Understanding Protective Factors for Suicidality and Depression Among U.S. Sexual and Gender Minority Adolescents: Implications for School Psychologists

Abstract

Sexual and gender minority (SGM) youth experience higher rates of adverse mental health outcomes, most notably suicidal thoughts and behaviors (STBs). The current study examines risk and protective factors for STBs and depression among 1,078 youth in high schools. We examine these outcomes through an intersectional lens, and we extend the use of the minority stress theory framework by focusing on resilience and protective factors and argue that bias against lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) youth should be addressed at the systemic, rather than the individual, level. Our findings suggest that family support is a notable factor protective of depression and suicide-related behavior among LGBTQ youth. Additionally, peer support, help-seeking beliefs, access to medical and counseling services, engaging in healthy activities, spirituality, and having trusted adults are protective factors for some groups. The nuanced findings in this study offer suggestions for school psychologists and professionals to promote healthy and safe school environments.

Impact Statement

The present study addresses the prevalence of suicide among LGBTQ adolescents and protective factors that may buffer their heightened risk. LGBTQ students are not inherently at risk because of their identities, but because of stigmatization they may face in society. As such, recommendations are provided to guide school psychologists and other professionals to foster a safe and inclusive environment for this population to reduce suicide risk.

Keywords:

• suicide
• LGBTQ youth
• heterosexism
• school climate
• protective factors
• resilience

ASSOCIATE EDITOR:

• Rhonda C. Boyd

IMPLICATIONS FOR SCHOOL PSYCHOLOGISTS

School psychologists possess a wide range of expertise in assessment, research, intervention, counseling, and prevention strategies and have an ethical responsibility to promote social justice and equity (National Association of School Psychologists, 2010). Thus, school psychologists have the knowledge and skill set required to identify and implement best practices to ensure that LGBTQ youth are supported at school by adults and their peers. All youth, including LGBTQ youth, are resilient and can thrive in schools where they feel supported, respected, and safe (e.g., Kosciw et al., 2016; Russell et al., 2014). It is important to note that identifying as LGBTQ does not automatically put youth at a greater risk for depression and suicidality; instead, it is being LGBTQ in a sexist, transphobic, heterosexist, and homophobic school or community where they are more likely to experience bias-based aggression, discrimination, and oppression that negatively impacts LGBTQ youth’s mental health (Kosciw et al., 2016; Russell et al., 2014). Given the prevalence of sexism and heterosexism, school psychologists interested in making a substantive change in practice and policy for the prevention and remediation of risk factors and adverse outcomes through the promotion of health and wellness of LGBTQ youth should focus on bolstering the protective factors identified in this study (e.g., family support, help-seeking). Because not all LGBTQ youth have access to the same level of support, school psychologists should infuse support systematically.

Multitiered systems of support in schools can provide school psychologists with a systematic framework and a team for implementing suicide prevention and mental health promotion strategies that are inclusive of LGBTQ youth and their experiences (Briggs, 2015). When screening at the beginning of the academic year, multitiered systems of support teams should consider collecting and interpreting data on sexism and heterosexism from peers and staff to understand which attitudes and behaviors are endorsed and where to intervene at tier 1. Additionally, data collection could capture the protective factors available in each school to help school psychologists identify the strengths and weaknesses in support of LGBTQ youth. Interventions at tiers 2 and 3 can be targeted for LGBTQ youth struggling with mental health (e.g., counseling) to ensure that they have at least one adult who affirms and supports their identity (Byrd & Hays, 2012).

Specific recommendations for school psychologists for school-based efforts to prevent suicidality and depression among SGM youth include (a) an emphasis on the protective factors available to LGBTQ youth and ongoing support of those factors; (b) educational curriculum on identity development and intersectionality to disrupt sexism and heterosexism at Tier 1; (c) development and implementation of a comprehensive antibullying policy at school that specifically prohibits bullying and harassment based on actual or perceived sexual orientation, gender identity, and gender expression; (d) professional development for all school staff regarding sexist, transphobic, homophobic, and heterosexist behaviors; (e) establishment and promotion of gender and sexuality alliances or similar identity-affirming student organizations (Heck et al., 2013); (f) affirmative counseling for LGBTQ youth at tiers 2 and 3; (g) partnering with families and the community to further their understanding of LGBTQ identities LGBTQ identities; and (h) visible allyship for LGBTQ youth that intentionally encourages and promotes help-seeking (Day et al., 2019). School psychologists are fundamental to the implementation of strategies that promote adolescent mental health in schools, and the findings from the current study along with the aforementioned recommendations can provide guidance around establishing a school environment that is protective for LGBTQ youth.

LIMITATIONS AND FUTURE DIRECTIONS

Despite the contribution to the literature on an intersectional understanding of protective factors for LGBTQ youth, this study has several limitations. First, the data presented in this article were cross-sectional and thus fail to capture how protective factors may change over time for LGBTQ youth. Future research needs to examine these associations longitudinally to fully explain how protective factors for mental health function in terms of specific sexual and gender identities and their intersections with race/ethnicity. Second, data were self-reported by high school students at school, which may increase the likelihood of response bias. The utilization of student self-report data also fails to present how other individuals in the school (e.g., peers, teachers) may observe protective factors in schools. Third, though we examined the experiences of transgender youth in our sample, we were underpowered to examine further intersections of gender and race/ethnicity (e.g., Black trans females). We urge scholars to collect data from youth with multiple marginalized identities and to disaggregate these identities when drawing conclusions about LGBTQ youth to understand nuances across identities. Further, our sample limited our ability to flesh out more intersectional features of identity with regard to racial/ethnic diversity. We recognize that this limits the interpretability of our findings in terms of intersectional aspects of youth. Finally, though we included eight potential protective factors, these factors are limited in capturing all of the variables that might serve to protect LGBTQ youth from depression and suicidality. Research, practice, and policy centered around mental health promotion would benefit significantly from a more comprehensive understanding of how specific sexual and gender identities are protected from these outcomes. We reiterate that it is critical for scholars to continue to combat the stigma faced by LGBTQ youth while using a strength-based approach, rather than a deficit-based model. In this way, we can harness the protective factors that already guide mental health promotion among this population in a way that celebrates the uniqueness of LGBTQ youth.

ETHICS APPROVAL

All procedures performed in studies involving human participants were in accordance with the ethics standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Institutional review board approval was received from the University of Florida, the University of Rochester, the Colorado Department of Public Health, and Texas Tech University.

INFORMED CONSENT

Informed consent was obtained from all individual participants included in the study.

Additional information

Funding

This work was funded with a grant from the Centers for Disease Control and Prevention (1 U01 CE002841) to DLE and PW (coprincipal investigators). None of the authors or collaborators have conflicts of interest to disclose, including conflicts through financial interests, activities, relationships, or affiliations. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Notes on contributors

Matthew Rivas-Koehl

Matthew Rivas-Koehl, BS, is a graduate student in the Department of Human Development and Family Sciences in the College of Human Sciences at Texas Tech University. His research interests include health promotion and violence prevention across the life span, particularly among individuals with marginalized sexual and gender identities. His graduate work includes research related to campus climate and mental health for sexual minority individuals, healthy relationships among gender and sexual minority individuals, and human sexuality across the life span.

Alberto Valido

Alberto Valido, BS, is a graduate student in applied developmental science and special education at the Peabody School of Education, University of North Carolina at Chapel Hill. Valido’s research interests include intersectionality with a mental health prevention focus and randomized clinical trials, specifically among adolescents who experience discrimination or are victimized at school due to their sexual, racial, or gender identities.

Dorothy L. Espelage

Dorothy L. Espelage, PhD, is a William C. Friday Distinguished Professor of Education at the University of North Carolina. She is recipient of the APA Lifetime Achievement Award in Prevention Science and the 2016 APA Award for Distinguished Contributions to Research in Public Policy and is a Fellow of APS, APA, and AERA. She is a member of the National Academy of Education. She earned her PhD in counseling psychology from Indiana University in 1997. Over the last 22 years, she has authored over 200 peer-reviewed articles, six edited books, and 70 chapters on bullying, homophobic teasing, sexual harassment, dating violence, and gang violence. Her research focuses on translating empirical findings into prevention and intervention programming and she has secured over $14 million of external funding. She advises members of Congress and Senate on bully prevention legislation. She conducts regular webinars for the CDC, NIH, and NIJ to disseminate research. She has conducted randomized clinical trials to evaluate K-12 social–emotional learning programs to reduce youth aggression, peer-led interventions to address sexual violence and suicidal behaviors, and virtual reality-based bully prevention programs. Findings of her research are guiding state, national, and international efforts to prevent youth violence and promote positive school climates.

Luz E. Robinson

Luz E. Robinson, BS, is a doctoral student in school psychology at the University of North Carolina. Her research interests include school violence prevention, mental health promotion, and resilience among Latinx and other marginalized youth.

Jun Sung Hong

Jun Sung Hong, PhD, is an associate professor in the School of Social Work at Wayne State University. He is currently the ­codirector of the Laboratory for the Study of Youth Inequality and Justice. For the past several years, Hong has primarily conducted research on factors associated with bias-based bullying and peer victimization of racial/ethnic minority, immigrant, LGBTQ, juvenile justice-involved and economically disenfranchised adolescents and young adults in the United States and in South Korea. He has also collaborated with scholars in South Korea, Taiwan, China, Sweden, Scotland, Switzerland, Spain, Ukraine, and Brazil on research projects.

Tomei Kuehl

Tomei Kuehl, MPA, is an experienced public health practitioner with expertise on the application of a shared risk and protective factor approach. Tomei currently works as a consultant providing support for organizations interested in applying and evaluating a shared risk and protective approach with an equity lens. Tomei has worked in the field of violence prevention for over 10 years at both the state health department and the state human services department on issues related to sexual violence, domestic violence, bullying, youth suicide, child abuse and neglect, and preventing repeat victimization with historically underserved populations.

Sasha Mintz

Sasha Mintz, MPH, is an epidemiologist at the Colorado Department of Public Health and Environment. Her work focuses on the epidemiology and prevention of child deaths due to injury and violence and sexual violence among young people. Using an equity lens, Sasha works to disseminate data to partners, stakeholders, and community members, which contributes to equitable injury and violence prevention at the state and local levels. She is interested in using a shared risk and protective factor approach to prevent multiple forms of injury and violence. Sasha coleads the national Fatality Review Health Equity Learning Collaborative. Sasha received her bachelor’s in biomedical sciences in 2012 from Colorado State University and her master’s in public health in 2017 from the University of Colorado Anschutz Medical Campus.

Peter A. Wyman

Peter A. Wyman, PhD, is professor and academic chief, Division of Child and Adolescent Psychiatry, University of Rochester School of Medicine. Wyman is a graduate of Columbia University and received his PhD in clinical psychology from the University of Rochester. He has focused his career on developing, testing, and implementing population-oriented preventive interventions for suicide, depression, and substance use. A key theme is leveraging natural change agents to strengthen health across a network. He has been funded by the NIH, the CDC, and the Department of Defense to develop network health interventions for diverse populations ranging from adolescents in rural communities to emerging adults. Wyman partnered with the U.S. Air Force to develop the Wingman-Connect program to strengthen mental health and reduce suicide risk among early career Air Force trainees. He has conducted training on upstream suicide prevention and prevention science methods for U.S. military and federal agencies, state and local school districts, as well as internationally. Wyman served as topic expert consultant to the NIMH/National Action Alliance for Suicide Prevention. He cochairs the New York State Governor’s Suicide Prevention Task Force and served on the U.S. Air Force Suicide Prevention Solutions Working Group (2017–2019).