LGBTQ youth mental health and COVID: where we are & next steps

LGBTQ youth mental health during the pandemic

United States (US) youth mental health has worsened during the COVID-19 pandemic [1]. The pandemic has been especially devastating for lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) youth—a population that pre-pandemic bore a disproportionate burden of mental health symptoms relative to non-LGBTQ peers [2]. Before going further, it should be emphasized that being LGBTQ doesn’t inherently predispose youth to poor mental health, rather it is the oppressive and adverse social and institutional inequities, barriers, and forces (e.g., discrimination, poor housing, lack of social support, isolation, harassment, homelessness, bullying) LGBTQ youth disproportionately experience relative to non-LGBTQ youth that translate to real health outcomes such as depression and anxiety. These experiences can also lead to coping strategies that further harm health, such as substance use, self-harm, and suicide.

Over 50% of LGBTQ youth reported their depression and anxiety symptoms worsened during the pandemic [3]. The prevalence of youth with persistent sadness or hopelessness and youth seriously considering or attempting suicide was highest among LGB high schoolers [4]. A national survey of 13–23 year olds found LGBTQ respondents experienced worse mental health impacts due to the pandemic compared with non-LGBTQ peers [5]. Among LGBTQ youth, non-binary and transgender youth are more affected by the pandemic than their cisgender peers, with 85% of transgender and non-binary youth saying the pandemic negatively affected their mental health compared to 75% of cisgender youth [6]. Moreover, a 2022 national survey of 33,993 LGBTQ youth found 56% of LGBTQ, 49% of cisgender, and >60% of transgender and non-binary youth reported poor mental health most of or all the time during the pandemic [7]. Alarmingly, consideration of suicide and symptoms of anxiety and depression are either trending upward among LGBTQ youth since 2020 or remain higher than national rates, indicating the mental health gap between LGBTQ and non-LGBTQ youth may be widening [7]. Trends may be worse for LGBTQ youth with intersecting identities as they face many systems of marginalization including race/ethnicity, sexual orientation, gender identity, disability status, and immigration [3].

These patterns are due to intersecting social, economic, and structural forces that interact with each other to exacerbate and produce poor mental health for LGBTQ youth. While pandemic-related school closures may have protected LGBTQ youth from school-based harassment and discrimination, it also cut LGBTQ youth off from social support, school-based health services, and forced them to stay in unsupportive living situations where they cannot express themselves and may be subject to abuse [3], [7], [8]. In fact, LGBT high schoolers reported lower feelings of peer connectedness than non-LGBT students during the pandemic, which is associated with greater hopelessness, poor mental health, and suicide [4], [5]. The pandemic has also removed and prevented access to mental health and gender-affirming care. Sixty percent of LGBTQ youth express unmet needs in mental health care during the pandemic, with low-income, racial/ethnic minoritized, and unhoused youth being most affected [8]. The absence or loss of affirming spaces has implications on mental health; the lack of family support is linked to poorer mental health outcomes and higher rates of suicide attempts among LGBTQ youth who do not identify their home, family and friends, or school as supportive [7], [8], [9]. LGBTQ youth are also more likely to experience homelessness, discrimination, and use substances—which are risk factors for adverse mental health and have likely worsened during the pandemic [3], [7], [10], [11].

LGBTQ youth are differentially impacted financially by the pandemic, with 40% of LGBTQ youth who were employed pre-pandemic reporting they lost their job due to the pandemic; LGBTQ youth are also more likely to report they lost their job compared with heterosexual, cisgender youth [6], [12]. Given COVID-19-related financial problems are linked with poorer mental health [13], it is likely these disproportionate economic effects will further widen mental health inequities. Anti-LGBTQ discrimination has also spiked during the pandemic—yet another pathway through which poor LGBTQ youth mental health manifests [14]. Ultimately, this constellation of structural and socioeconomic factors likely interact with each other and/or create pathways to disproportionately burden LGBTQ youth.

Post-pandemic threats to LGBTQ youth mental health

Homophobia, transphobia, and threats to every facet of life for LGBTQ youth (e.g., sports, bathrooms, education, healthcare), have risen in the US, which can have serious ramifications for LGBTQ youth mental health [6], [7], [12]. The propagation of homophobic misinformation and discourse in politics and media during the mid-2022 mpox outbreak was reminiscent of the response to the 1980s HIV epidemic—highlighting the deeply ingrained anti-LGBTQ societal and structural violence and legacy of misinformation that continue to threaten the lives of LGBTQ groups [15]. The spread of online hate toward LGBTQ groups will likely increase violence toward LGBTQ individuals and worsen LGBTQ youth mental health [15].

Sweeping anti-LGBTQ legislation targeting and dismantling gender-affirming care, sexual education, and representation of LGBTQ history and culture in schools is on the rise (e.g. Florida’s HB 1557). These attacks on LGBTQ rights will bar access to vital services, education, and healthcare that are known to both improve LGBTQ youth mental health and foster safety and acceptance of LGBTQ individuals in schools and communities [7], [16], [17]. Downstream implications of such policies may include reluctance to interact with healthcare and other institutions among LGBTQ individuals, increased anti-LGBTQ misinformation, poor or non-existent training on LGBTQ issues among educators and healthcare professionals, limited access to affirming spaces and life-saving therapies, increased rates of suicide and mental health symptoms, and generations of increased anti-LGBTQ violence and discrimination.

What is needed?

Systemic and generational change is needed urgently to secure a healthy future for LGBTQ youth. LGBTQ youth cannot afford to wait for change to happen as they live in communities intolerant of their identity and face institutionalized violence and health, education, income, and wealth inequity. There must be institutional recognition of existing disparities and subsequent commitment to addressing LGBTQ youth mental and physical health at the federal, state, and local government levels. This can be done through banning conversion therapy, expanding access to gender-affirming care for youth, and federally and locally mandating the implementation of LGBTQ-affirming practices in schools. When drafting legislation concerning LGBTQ communities, involvement of the LGBTQ community and other experts and stakeholders in LGBTQ issues is necessary. LGBTQ-specific language must be written into new and existing policies to avoid ambiguous interpretations by bad actors and to correct implicit cisgenderism, homophobia, and transphobia that exists in previous legislature. LGBTQ-affirming care in medical training and education should be standardized nationally, made mandatory for every health profession student, and integrated and woven throughout all healthcare curriculums and professions [18].

Data collection and research on LGBTQ health must be improved. At the time of writing (May 2023), no national data are available on COVID-19 morbidity and mortality by sexual orientation or gender identity, highlighting the implicit cisgenderism, homophobia, and transphobia in the public health system. This subsequently excludes LGBTQ communities from public health surveillance and research, masks inequities, and further harms and burdens LGBTQ communities and health systems. Improvements needed include (1) providing and standardizing more expansive options for sex, gender identity, and sexual orientation in surveys; (2) including nuanced questions related to the unique stressors of LGBTQ communities; and (3) addressing data inequity [19]. Of note, the resilience of LGBTQ youth cannot be understated and despite the constant degradation of their rights, health, and livelihood, they continue to find ways to thrive [20]. Ultimately, we cannot settle for the status quo that continues to harm LGBTQ lives and instead must build—together—a safer, healthier future for LGBTQ youth.