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Attracting Attention to Sexual Minority Youth

      See Related Article p. 38
      Although some emphasize that “most LGBQ youth lead happy, healthy lives,” [
      • Shearer A.
      • Herres J.
      • Kodish T.
      • et al.
      Differences in mental health symptoms across lesbian, gay, bisexual, and questioning youth in primary care settings.
      ] it is during adolescence that health disparities among lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth arise [
      • Russell S.T.
      • Fish J.
      Mental health in LGBT youth.
      ]. In this issue of the Journal of Adolescent Health, Shearer et al. [
      • Shearer A.
      • Herres J.
      • Kodish T.
      • et al.
      Differences in mental health symptoms across lesbian, gay, bisexual, and questioning youth in primary care settings.
      ] examined mental health symptoms among youth with different sexual orientations in primary care settings. The authors divided their sample into four groups based on subjects' attraction to males, females, both males and females, or whether they were “unsure” of their attraction. Based on the youths' reported gender, the authors then compared these groups on six mental health outcomes. Confirming their hypotheses, sexual minority youth reported disparities in mental health symptoms compared with heterosexual youth.
      The innovative aspect of the study by Shearer et al. [
      • Shearer A.
      • Herres J.
      • Kodish T.
      • et al.
      Differences in mental health symptoms across lesbian, gay, bisexual, and questioning youth in primary care settings.
      ] is that it examines differences between sexual minority groups. Two groups of youth are shown to have a greater risk of developing mental health problems: (1) youth who are attracted to both males and females and (2) youth who are unsure of their attraction [
      • Shearer A.
      • Herres J.
      • Kodish T.
      • et al.
      Differences in mental health symptoms across lesbian, gay, bisexual, and questioning youth in primary care settings.
      ]. These two subgroups are thought to experience unique stressors that lesbian and gay youth may not, such as stereotypes of promiscuity or “the added pressure of exploring their sexual attractions in the context of a society that reinforces a dichotomous view of gender and sexuality…” [
      • Shearer A.
      • Herres J.
      • Kodish T.
      • et al.
      Differences in mental health symptoms across lesbian, gay, bisexual, and questioning youth in primary care settings.
      ].

      Methodological Barriers

      Shearer et al. [
      • Shearer A.
      • Herres J.
      • Kodish T.
      • et al.
      Differences in mental health symptoms across lesbian, gay, bisexual, and questioning youth in primary care settings.
      ] should be lauded both for asking youth about their attractions and for including an option for youth who are unsure of their attraction. However, despite this important addition to existing research, the authors labeled their study subjects using terms that are usually limited to describing sexual identity (i.e., gay, lesbian, bisexual, or questioning). Sexual attraction does not necessarily overlap with sexual identity (i.e., a woman who is attracted to females may not identify as a lesbian), and unfortunately, we know very little about the mental health of young people who struggle with their sexual identity or prefer not to label their identity at all. Although labels such as lesbian, gay, bisexual, and questioning are convenient and are often used to describe and interpret group differences, researchers should observe the wide diversity of sexual orientations among youth and ask questions about individual experiences with romantic and sexual attraction (or lack thereof), multiple identities, and past and current romantic and sexual partners.
      Furthermore, though Shearer et al. [
      • Shearer A.
      • Herres J.
      • Kodish T.
      • et al.
      Differences in mental health symptoms across lesbian, gay, bisexual, and questioning youth in primary care settings.
      ] have identified four sexual minority subgroups (gay, lesbian, bisexual, questioning), the study does not mention transgender youth. There may be various reasons for this: (1) The sample of transgender youth was likely small or (2) the items in the survey may not have allowed the identification of transgender youth. However, some of the youth in the study sample may identify as transgender and as such may face unique stressors that cisgender youth do not. Despite the growing research attention being paid to subgroups of the LGBTQ community, it is important not to disregard youth because there are few of them or because they are difficult to identify. Furthermore, research that takes into account the intersection of racial and ethnic, cultural, and social identities is necessary to better explain differences across (sub)samples [
      • Russell S.T.
      • Fish J.
      Mental health in LGBT youth.
      ].

      Moving Forward

      One reason many large-scale nationally representative studies have limited information on sexual orientation and gender identity is that they were not designed for that purpose. Researchers often have to negotiate even to include items about sexuality. And, as mentioned previously, reliably assessing young people's sexual orientation and gender identity while reflecting their diversity is difficult, and even in large samples, some groups may be small in number [see
      • Ridolfo H.
      • Miller K.
      • Maitland A.
      Measuring sexual identity using survey questionnaires: How valid are our measures?.
      ,
      Sexual Minority Assessment Research Team
      Best practices for asking questions about sexual orientation on surveys.
      for best practices to collect data on sexual orientation and gender identity].
      Importantly, research on sexual orientation and gender identity among young people is often met with concern for their protection [
      • Snapp S.
      • Russell S.T.
      • Arredondo M.
      • Skiba R.
      A right to disclose: LGBTQ youth representation in data, science, and policy.
      ]. Some institutional review boards have expressed concern over who has access to the data, whether youth may be “outed” by participating in a study, or whether study subjects may be confronted with “sensitive” topics [
      • Snapp S.
      • Russell S.T.
      • Arredondo M.
      • Skiba R.
      A right to disclose: LGBTQ youth representation in data, science, and policy.
      ,
      • Fisher C.B.
      • Brunnquell D.J.
      • Hughes D.L.
      • et al.
      Preserving and enhancing the responsible conduct of research involving children and youth: A response to proposed changes in federal regulations.
      ,
      • Mustanski B.
      Ethical and regulatory issues with conducting sexuality research with LGBT adolescents: A call to action for a scientifically informed approach.
      ,
      • Tufford L.
      • Newman P.A.
      • Brennan D.J.
      • et al.
      Conducting research with lesbian, gay, and bisexual populations: Navigating research ethics board reviews.
      ]. However, excluding survey questions about sexual orientation and gender identity can have serious consequences. Not only does it conflict with young people's right to participate [
      • Snapp S.
      • Russell S.T.
      • Arredondo M.
      • Skiba R.
      A right to disclose: LGBTQ youth representation in data, science, and policy.
      ], but also the current lack of data may sustain the harm that is being done by failing to provide policymakers with the necessary information that could lead to policy change. For example, the lack of data on educational disparities for LGBTQ youth has made it more difficult to protect them from discrimination in school [
      • Snapp S.
      • Russell S.T.
      • Arredondo M.
      • Skiba R.
      A right to disclose: LGBTQ youth representation in data, science, and policy.
      ]. Negative effects of participating in research on “sensitive” topics are limited, and benefits are found to be substantial [
      • Kuyper L.
      • de Wit J.
      • Adam P.
      • Woertman L.
      Doing more good than harm? The effects of participation in sex research on young people in the Netherlands.
      ,
      • Kuyper L.
      • Wijsen C.
      • de Wit J.
      Distress, need for help, and positive feelings derived from participation in sex research: Findings of a population study in the Netherlands.
      ,
      • Yeater E.
      • Miller G.
      • Rinehart J.
      • Nason E.
      Trauma and sex surveys meet minimal risk standards implications for institutional review boards.
      ]. Thus, excluding questions about sexual orientation and gender identity makes these young people and their experiences invisible and creates more barriers to decreasing mental health disparities [
      • Mustanski B.
      Ethical and regulatory issues with conducting sexuality research with LGBT adolescents: A call to action for a scientifically informed approach.
      ]. Data collection by Shearer et al. [
      • Shearer A.
      • Herres J.
      • Kodish T.
      • et al.
      Differences in mental health symptoms across lesbian, gay, bisexual, and questioning youth in primary care settings.
      ] included only one question about attraction, and yet by recruiting a nationally representative sample, the authors were still able to draw generalizable conclusions on sexual minority youths' mental health.
      Although Shearer et al. have shown that young people are willing to report their sexual orientation in primary care settings, health care workers are often hesitant to ask patients about their sexual orientation and gender identity [
      • McClain Z.
      • Hawkins L.A.
      • Yehia B.R.
      Creating welcoming spaces for lesbian, gay, bisexual, and transgender (LGBT) patients: An evaluation of the healthcare environment.
      ,
      • Neville S.
      • Henrickson M.
      Perceptions of lesbian, gay and bisexual people of primary healthcare services.
      ]. Clinical settings are not always safe spaces for LGBTQ youth to disclose this information, and personnel are not always adequately trained to handle related issues. In some instances, sexual minority youth have been referred to conversion therapy after disclosing their sexual orientation; a harmful practice that states in the United States have started to ban only in the last year [
      SAMHSA, Substance Abuse and Mental Health Services Administration
      Ending conversion therapy: Supporting and affirming LGBTQ youth.
      ]. Although primary care settings may create opportunities for studies on sexual orientation and gender identity, access to adequate care for LGBTQ youth requires further attention.
      From this perspective, the findings of Shearer et al. lead us to three important conclusions:
      • 1)
        Large-scale studies are important for the identification of health disparities and mechanisms and to improve the development of (preventive) interventions for LGBTQ youth. To protect young people and honor their right to participate, researchers should continue to ask questions about sexual orientation and gender identity, as well as other intersecting identities.
      • 2)
        Due to unique stressors, bisexual and questioning youth are at greater risk of developing mental health problems. Future research should focus on the stressors experienced by young people with different sexual orientations and their potentially differential impacts on mental health.
      • 3)
        Primary care settings provide the opportunity to diagnose mental health problems and improve access to adequate care for LGBTQ youth.

      References

        • Shearer A.
        • Herres J.
        • Kodish T.
        • et al.
        Differences in mental health symptoms across lesbian, gay, bisexual, and questioning youth in primary care settings.
        J Adolesc Health. 2016; 59: 38-43
        • Russell S.T.
        • Fish J.
        Mental health in LGBT youth.
        Annu Rev Clin Psychol. 2016; 12: 465-487
        • Ridolfo H.
        • Miller K.
        • Maitland A.
        Measuring sexual identity using survey questionnaires: How valid are our measures?.
        Sex Res Social Policy. 2012; 9: 113-124
        • Sexual Minority Assessment Research Team
        Best practices for asking questions about sexual orientation on surveys.
        Williams Institute, Los Angeles, CA2009 (Available at:) (Accessed April 15, 2016)
        • Snapp S.
        • Russell S.T.
        • Arredondo M.
        • Skiba R.
        A right to disclose: LGBTQ youth representation in data, science, and policy.
        in: Horn S. Ruck M. Liben L. Equity and Justice in Developmental Sciences: Theoretical and Methodological Issues. Elsevier, Philadelphia, PA2016: 135-159
        • Fisher C.B.
        • Brunnquell D.J.
        • Hughes D.L.
        • et al.
        Preserving and enhancing the responsible conduct of research involving children and youth: A response to proposed changes in federal regulations.
        Soc Policy Rep. 2013; 27: 3-15
        • Mustanski B.
        Ethical and regulatory issues with conducting sexuality research with LGBT adolescents: A call to action for a scientifically informed approach.
        Arch Sex Behav. 2011; 40: 673-686
        • Tufford L.
        • Newman P.A.
        • Brennan D.J.
        • et al.
        Conducting research with lesbian, gay, and bisexual populations: Navigating research ethics board reviews.
        J Gay Lesbian Soc Serv. 2012; 24: 221-240
        • Kuyper L.
        • de Wit J.
        • Adam P.
        • Woertman L.
        Doing more good than harm? The effects of participation in sex research on young people in the Netherlands.
        Arch Sex Behav. 2012; 41: 497-506
        • Kuyper L.
        • Wijsen C.
        • de Wit J.
        Distress, need for help, and positive feelings derived from participation in sex research: Findings of a population study in the Netherlands.
        J Sex Res. 2014; 51: 351-358
        • Yeater E.
        • Miller G.
        • Rinehart J.
        • Nason E.
        Trauma and sex surveys meet minimal risk standards implications for institutional review boards.
        Psychol Sci. 2012; 23: 780-787
        • McClain Z.
        • Hawkins L.A.
        • Yehia B.R.
        Creating welcoming spaces for lesbian, gay, bisexual, and transgender (LGBT) patients: An evaluation of the healthcare environment.
        J Homosex. 2016; 63: 387-393
        • Neville S.
        • Henrickson M.
        Perceptions of lesbian, gay and bisexual people of primary healthcare services.
        J Adv Nurs. 2006; 55: 407-415
        • SAMHSA, Substance Abuse and Mental Health Services Administration
        Ending conversion therapy: Supporting and affirming LGBTQ youth.
        Substance Abuse and Mental Health Services Administration, Rockville, MD2015

      Linked Article

      • Differences in Mental Health Symptoms Across Lesbian, Gay, Bisexual, and Questioning Youth in Primary Care Settings
        Journal of Adolescent HealthVol. 59Issue 1
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          Lesbian, gay, bisexual, and questioning (LGBQ) youth exhibit significantly higher rates of mental health problems, including anxiety, depression, suicidal ideation, and nonsuicidal self-injury than their heterosexual peers. Past studies tend to group LGBQ youth together; however, more recent studies suggest subtle differences in risk between sexual minority groups. This study examined differences in mental health symptoms across male and female youth who are attracted to the same sex (gay and lesbian), opposite sex (heterosexual), both sexes (bisexual), or are unsure of whom they were attracted to (questioning) in a sample of 2,513 youth (ages 14–24 years).
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