 2021, as well as a lack of population‑level data that explores the impacts of this specific legislation for youth, as well as how youth and others are responding or advocating for change.  We also have very few studies that center youth as the sample, and we need more longitudinal studies to examine the impacts of these policies over time.  Finally, we lack studies that explore the impacts of policies from an intersectional lens.  Impacts on mental health from these policies likely vary based on gender, sexuality, race and ethnicity, the region of the country that people are living in, class, age, and other relevant social identities.  

So given these gaps and limitations in the research, we suggest a need for more cross‑sectional and longitudinal studies on the impacts of anti‑trans policies on trans youth, as well as examinations on the decision‑making processes of families with trans and LGBTQ youth in high‑risk states.  For example, as we talked about earlier, there's some evidence that families are considering or are already moving to states with more protection.  We don't understand that experience or the decision‑making that goes into it or the impacts of that move on the family.  We also recommend research on the ways in which medical and mental health providers are supporting trans and LGBTQ+ youth in light of these policies.  Finally, we recommend that funding priorities include opportunities to study these impacts on a broad scale across the U.S. 

Thank you so much, and we look forward to your discussion. 

CRYSTAL BARKSDALE:  Thank you so much, Dr. Paceley and Spencer Evans.  Now we're going to invite actually all of the speakers to turn on their cameras, and we'll have Brian Altman join us on camera to provide his remarks for the discussion.  

BRIAN ALTMAN:  Thank you, Crystal.  And if I could get my slides up as well, that would be great. 

Good afternoon, everyone.  Thank you so much for joining us.  There we go.  My name is Brian Altman.  I use he/him pronouns and I'm the director of the National Mental Health and Substance Use Policy Laboratory at SAMHSA.  I also serve as the LGBTQI+ lead for policy and programs at SAMHSA.  I serve as our executive sponsor of the Pride Employee Resource Group here at SAMHSA and the co‑chair of the HHS‑wide LGBTQI+ coordinating committee of the policy subcommittee.  So, I want to thank all of our presenters for their research and remarks and the work that you all have done to hone these research studies and the recommendations you have made as well.  I think all of our presenters, as we know, highlighted that LGBTQ+ youth have higher rates of behavioral health conditions, including depression, anxiety, suicidality, and substance use, but we also like to emphasize, as many of them did, that it's not due to their identities themselves; it is due to the fact that they have faced discrimination, stigma, bullying, and harassment associated with being LGBTQI+ youth.  

Next slide, please.  One thing I did want to highlight ‑‑ as many folks talked about suicidality as well as increased rates of suicide among LGBTQI+ youth and crisis services ‑‑ is that I wanted to make sure everybody knows that the 988 suicide and crisis lifeline has LGBTQI+ youth and young adult specific support available.  Anyone can call 988, and if you're in texting you can text "pride" to 988 and receive the specialized services.  If you call, you press three, and if you chat, you can identify in the pre‑chat survey that you would like these specialized services.  There's a website here where you can find out more information about these specialized services.  We do have a full sub‑network of crisis centers that answer these 24/7 specialized services activities.  Though we know that crisis services are essential in addressing behavioral health conditions faced by LGBTQI+ youth, we obviously need to acknowledge and address the underlying factors that impact LGBTQI+ mental health and well‑being.  

And therefore, as many of our researchers talked about, family acceptance and family support are very key to this effort.  That is why last fall SAMHSA launched an LGBTQI+ family support grant program.  This grant program provides up to $425,000 per year for three years to community‑based organizations to provide a family acceptance project model and affirm caregiver trainings and workgroups, to help connect that family support and acceptance between the caregivers and parents and those LGBTQI+ youth.  We have so far given out eight of these awards, for a total of 
$6.8 million.  And thinking back to Dr. Abreu's presentation, one of the grantees currently is the Latino Commission on AIDS in New York City, and so they are obviously focusing on that very specific population that Dr. Abreu mentioned at the intersectionality of Latino youth.  

We also want to note that these interpersonal interactions are compounded by the structural stigma that LGBTQI+ youth are facing.  So, we appreciate that Dr. Paceley and Spencer highlighted that there's been an increase in anti‑trans and anti‑LGBTQI+ legislation over the last few years and this has impacted the mental health of LGBTQI+ youth.  I would note that Dr. Prince and Dr. Hereth discussed how adverse experiences and structural challenges are compounded for LGBTQI+ youth and those who are connected to child welfare and juvenile justice systems.  In this realm, I would highlight some of the actions that my sister entities within HHS have taken recently.  Some of you may have noticed that the Administration for Children and Families, which I know Dr. Prince referenced having a grant fund, they recently released a designated placement rule that notes that within the child welfare system and foster care, that the LGBTQI+ youth must be provided a designated placement that is supportive and affirming to them.  And also, just last week, the Centers for Disease Control and Prevention ‑‑ I know Kathleen Ethier was on earlier.  I don't know if she mentioned their recent document noting that the stigma and discrimination of LGBTQI+ youth should be considered in the adverse childhood experience, and so these actions taken by HHS are very interconnected with the presentations that we've heard from.  

We also know that Dr. Jackson discussed how there are positive factors like ‑‑ I call them SOGI change effort bans.  At SAMHSA, we don't use the term conversion therapy, because we know that it doesn't convert anybody and it's not therapy.  So, we tend to not use that term; we use sexual orientation and gender identity change efforts.  And in this vein, last year we released the "Moving Beyond Change Efforts Report, Evidence and Action to Support and Affirm LGBTQI+ Youth."  So, this report reviewed effective and ineffective therapeutic practices.  It provided an update, an evidence‑based roadmap for supporting and affirming LGBTQI+ youth, and it offered guidance and highlighted resources for healthcare providers, educators, families, community leaders, and others.  And it also ‑‑ as mentioned in the last presentation about policy levels, it talked about how we can improve the behavioral health of LGBTQI+ youth through different policy actions.  So, we know there's much more research to be done as well, as highlighted in the last presentation, and this report also notes where there are research gaps that we could not speak about as definitively in the Moving Beyond Change Efforts Report.  So, we know that we need further study on the impact of policy environments, school climate, cultural norms, anti‑LGBTQI+ rhetoric, and the intersection of systems and identities that are needed.  But beyond research, we know that there are clear positive changes that can help protect sexual and gender minority youth and create an environment where we can live in.  So, encouraging ‑‑ as this report did and our grant program does ‑‑ family acceptance and community support, as Dr. Abreu highlighted, positive school climates, as Dr. Conron explored, and instituting wider structural protections can help boost the well‑being of these youth.  So, for our part at SAMHSA, we're strongly committed to continuing this work.  
 

And I think we have about five minutes.  Six presentations are a lot in this segment.  So, we have about five minutes for any questions that may be left for the presenters.  So, Crystal, I don't know if you have one of those queued up for us or not.

CRYSTAL BARKSDALE:  Yes, we do.  Thank you so much for your comments and thank you to the panel again.  Wonderful presentations.  And we do have actually a few questions.  So hopefully we can get to hear your thoughts on a couple of these.  So, a question from the audience.  "Compounding stigma is harder for those of us who are disabled and are of two spirits, TGI, LGBTIAQ+ community.  How can we address the multiple stigmatized impacts and causes for our folks when we are also living with multiple intersectional inequities that impact our health, brain health and mental health?"  Big question, but, again, I think it gets to many of the issues and particularly social, structural factors and intersectional issues that many of you all addressed or alluded to.  So, anybody wants to make an attempt at addressing that question?  

DANA PRINCE:  Can you hear me?  

CRYSTAL BARKSDALE:  Yes.  

DANA PRINCE:  I appreciate the question.  I don't know if I can address it the way that I would like to, but I absolutely ‑‑ as I am disabled, I care for a disabled child.  Something I'm really pleased about with NIH is the recent move towards inclusion of more disability research.  This has been a long time coming, and there's been a lot of community involvement from disability folks, disability leaders, researchers, activists to help shape that agenda.  So, I think that ‑‑ you know, we know that folks with disabilities are also disproportionate in marginalized statuses as well, and at the same time I think the disability culture and queer disability culture has so much to teach us about how to care for one another, about how we share resources, about a lot of community types of response to the pandemic, for example.  So, I think there's also an opportunity there to kind of center disability in a way that looks at disability culture as well.  We want to look at race, ethnicity, culture.  We also know disability is multiple cultures.  It's not just a check mark of "Oh, yeah, I can't do these things."  

So, I appreciate the question.  I don't have a big answer, but I am pleased to see NIH moving in a direction that focuses more on bringing disability as well as intersectional types of questions. 

CRYSTAL BARKSDALE:  Great, thanks.  Dr. Conron.  

KERITH CONRON:  Just to add one thought, that I think folks who have R01s can really encourage students with disabilities and others to write supplemental grants to do small projects that build off of larger R01 mechanisms.  I think it requires environments, though, that allow people to disclose disability without fear of stigma.  So, I put that out there.  I think there are lots of brave young people who are raised in a way that they feel they can just say "Hey, this is what's going on for me and this is what I need," which is amazing, but I would want to make sure we're also monitoring environments to make sure that they are safe spaces for people to disclose and to get the support that they deserve.    

CRYSTAL BARKSDALE:  Great point.  Thank you.  

Any others?  

BRIAN ALTMAN:  I can see a question pop in, if there was additional opportunity to apply for the family support grants.  So, we ran an open competition last spring and summer.  We received 53 applications, and at the time we posted that there was a funding opportunity, we only had funding for four grants.  We did find funding in the winter for an additional four grants.  So, we got to a total of eight grantees, but we don't have any additional money at this time to post a new NOFO or to continue going down that list.  Unfortunately, we made it only to a score of 93, and all 53 applicants scored high enough to be funded, if we had the funding.  So, we don't have an open NOFO coming any time soon, but hopefully if there are additional funds provided, we could either run another opportunity announcement or continue going down the list of scored applications we've already received. 

CRYSTAL BARKSDALE:  Thank you.  Thank you for that information.  

Well, I'm aware of our time, and unfortunately, we are at our time, but I want to thank you all again for just an excellent set of presentations on a really important topic, particularly focused on the social determinants of health at the community, social and structural levels.  You've provided us with incredible information on these important social and structural factors that impact SGM youth's mental health, and we greatly appreciate it, and from my perspective, I've certainly learned quite a bit.  

So, we thank you, thank you for your time, and we now have a break.  So please enjoy, and we will be back, I believe, at 3:30.  So thank you all again. 
[Break]

Panel Discussion with Youth‑Serving Organization 


STACIA FRIEDMAN-HILL:  Thank you.  Welcome back from break.  And, again, I'm Stacia Friedman-Hill.  I'm a program director at the National Institute of Mental Health, and my pronouns are she/they.

I am delighted to be able to introduce the last panel of Day 1 of our workshop. 

In putting together this workshop, one of the priorities of the planning committee was to include opportunities to hear from organizations which work with and represent sexual and gender minority youth and to also hear from LGBTQIA+ youth leaders themselves.  And we are privileged to have representatives from four youth‑serving organizations join us this afternoon. 

From Advocates for Youth, we have Louie Ortiz‑Fonseca and Sebas Abbate. 

From the Human Rights Campaign we have Ted Lewis and 
Kei Smith. 

From It Gets Better we have Justin Tindall, Rae Sweet and Alejandro Jiménez de Ferry. 

And, lastly, from True Colors United we have Aleya Jones. 

I'm going to let our panelists introduce themselves and their organizations in more depth in just a minute. 

The discussion will be moderated by Dr. Tamar Mendelson, Professor of American Health and the Director for the Center for Adolescent Health at the Johns Hopkins Bloomberg School of Public Health. 

Dr. Mendelson, I'll turn the discussion over to you now.  

TAMAR MENDELSON:  Thank you so much for that intro. 

So, yes, my name is Tamar, and my pronouns are she/her.  I am really honored to be here today with all of you, and very excited to be in conversation with our amazing panelists. 

So let me start by asking each of you to tell me a bit about your role within your organization, and perhaps at least one person from each organization can also say a bit about the mission. 

Does anyone want to go first?  

ALEYA JONES:  I'm fine to jump in. 

Hi, everyone.  My name is Aleya Jones.  I use her/her pronouns.  I work at an organization called True Colors United. 

I'll start with the mission.  True Colors United implements innovative solutions to youth homelessness by focusing on the experiences of those who are most impacted, which is LGBTQ and BIPOC youth. 

So currently I hold two positions, actually.  I'm a Senior Policy Officer, and I collaborate with key national, state, and local partners to educate and guide governors' offices and state agencies to ensure that the policies and systems are in place to end youth homelessness, and then I'm also the Senior Officer of Culture and Engagement, working to improve and enhance the structures, systems, human capital and management practices internally at True Colors United.  

TAMAR MENDELSON:  Thank you so much.  Great work. 

Who wants to go next?  

JUSTIN TINDALL:  I'm happy to hop in there and introduce It Gets Better. 

I'll start with myself.  I'm Justin Tindall.  I use both he and they pronouns.  And there's also a little MPH on the end of my name, which is really fun that this audience probably knows what that means when most of the audiences I work with aren’t that familiar.  But I am the Senior Director of Programs and Operations at It Gets Better. 

Like Aleya, I think at most nonprofits we carry a lot of hats.  So, similarly, I help lead our education and global programming while also helping us with the operations end, keeping the organization running. 

As an organization our mission is to uplift, empower and connect LGBTQ+ youth around the globe.  We do that primarily through story‑telling, community‑building efforts, including on a global scale. 

And I've got two wonderful people here with me. 

Rae, do you want to go?  

RAE SWEET:  Hi, everyone.  I'm Rae Sweet, I use they/them pronouns, and I'm the Senior Coordinator of Education at It Gets Better, so taking all of our story‑telling efforts one step further and connecting it directly with LGBTQ+ youth like Alejandro. 

I'll pass it to you.  

ALEJANDRO JIMÉNEZ DE FERRY:  Hi, everybody.  I'm Alejandro.  My pronouns are he/him.  I'm youth voice along with It Gets Better.  I served a really great two years with them learning how to really uplift and connect with my queer youth community.  It was really great.  

TAMAR MENDELSON:  Awesome.  Thank you so much, all of you.  Who wants to go next?  

TED LEWIS:  I can jump in next.  

So good afternoon, everyone.  My name is Ted Lewis.  I use they/them pronouns.  I serve as Director of Youth Well‑Being for the Human Rights Campaign.  Most people know HRC for our C4 entity, which does political organizing around partisan politics and getting pro‑equality elected officials elected. 

I work on the foundation side, which is our 501(c)(3) entity.  So, we work around education and advocacy on a smaller level for LGBTQ community members.  We have several programs that work and focus on youth that we'll talk about today.  I'm excited to be joined today by one of our amazing youth ambassadors, Kei.

Kei, I'll pass it to you.

KEI SMITH:  Hi, everyone.  My name is Kei Smith.  I use she/they pronouns.  I'm a second‑year youth ambassador with HRC.  I'm specifically representing Illinois.  And a lot of my work has focused on Asian‑American advocacy as well mental health advocacy.  So, I've really enjoyed my time here and, yeah, excited for today.  

TAMAR MENDELSON:  Fantastic.  So, you're all doing really critical, really important work, and we'd love to learn more and go a little bit deeper. 

So next I'm wondering if you could each say a bit about some of the current projects that you are working on with your organization and specifically, also, how you're engaging young people in those projects.  I don't want to sort of call on people, so I'll sort of open it up to you each to speak as you wish.  

TED LEWIS:  I'll jump in.  We're all kind of staring at each other awkwardly. 

So HRC has lots of various programs and initiatives.  We have several that focus on youth and young adults.  Welcoming Schools works with pre‑K through 12 schools.  We have a Historically Black Colleges and Universities initiative that focuses on HCBUs across the country and works with about a third of them.  We have an All Children All Families program that works around child welfare and foster care systems.  And we have some new initiatives like economic empowerment programs, including Next Level, which supports young adults ages 18 to 30 around financial wellness and job readiness. 

We have a lot of different ways that we connect and hear from youth and young people.  We do a survey roughly every five years with the University of Connecticut, and that gives us data on LGBTQ youth across the country.  And we also have amazing young people like Kei who serve as youth ambassadors with our program who are able to assist us in learning more directly from youth in the current moment but also can help us shape programs in the future. 

Kei, I don't know if you want to add anything based on your experience with the Youth Ambassador Program.  

KEI SMITH:  Yeah.  So, in terms of the Youth Ambassador Program, I would say it's a really good network of people ‑‑ youth doing activist work within their local communities, and then we kind of come together, and I feel like we get to pool resources, ideas.  So, it's a really great program where we're bringing a lot of our expertise to HRC, but we're also able to band together and kind of create a sort of network for ourselves so that we can rely on each other when we want to do advocacy for us locally.  So, yeah.  

TAMAR MENDELSON:  Thank you. 

And I need to apologize to Advocates for Youth.  I moved way too quickly through our intros.  So let me pause and give you both a chance to introduce yourselves, and then if you'd like, you can also address this question after you introduce.  

LOUIE ORTIZ‑FONSECA:  No worries.  I get it.  3:30 in the afternoon.  People are ready for their afternoon drink, coffee, Judge Judy, the news. 

I'm Louie Ortiz‑Fonseca.  I use all pronouns, but people get weird when you say that, so he/they.  I'm Director of LGBTQ Health and Rights at Advocates for Youth. 

Really quickly, Advocates for Youth has been around for a little over 40 years.  We're primarily known for championing sex ed to ensure that all young people have sex ed that is affirming, factual, and that is inclusive of young people living with HIV and young people who identify as LGBTQI+. 

But we all know that sex ed is this wonderful, beautiful umbrella, so a lot of the work I hold with the great team that I work with is our HIV work and our LGBTQ health and rights work. 

And in addition to working with community‑based organizations, organizing groups and national organizations, we work with a collective of youth activist cohorts or councils, depending on which staff you ask.  Some people say council; some people say cohorts.  I'm more the latter. 

And we have about eight of them.  We have the Young Women of Color for Reproductive Justice, which is the collective of young Black and Brown women and nonbinary people who do work around reproductive justice; we have the Muslim Youth Leadership Council; and then there are two that I work closely with, which is ECHO, Engaging Communities around HIV Organizing, which is a collective of young people living with HIV who do work at the local, state and national level; and Youth Resource, which is a collective of LGBTQ young people who do work both in‑person and digitally around LGBTQ health and rights. 

And we have one of those representatives, Sebas, who does amazing work around mental health, HIV, and sexual health as part of Youth Resource but also as part of the great work that they're doing in their community in Florida. 

And I'll give them the mic so that they can talk a little bit about what they're doing and what Youth Resource does.  

SEBAS ABBATE:  Thank you. 

Hi, y'all.  I'm Sebas Abbate, as Louie mentioned.  I also use all pronouns with a trey/he preference.  I am based out of South Florida, Lake Worth Beach specifically.  I'm going into my third year as a Youth Resource cohort member, which I am really happy and proud about.  It's an amazing group of queer youth of color, specifically, doing work across the country.  I've met some really amazing folks through the program. 

I specifically do work with young people in the capacity of HIV prevention as well.  I work at Compass LGBTQ+ Community Center in Lake Worth, and I host our young adult program.  So, I basically help people 18 to 30ish, we like to say, coming into adulthood, and I provide a social and support group space for them. 

So with that, I've also created a sexual health and education program called Pride and Pleasure, which is a really great program that actually gives people the chance to talk about our actual experiences and learn through a comprehensive lens about HIV prevention, mental health, sexual health, and all the issues that we're actually experiencing rather than the abstinence‑only education we're used to in addition to all the hate we're getting from every level here in Florida.  So, my goal is to provide a safe space for all LGBTQ youth in my area.  

TAMAR MENDELSON:  Thank you.  And, again, apologies for the initial bypass. 

So, Aleya, would you like to speak next?  

ALEYA JONES:  Yeah.  That's fine. 

So, I would say, in general, all of our work is very much relevant to sexual and gender minority youth, and youth collaboration is a top priority, shapes the work that we do since all of our work is aimed at ending youth homelessness. 

We have an entity at True Colors United called the National Youth Forum on Homelessness, and it's a group comprised of exclusively young people who contribute to the national growing dialogue on how to make youth homelessness rare, brief, and non‑recurring. 

The forum ensures that the national conversation is informed and filtered through the perspectives of young people who have experienced homelessness and that strategies to end homelessness are generated by youth and adults themselves who have experienced it firsthand. 

I would say more on the advocacy level and some of the things I've been particularly involved with over the past year is any sort of state‑based work advocating against the rampant anti‑LGBTQ and anti‑trans legislation that's being introduced across the country, and we at True Colors United particularly focus on the dangerous trends that impact youth and young adults. 

And I'll talk a little bit about this later, but so often the dialogue around anti‑LGBTQ legislation is focused on adult populations, and so we really care a lot about making sure that youth and young adults are being talked about in that conversation as well.  

TAMAR MENDELSON:  Thank you. 

And It Gets Better.  

JUSTIN TINDALL:  Yeah, I'm happy to jump in. 

First off, I'm a huge fan of the other organizations that are here.  I love the expression "it takes a village."  Like, that's the world of nonprofits.  There are so many nonprofits out there, but we're all trying to meet a particular need, and these ones are very special.  So, if you're not familiar with them, dive into it online and get to know them better because they're great organizations. 

It Gets Better, we're probably best known for kind of our digital online story‑telling efforts, sort of PSAs.  If you go onto TikTok or YouTube or Twitch or any of the wonderful platforms where young people congregate, you'll find us there trying to tell the stories of our community.  More than anything, we try to hand over the mic to make sure that our community members can tell those stories to reach people with positive messages, with messages of hope, hopefully meet them before ‑‑ meet LGBTQ youth before they're ever in crisis, but even during, to help them navigate those tough times. 

Rae will tell you a lot more about that, but I do want to mention just two of our kind of programs that exist that ‑‑ to engage with LGBTQ+ youth offline, maybe off of their screens. 

One is a great program called "50 States. 50 Grants. 5000 voices," a grant‑giving program where we're able to distribute grants to schools across the U.S., up to $10,000 per school, to help them make change happen in their schools. 

In the past two years alone we've been able to distribute over $1 million to schools all over the country, which has been just an absolutely incredible, incredible thing to see.  We love all of the schools and grantees that we've been able to support through that. 

We also just launched, actually a couple of months ago, Queerbook.  Like a yearbook, it's a book of contributions of young LGBTQ+ people.  They submitted poetry, art, photography, other wonderful elements that we were able to compile into a book and publish. 

Rae is throwing some great links in the chat.  I think they're just going to the panel, but hopefully those can go out to the full audience as well.  They're great links, so you can learn how you can ‑‑ you can learn more about them. 

But I'll hand it over to Rae to tell you more about the folks that we often hand the mic over to.  

RAE SWEET:  Thanks, Justin. 

Yeah, I was sending the links in the wrong chat.  Thank you so much, EVENT PRODUCER. 

Yeah, like I kind of said earlier, so Justin mentioned we're a story‑telling nonprofit, but my work is really connecting directly with youth.  So, we do community engagement where we go into schools, classrooms, conferences, wherever we can go, sharing those stories, but also engaging with youth and educators in those stories and how to tell those stories in ‑‑ or bring those stories into classrooms. 

We offer resources like our Edu guides where educators can bring those stories directly into their classrooms, connect them to core ‑‑ what are they called?  Oh, my gosh ‑‑ core standards for classrooms.  And, yeah, a lot of really great resources online. 

But, honestly, one of our highlight programs is our Youth Voices, which Alejandro is an alumnus of.  This is a group of anywhere between, like, 5 to 13 LGBTQ+ youth, depending on what year you look at, a group of 5 to 13 LGBTQ+ from across the U.S., ages 13 to 18, and they work with us for a full year, and we provide them with skill‑building, workshops, trainings, all kinds of opportunities to really build their skills and confidence in telling their story, in being able to tell their story in whatever ways and platforms they feel most comfortable with and connecting them with opportunities to tell those stories, whether that's at a conference, going live on Instagram, telling their stories to the New York Times or Teen Vogue.  Those are some opportunities that the Youth Voices have had.  So just connecting them with those opportunities to tell stories, and, again, with the mission to uplift and empower and connect LGBTQ+ youth. 

And I think really it comes from this need of like ‑‑ It Gets Better started with adults talking to kids, but I think kids want to hear from other kids.  And so that's really where we're leaning more towards is getting youth more involved in supporting each other.  Yeah. 

Alejandro, do you want to talk a little bit about your experience?  

ALEJANDRO JIMÉNEZ DE FERRY: Yeah, I would love to. 

It Gets Better was one of, honestly, probably the highlights of my high school career.  I think that it was maybe one of the coolest things I did, not just because I got to pretend to be a celebrity and really tell my story, like who I was, but also because, you know, for the first time in my life, and considering the time back then, I feel like the first time in a lot of queer youth lives that that was the first time that anyone like me has ever been able to tell their own story, which I like to think that I have a pretty unique story.  And it was just a really amazing thing to do. 

Something that I've recently been able to do is ‑‑ again, back to the Queerbook ‑‑ I was able to choose a lot of the entries that were submitted, which we had so many incredible entries.  And it was just such an honor to go through such beautiful pieces of art that, you know, I was really able to resonate with. 

And it was crazy, you know.  Back when I was working with It Gets Better, since I'm an alum now, it was really crazy to think that there were people like me out there, literally exactly like me, and then still, you know, there's just more of them coming out, and it's ‑‑ literally and figuratively.  And it's just crazy. 

And it's such an honor to really be part of it, and I would really encourage everyone to check them out. 

I don't know if I'm allowed to answer questions, but there's a question that is asking if there's an online group in Spanish, and this is another It Gets Better plug. 

I don't know how many chapters there are, but there are a bunch of Latin American chapters of It Gets Better.  The ones that come to mind is It Gets Better Mexico and It Gets Better Peru.  I'm Peruvian, so shout‑out It Gets Better Peru. 

But, yeah, to answer that question and just the general question of I love It Gets Better, it made my life better, and that is my true facts.  

TAMAR MENDELSON:  Thank you so much. 

And today there's been a lot of discussion about challenges that are facing LGBTQ+ young people, but also really want to hear from you all about what sources of joy are LGBTQ+ people finding right now.  What are you seeing?  

ALEJANDRO JIMÉNEZ DE FERRY:  I would really love to take this one. 

I think as an It Gets Better youth ‑‑ I'm 19 years old.  I like to think that that's youthful.  I don't know if that's a controversial take.  19 is pretty young in my mind.  But something that I've found that brings me joy as an adult now because I'm 19, but also back when I was still younger, is queer media. 

And just the other day I was watching this movie.  It's called Bottoms.  It's a dark comedy movie.  It's great.  It's got a super diverse woman of color ‑‑ queer women of color cast, and that is one of the best things that I believe ever happened to me. 

I feel like ‑‑ right now, in the world that we are right now, queer media is genuinely at an all‑time rise.  And it's something that is new to me.  I've never seen this much explicitly queer music ever in my life. 

Some people that come to mind are Billie Eilish and Chappell Roan and ‑‑ oh, she played Regina George in Mean Girls on Broadway.  Can't remember her name, but she is also queer.  And it is just incredibly eye‑opening at how many queer celebrities exist and are coming out right now and queer media that exists and is coming out right now; not five years ago, not before my time, but now.

And knowing that right now queer media is so big, that makes me wonder what's in the future.  And I genuinely believe that I'm so blessed to think about what comes next.  As a queer actor myself, knowing we have these trailblazers making this path for people like me, that's my queer joy.  That's where I get so much queer joy is just ‑‑ it's incredible, and I'm blessed.  I really, truly am.  

KEI SMITH:  If I can jump in as well, I think for me I would say a lot of queer joy I'm finding is through solidarity between communities.  I think often I've actively looked for queer‑specific spaces but also in other activist spaces and advocacy spaces.  I think I've found a lot of allyship as well as just other queer people who are doing really important work. 

I work at a domestic violence organization right now for Asian‑American women and trans people, and that organization, it is largely catering to cis women, but there's a huge push now to actually start reaching out to queer people in the Asian community.  And I'm finding that, like, there is a really big shift that's happening with solidarity between communities, trying to create those intersectionalities and intersectional spaces for each other. 

So, I find a lot of strength in that.  It's really uplifting.  And it is kind of depressing to see the news all the time and seeing how people are getting policed; but, at the same time, there is a lot of good work happening up there.  You just have to go out and find it and keep building it up.  

JUSTIN TINDALL:  I can answer that.  I do think that, as well, representation is extremely important.  I think there was a research study that came out just a few years ago where they're looking at young adult and children's books, and there was a greater percentage of children's and young adult books that had an animal as a protagonist than an LGBTQ person or a person of color. 

That is changing rapidly, thank goodness.  Of course, we all love animals, but we love people to connect with people who come from our communities who look like us. 

I would say that's, like, something that I often get to hear from Alejandro and from the other young people that we work with is that if they're into gaming, if they're into crafting, if they're into table games, if they're into online spaces, if they're into photography, like there's so many spaces in the world where they can go and be themselves.  And that is like a silver lining in a lot of kind of the state of the world and a lot of the attacks against LGBTQs that are happening in legislatures across the country is kids, despite that, are finding spaces in which they can thrive, in which they see themselves being part of where they can connect with other young people like them.  That is radically different from my generation or from any generations before, and that is truly exciting to see.  

SEBAS ABBATE:  Also, I can add that I think finding community is such a huge part of it, like everybody else has been saying that I'll echo.  In‑person gatherings and spaces that are safe for us, like that's what's really bringing joy to myself and my community that I'm finding.  Like we're having a queer beach gathering next week where we can express ourselves in the way we want to. 

A lot of the youth I work with don't come from safe homes that are affirming of their expression, so being able to, like, wear the bathing suit that you want and be able to just, like, have some  (inaudible) in the sand and not worry about, you know, your family or protesters or anything like that, I think that's really important. 

And thankfully, Pride Month does have a lot of opportunities.  It's almost, like, too many, like you can't choose which to go to, even down here in Florida.  So that's really lovely is that we are still creating those spaces for us and by us, and that's what's really important is when it's actually by us, you know, when it doesn't feel like we're just being catered to, you know, with pink‑washing and, like, queer capitalism and everything, where we're actually like ‑‑ it's just us.  That's what I really enjoy. 

Do I need to repeat any of what I just said?  I just saw a message.  

TAMAR MENDELSON:  I could hear you well.  

SEBAS ABBATE:  Okay.  

TAMAR MENDELSON:  Yeah.  But that's a good reminder to all of us, I guess. 

Did anyone else want to answer this question?  

ALEYA JONES:  I ‑‑ just from hearing everyone talks, something that's been really important at the organization I work for and just in general has been collective care.  Right?  Realizing that ‑‑ realizing how vital it is to lean on each other to find different supports and resources and reminders that we're not alone.  And there's a certain obligation for us to not only check on ourselves but check on the people around us. 

But, again, just like communal care, collective care, we do not have to get through this alone, and I know in this society that can be very individualistic.  It's important to uplift kind of that reminder that we can collectively get through this. 

And so that's ‑‑ what everyone's sharing just reminded me of collective care, and I wanted to put that into the space 

TAMAR MENDELSON:  Thank you for sharing that. 

So please give me a signal if you still have something you want to say on this question. 

Okay.  So, I will ‑‑ you've already ‑‑ some of you have touched on this in some ways, but I'm curious to hear from your perspective and your organization's perspective a bit about how you see LGBTQ+ youth contributing to their communities for the better right now.  What are you seeing?  

LOUIE ORTIZ‑FONSECA:  I think what ‑‑ going back to the last question, which connects to this, is that I've been in this work since I was a teen, and there was always a certain kind of young person that was elevated or provided a space at the table.  Like there was this notion of what's going to make the movement or what's going to make the right really take us seriously, and I think that over the past couple years and with the advent of social media, that has changed.  Right.

LGBTQ culture has rightfully been reminded about its Black roots and being unapologetically Black and not having to quote, unquote, code switch in order to explain something or gain access to a space.  And it's been wonderful to see that and advocates supporting them in the work that they want to do even if it challenges some of the notions of how organizing ‑‑ how we may think organizing should be done and when it should be escalated.  Right? 

Expanding the conversation around what it's like to be queer beyond coming out, that's important, but, you know, when I was a young person, I was always out.  I wanted conversations around mental health and what it was like to grow up with a mother and father who were addicted to crack.  Like that conversation was never going to be had in terms of LGBTQ young people in the '90s.  Right. 

And I feel like that conversation is happening now, like what does it look like for a complete LGBTQ young person, particularly those who are of color, what does that experience look like beyond just the identity part.  Right?  Because all of our identities are made with the sums of our parts.  And I think that it's been wonderful to see that and have the opportunity to support that. 

You know, they've created a tool kit around how to divest from police and invest in sex ed, like how do we amplify and expand all of the work that they want to do but, at the same time, supporting them within that around the emotional and mental health.  Right?  Like how we create safer spaces. 

We're not direct service, but we still have a responsibility to support the young leaders that we are working with.  And sometimes that means having, you know, workshops around protest safety, what does it look like for supporting mutual aid efforts locally so that young people who may have lost their jobs or who may not ‑‑ who may be out of work can have access to some money so that there's not one more thing for them to worry about. 

So, it's been great to see all of that in motion.  Sometimes it feels like the movement is catching up, and then it sometimes feels like I have to catch up.  And I think that while that can sound exciting, and it is, it can also be very exhausting. 

But I think that going back to what was said about community care, seeing that really be the foundational part of what LGBTQ identity is has been absolutely a learning experience and something that has breathed oxygen into all of our programs.  

JUSTIN TINDALL:  I couldn't agree with all of that more.  I ‑‑ gosh, this is a great group.  Again, I'm a big fan of those organizations. 

I think that as adults, especially as adults who are educated, who work for major institutions, we often can feel like we have the answers.  Right?  We know what's best for LGBTQ+ youth.  And I have learned over the course of my career that that is not always the case, that great intentions don't always lead to great impact or great success. 

Where I think It Gets Better has had the most success is, again, when we hand over the mic or we hand over the reins.  That is kind of at the heart of that grant program that I mentioned. 

We don't prescribe what needs to happen in a local community with those grant dollars.  Instead, we ask those applicants what your community needs from your perspective as a young person, what would make your school environment more welcoming for students like you and for the broader student body and being able to really listen to them and take into ‑‑ take to heart and really just believe that they know what's best has made the program extremely successful. 

So, I would definitely encourage all of you that have the opportunities to work with LGBTQ youth, take the time to just listen, to ‑‑ just take the opportunity to really learn and grow from what they have to share because it'll give you more wisdom than you possibly could get just from doing your job alone.  

TAMAR MENDELSON:  Thank you.  And just to repeat the question again as we move forward ‑‑ because I know a lot of folks here, and it's great to hear all of these perspectives ‑‑ how LGBTQ are+ youth contributing to their communities for the better at this time, if anybody else wants to weigh in on that.  

RAE SWEET:  I'll chime in because I ‑‑ I'll out myself.  I had messaged Tamar asking to repeat the question because I just wanted to make sure ‑‑ I have an answer, but I want to make sure I didn't go off ‑‑ but, yeah, something that's been really incredible with, like, working directly with LGBTQ+ youth is seeing the energy that is coming out and that they are bringing to the table even if they're not out. 

I mean, that has been really just, like, heartbreaking but beautiful to see these LGBTQ+ youth coming to It Gets Better saying I want to be a youth voice, I want to make a TikTok for you, I want to write a blog article for you, I want to apply for the grant program, I want to submit to Queerbook, whatever it is, but ‑‑ even if they're not out yet.  And it's so tricky because we have to protect our young people. 

A lot of our work is very front‑facing, so we can only accept folks who are already out.  But the energy is there even if they're not out, even if they don't have support of their family.  I mean, we have had youth voices in the past who, you know, they signed up, they didn't have parent support, but they were able to make it work somehow.  And that's just been really incredible. 

I mean, also seeing our young people giving ‑‑ testifying in public hearings, going to rallies and speaking at rallies, like it is just ‑‑ there's so much energy and there's so much passion and dedication and fearlessness that just ‑‑ it's really been incredible to see from young people, especially with everything that's going on right now politically.  

TED LEWIS:  And I was just going to add to what Rae was speaking to that I think sometimes we forget ‑‑ because the community's made progress, we sometimes forget that the goalposts move with progress and that young generations who have ‑‑ like when I was a kid, the idea of a same‑sex couple getting married felt like it was never going to happen in my lifetime.  That's the reality for most young people for the majority of their life at this point.  That goal post is way behind a lot of young people.  So, touting that as a success isn't helping LGBTQ kids right now, particularly queer and trans kids that live in places like Florida and Texas and Tennessee. 

And so, I think that it's helpful for folks me like who have been in this movement for a while to remember that past victories don't equal current things we can cheer about necessarily because it's not necessarily impacting the lived experiences of young people.  Right. 

And then the other piece I would just add is that I think sometimes it's important to recognize that simply existing in the hostile state that we are in in the United States comes with a certain level of resistance that I don't often think young people understand.  And today, with social media, one young person who puts something on TikTok could reach millions of people. 

And so, whether that's through It Gets Better, whether that's through HRC, whether that's through Advocates for Youth or True Colors, those voices have a way to reach places that they couldn't when I was a kid that I had to go to the library and find a book about that now you can click on your phone and access. 

But even simply a young person going through their high school day using a pronoun different from what people assume, coming out, inviting people into who they are, talking about their lived experience with even friends and family makes a huge difference. 

I can't tell you how many parents and caregivers have contacted us with questions and often talk about, well, luckily there's a kid down the street that's nonbinary who came out first that helped me understand who my kid is because they were already out.  Right?  And so, I think we forget that youth can be role models for each other often more so than adults because it's a peer and someone like them, and that that simple existing, particularly in the hostile environment that we see now, is a form of resistance, is a part of contributing to what is happening in the world. 

And living out and proud on the beach with your feet in the sand, right, at the Pride Festival, presenting in your classroom, but also just wearing a pronoun button pin, putting your pronoun by your TikTok profile, sharing who you are on X, all that stuff matters and impacts the community even if you don't directly see it in the moment.  

JUSTIN TINDALL:  Ted makes a great point in one of those earlier comments that for generations I believe that queer youth in particular were kind of an invisible subpopulation of the queer community at large.  I think that society often thought that queer issues were adult issues and, thus, a lot of the attacks on the queer community were focused on adults, whether it was housing discrimination, job discrimination, attacks against marriage equality, which still continue. 

But I do think that the more and more young people that are coming forward like Alejandro and Kei that are sharing their stories, their perspectives, saying we're right here and we know what we want, we know what we need, and we know what we want to do on behalf of our communities, I think that's where we've seen this shift and that the attacks have now ‑‑ are now largely focused on young people ‑‑ it almost feels as retribution ‑‑ for finally speaking up and giving a face to their community. 

That's very unfortunate.  But at the same time, like Rae's point, these are incredibly resilient young people who are determined, they are passionate, they are energetic, and they're not going to let up even if the attacks continue to build. 

I think that they're making a difference in their community, for all the ways that Ted listed, just by owning who they are.  That is a huge first step for most queer people, but more and more young people are getting there a lot quicker than previous generations.  

TAMAR MENDELSON:  Just checking if anybody wanted to add to that or has another comment to make.  Okay. 

So, I'm curious, too, about hearing about how each of your organizations works with others in terms of the projects you take on and the initiatives that you do.  So, if you could speak a little bit about that and about working with others as a way to amplify and coordinate efforts, strengthen collective impact.  

TED LEWIS:  Well, I'll jump in. 

So, I think that it's ‑‑ I also want to be transparent with you all.  I work for the Human Rights Campaign.  HRC doesn't have the best track record of partnering.  Part of that is because of how the ‑‑ I'm going to get a little wordy here but ‑‑ the nonprofit industrial complex works. 

Yes, we have organizations that overlap in terms of our mission, and we're all needed in this movement.  But it can also be hard to find our space for how we partner together while still carving out our own space to be able to get funding, to be able to get resources, to be able to pay people what they are needed to survive and do this work. 

So, I want to acknowledge that there are some hurdles into collective work, especially when you're in movement spaces that are already often underfunded, under resourced, understaffed.  Right?  And I think there are opportunities now where we're seeing, because of the political landscape, there is a moment for organizations who are not directly working with LGBTQ people or youth in particular to step up and meet the need of the moment. 

And so, like at HRC we have an initiative called Project Thrive which works with over 30 national partners, including folks like Advocates for Youth, one of our newer partners, that have a pledge on the thriving of LGBTQ young people as part of their work.  And that includes people like the National Association of Social Workers, National Education Association, American Medical Association, Big Brothers Big Sisters, Boys & Girls Clubs, et cetera.  And so, I think there is opportunities for us to approach, quote, unquote, mainstream organizations to get them to dedicate resources, time, and their presence, their collateral, their esteem in the world to uplifting LGBTQ young people. 

Any of the organizations on here can give you fabulous resources, research, and stories from young folks.  And I would bet every one of us has heard from other professionals, well, it's biased because it's coming from an LGBTQ group or it's coming from a progressive group.  But I think that there are opportunities for us to encourage other industries to start speaking up and making a difference. 

We've actually seen this help already in terms of legislation when people who are in professions such as mental health or physical health are able to talk about the harm that comes when you deny transgender kids age‑appropriate, necessary gender‑affirming care.  That goes a long way in helping turn the tide, in addition to hearing from young people who are impacted, in addition to hearing from community advocates.  It's really helpful. 

And I also see ‑‑ there's ‑‑ this is, I think, one of those questions where, like, we as adults can talk all day about what 
that looks like, but I would encourage our youth on here to also chime in, not just from an organizational standpoint, but where do you see those coalitions as well.  

RAE SWEET:  I was ‑‑ Kei, you unmuted.  No, you go ahead.  

KEI SMITH:  No, That's okay.  Sorry. 

I was just going to say, to add a little bit of youth voice since ‑‑ I mean, I am a youth ambassador, but I'm not necessarily staff at the organization. 

I do want to say that I think something that a lot of nonprofits can learn from in those kinds of spaces to learn from with youth organizing is, like, there is a lot of grassroots work happening within youth movements, and I think we're really good about connecting with each other and, like, pooling resources and kind of banding together. 

And I think that kind of also relates to the last question, like that's how we contribute to our communities is, like, we're really good at building community.  So, I think that's something that, like, we are trying to bring to more nonprofit spaces and to larger institutions.  So, I think that's something that we can all learn from is grassroots work.  

RAE SWEET:  Yeah, I totally agree. 

I love this question because I'm really ‑‑ I love partnerships.  And I think to what Ted said about, as nonprofits, we are understaffed, we are under resourced, and so partnerships is exactly what we need to be doing in order to fill those gaps. 

It Gets Better, especially our education department, we lean on our partnerships in a way that is mutually beneficial. 

And so, a great example of that is we partnered with Hope Lab in creating ‑‑ helping create IMI.  IMI is a digital mental health resource tool for LGBTQ+ youth, and they needed LGBTQ+ young people to help create the app, and we had youth voices who needed work to help share their voices and help be involved in advocacy and mental health and all those things. 

So, we had our youth voices help create the app.  They gave feedback, they were in focus groups, all kinds of things.  That is one great example. 

Another recent example, an organization called No Filter reached out, and they were like, hey, let's collab.  And No Filter is focused on creating safe resources for how to be safe online for youth.  So, you know, you're on Instagram and TikTok and you're DM'ing strangers on the internet.  Like how do you that safely. 

And as a digital nonprofit, we're putting our youth out there online, and we want them to be safe, and so how can we bring those together. 

So, we had both of our youth cohorts come together to create a guide on how to be safe as an LGBTQ+ person online.  We crossed our two missions together and had both of our youth come together and brainstorm and create a guide, and that guide will be coming out soon.  It's not out yet. 

But just finding those ‑‑ those intersections, like ‑‑ it's there.  It exists.  So, what is your mission, what is our mission, what are the gaps that we can fill, you know?  And I think we've built a lot of programs where it's kind of built in where we can have those opportunities. 

So twice a year we have a career day.  And so, if I'm collaborating with corporate partners even ‑‑ oh, you want to be engaged with our youth?  Come to career day.  Come share about your life as an LGBTQ+ person in the corporate world.  Wherever you can find opportunities to connect, I think it's really important to fill those gaps because we're under resourced. 

Yeah.  Thank you.  

STACIA FRIEDMAN-HILL:  And, Rae, there's a question in the Q&A box asking:  Will you say more about the app, whether they're free, how to get them maybe.  

RAE SWEET:  Yes.  Absolutely.  They are free.  They're not a downloadable app like you go into the app store.  It's a web‑based app.  So, you just type in ‑‑ I think we just typed the link.  Thank you.  It's IMI.guide.  IMI.guide.  And it's just an easy‑access digital tool, and you can click through and do a little five‑minute activity and it should boost your day.  Yeah, that's a great one. 

And then No Filter is also linked there. 

Thank you for the question.  

TAMAR MENDELSON:  Thank you.  
Folks from Advocates for Youth, do you want to speak to this?  

LOUIE ORTIZ‑FONSECA:  Can you repeat the question?  

TAMAR MENDELSON:  Sure.  So, the question is about ‑‑ the question is about how your organization works or partners with others to amplify impact and strengthen collective impact.  

LOUIE ORTIZ‑FONSECA:  Right.  This is weird.  They probably don't want me to be able to plan. 

No, I kind of think of everything as kind of like a record label because music is my favorite thing.  Right?  So, there's things that make sense in amplifying, maybe the policy asks or maybe to make something sound even more beautiful.  Right? 

So sometimes it is driven by the connection you have with someone and sometimes it's like your supervisor saying, "Make this work."  And both things can turn out to be beautiful. 

But all of the things that are outward facing that we partner with do not see the light of day without getting reviewed by our young people.  So regardless of if I think the partnership may have not been the best use of my time or if I think it was the most transformative, amazing thing, right, which is more of the reality most of the time, all that stuff still has to be reviewed by young people.  Right. 

And I think knowing that helps us to figure out what makes the most sense and who we partner with.  Right?  Let's say that we're that girl and that we get to choose, but some things, you know, it's not in our wheelhouse.  Right. 

We did some support around community ‑‑ I used that term earlier, when you share funds ‑‑ mutual aid.  That's when a large organization says, hey, we want to partner with you with mutual aid.  That's not our lane.  Right?  So, yes, we want to partner with you, but that's not our lane, so let's pass this off to over here because this is what they do. 

So, partnerships are also knowing what we can bring to the table, what are the opportunities, but also not being led completely by the opportunities because sometimes we're just not that ‑‑ we're not the best organization to do ‑‑ to support that work when a lot of times it should be community‑based organizations. 

But, again, because the young people who we work with like Sebas review everything, like, that keeps ‑‑ that helps to keep us grounded in our mission, in our vision, in our goals around who to partner with regardless of personal feelings.  Right?  Because this work can be personal.  Right?  Sometimes we bring everything we have to this. 

So, I would say for us, the young people ‑‑ sounds cliche ‑‑ serve as our guide. 

And I'm not sure if Sebas wants to add anything. 

Even like what ‑‑ how we partner with our young people, we don't tell them what to do in their community.  Right?  They kind of run their ideas by us.  We may fund some of their projects, and we support them, but ‑‑ and connect them to partners, but it's for them to decide what works best for them.  Because I'm not in Florida.  My family is.  That's why I'm here in D.C. 

But I'll turn it over to Sebas, if they have anything else to add around partnerships, to speak from a youth perspective.  

SEBAS ABBATE:  Thank you. 

I'm trying to figure out, like, what I can add to this. 

I think, like, I really enjoy being able to form those partnerships, especially within Advocates for Youth, because you have that, like, national space, where I'm limited in my job at Compass where we're very, like, county‑specific.  Right?  And so, we just work within, like, the nonprofit complex here, like everybody has, like, these grants and these grants, and we can just share, like, part of the pie, and it's kind of limited with what resources we have where, like, we have youth.  Like we'd like to serve, but, oh, no, you're just, like, one city too far away. 

So being able to have, like, a national space and, like, a digital space can be so empowering because you can reach everybody that, like, maybe space or, like, physical space is a limiting factor for. 

So that's something I really enjoy, especially with, for example, HIV AIDS awareness days.  That platform can reach the voices that it ‑‑ or the ears that it needs to and being able to amplify the voices that, like, need that amplification, right, that we just, like, don't have the ability to do on our own.  And I think being able to find that strength in community is really (inaudible).  

TAMAR MENDELSON:  Thank you. 

And, Aleya, do you want to speak at all about partnerships that True Colors United engages with?  

ALEYA JONES:  You know, I think so much of what was already said is what I was going to add to the conversation.  But I would love to answer the next question first.  I just don't want to ‑‑ 

TAMAR MENDELSON:  That's fantastic.  Let's do that.  Okay.  So ‑‑ and I see we're coming up on time here.  I feel like you all have so much amazing input to share.  I wish we had a longer time. 

But this workshop is sponsored by the National Institutes of Health, and they have a research focus, and so I would love to hear you speak a bit about the kinds of questions and the types of data that you wish researchers could provide that would be impactful for the work you do.  

ALEYA JONES:  I'll start this one.

There was one question I really wanted to answer because I wanted this space to hear it, so I'm going to answer the question I wanted to answer ‑‑ 

TAMAR MENDELSON:  Yeah, you answer the one you want to answer.  

ALEYA JONES:  Is that okay?  I gotta talk about this.  

TAMAR MENDELSON:  You answer what you want to answer.  

ALEYA JONES:  Okay.  So, this is a question about the trends and needs that we've seen from sexual and gender minority youth over time and something I really wanted to amplify in this space for particularly, like, unhoused youth is that, in a very general sense, there's a lack of comfortability and safety that LGBTQ young people are facing navigating various systems and environments such as, like, shelters.  Right. 

Many youth shelters are actually very homophobic.  They're not suitable for sexual and gender minority youth, and we have to name that.  Right?  Because often you might hear a narrative of, oh, well, there's shelters.  Just because there's a shelter, it doesn't mean it's safe for folks.  Right. 

There's actually not a lot of protocols put in place for LGBTQ youth in shelters, safe‑based shelters (inaudible) discriminatory against trans communities in particular.  So, for instance, folks are not able to use showers that match their gender identity. 

And another general trend I've seen over time is that Black trans youth are dying, are being killed.  Right?  And I know that we've centered joy in this experience too, and I think that's important, but I also think it's vital that we name that Black trans youth need to be protected.  And while we've made progress over the past five years, we also have to name the way violence does show up against Black trans bodies, and it needs to be eliminated.  We need to talk about it, and we need to figure out ways to protect our Black trans youth.  So that was one thing I really thought was important to name in this space. 

In terms of research, I'm actually particularly interested to hear about how what's happening at, like, state levels in terms of anti‑LGBTQ legislation, how it's literally impacting young people on the ground.  But I don't want it to just be data.  Right?  I don't want it to just be, like, data‑driven.  I want it to actually be story‑telling and narrative‑sharing, amplify what numbers already exist, but by way of young people really being able to use their voice to say this is what it feels like for me going to school during this time or this is what it's like for me just being myself every single day, as someone else mentioned.  Those are things that I would love to see, just more qualitative data.  I'm a big qualitative, story‑telling kind of gal, and that's what I would love to see.  So yeah.  Thank you.  

TAMAR MENDELSON:  Thank you so much. 

Advocates for Youth, do you want to take this next?  

SEBAS ABBATE:  I have a perspective that I would love to be amplified which I've come across in my work a lot, especially recently, is ‑‑ well, I work a lot in the HIV prevention field, and so we deal with a lot of HIV studies, right, or, like, any other studies in the safer sex/sexual health realm.  And so often the voices or experiences of, like, trans masculine people just don't exist in these studies.  And it's so frustrating because it affects me, it affects my friends because, like, we might have a uterus or we might not, but, like, the cis women that are being studied, like they have different experiences than us.  Their medication might be different, like if we're taking testosterone.  It's just really frustrating. 

And also seeing, like, trans feminine individuals being lumped in with cisgender men.  It's just really frustrating that our experiences are still not being amplified, and then the companies that are doing the studies keep just saying, well, like, it's so hard to find the population, because it's not.  We are here, and we do want our experiences to be represented.  Right?  You just have to do the work of finding us, because we also want, like, safer sexual, like, health and lives.  We just ‑‑ we have to put in the work to find us, right, or, like, partner with the organizations that do work with us, right, to, like, create that bond. 

That's just something I'm really passionate about, something I'm in discussion with my community a lot about is just that, like, we don't have that representation, and it's really frustrating, especially for, like, people of color, the numbers go down, like, way more. 

So that's my platform.  Thank you.  

TED LEWIS:  I'll just add one thing really quick, and it's that a lot of great research is being done and then you lock it behind a paywall that most nonprofits cannot access.  We rely on our college interns to actually access the great research you all do. 

So, my big ask of researchers is to get your data and your information and your research out there into the public sphere, make it accessible. 

A 500‑page research project is great.  Can you partner with someone to make some infographics, can you give me top lines, can you send the information directly to folks that work with you that work in community?  Because most of you are doing amazing, fantastic, cutting‑edge research.  We don't find out about it until five years later when it's finally accessible.  

TAMAR MENDELSON:  That's a really important one.  Thank you. 

How about It Gets Better?  

JUSTIN TINDALL:  I have the honor of being able to participate on an advisory committee with Equality California, because we're based here in California, for their Safe and Supportive Schools Report Card. 

Essentially Equality California puts out a report card saying how well are districts across the state performing in terms of their support for LGBTQ+ students.  And that survey is mostly filled out by adults saying, well, we have these policies in place or we're doing these various things at our schools to be able to support LGBTQ+ students.  But if you would ask LGBTQ+ students at those schools if those policies or if those resources actually reach them, the answer would probably be no. 

And so, I would just love to see research that includes more perspectives of young people, including in terms of what recommendations should be provided to accompany that research. 

Again, I think that young people know what they need a lot better than we think that they do, and I would just love for data to come with "and here's what the youth who participated in the survey or in this study have to say on the matter."  Not just how they're impacted but what can be done to change it and make it for the better.  

TAMAR MENDELSON:  These are all fantastic suggestions for those of us who do research, so we appreciate that.  Thank you very much. 

I know that we're now at 4:32. 

Stacia, let me turn it to you.  

STACIA FRIEDMAN-HILL:  Thank you.  Thank you for doing a great job moderating this discussion, Dr. Mendelson. 

And thank you to all of the representatives of the organizations who are able to join us today. 

I think that was a really great note to end on to really sort of tie together all of the panels that we heard today and that we're going to hear tomorrow is to think more about how this all fits together, how do we make our research translatable into action.  And I hope that we can keep that in mind. 

So, again, I really want to thank all of you for participating in this conversation. 

We're not done yet for the day.  I've asked one of my colleagues who's in the Office of Disparities Research and Workforce Diversity to close out our day for us, so I'm going to pass the baton to Beshaun Davis.  And, again, thank you, everybody.  This was really wonderful.  

BESHAUN DAVIS:  Okay.  Thanks, Stacia. 

And I know people have been really engaged in really great discussions today across all the panels, especially this last one.  So, first of all, I just want to thank Stacia for organizing this workshop series.  It's been a great conversation.  We've had a lot of really ‑‑ we've heard about a lot of really great research today, so it's been really wonderful. 

Like Stacia said, I'm a colleague from NIMH.  I'm in the Office of Disparities Research and Workforce Diversity where I'm a program director for minoritized populations mental health research.  And so, as a part of that, the reason why I'm closing out today is because a big chunk of my sort of portfolio is the sexual and gender minority mental health research portfolio.  So, it's really great to hear about all the sort of cutting‑edge research in this area and also to hear from all of the community organizers and the youth today who are doing work in this space. 

So, I just want to second what Stacia said in thanking all of the speakers and researchers and panelists today.  This was a really great ‑‑ really great day to hear about all the sort of work that's being done.  And we've heard a lot about a bunch of different areas.  Right?  So from that first panel on the measurement of sexual and gender identity sort of data, developmental trajectories and trends, we heard a lot about this idea of like ‑‑ I think one key takeaway I got was this idea that, like, creating an environment that's affirming for LGB students in schools does not just improve the mental health of LGB students; it improves the mental health of all students.  Right. 

So, I think, you know, there's this idea that, like, when we sort of tailor to the most marginalized folks in our society, that it is a benefit to everyone.  Right?  It's not just ‑‑ it's not just for LGBTQI+ individuals; it's for everyone.  So, it's really great.  And I think that's a huge benefit. 

You know, we've heard a lot about the improvements that are happening and how like ‑‑ you know, I think in the last panel we talked about the idea of the goal posts being moved.  Right?  Like 20 years ago, 30 years ago, we would have been talking about very different issues, but there's so many parts of the community that need to be ‑‑ that have needs that are not being addressed by the current mental health care systems.  Right. 

So, it's really great that we're hearing about some of the research in this space, you know, thinking about including more diverse and intersectional samples in the research world and really addressing, you know, some of the concerns of LGBTQ+ youth like at multiple levels.  Right. 

We've talked about systems‑involved youth and how it can be really tough for systems‑involved, like, LGBTQ+ youth to be placed in certain ‑‑ in foster care or group homes and things like that.  And so, this just speaks to the stigma and the sort of disadvantage that's not fully being addressed by the systems that we have.  Right. 

And so, a lot of the work that was talked about today involved community‑engaged research and, you know, really centering the perspectives of the youth.  And that was really great hearing about how the research can be shifted in that direction. 

So overall I think we've had a really great day hearing about a lot of really great research, and I think that it was really fitting that we ended with this panel of all the youth organizations and some of the youth who are really involved in doing ‑‑ you know, advocating for change for LGBTQ+ individuals. 

I think it was really great to hear about, you know, how lots of these organizations were empowering youth to tell their stories, to build community, and to get access to much needed resources and information as well as, you know, not only focusing on sort of, like, this deficit model; there was this focus on strengths.  Right?  That the youth can sort of form community and share their experiences and talk about, you know, media and representation and things like that to really, you know, have a positive effect on trajectories of so many ‑‑ so many youths. 

So, all of that to say this was a really great day.  Tomorrow we'll be covering a broad set of topics, as well, under the umbrella of, like, more community‑engaged research, risk and resilience across individual, interpersonal and family levels, as well as services, intervention, and prevention research.  So, I hope all of you will come back tomorrow and that we'll get to hear about some more cutting‑edge research in this area.  So, thank you all, and we'll see you tomorrow. 

STACIA FRIEDMAN-HILL:  Thank you, Beshaun.  And we're ready to close the day.  

EVENT PRODUCER:  Thank you, everyone.  And we'll see you tomorrow morning.