Hostile Laws and Hospitalization: Why Anti-LGBTQ+ Legislation Threatens Adolescent Lives

For many lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ+) adolescents, the first time they visit a hospital beyond infancy is following a suicide attempt. Suicide attempts are rising among all US adolescents; the number of adolescent emergency department visits involving self-harm increased by over 350% from 2007 to 2016,¹ and suicide is the second leading cause of death for people aged 10–24.² Yet, LGBTQ+ young people are at an even higher risk of planning, attempting, and completing suicide. According to 2021 US Centers for Disease Control and Prevention (CDC) data, as compared to their heterosexual peers, lesbian, gay, and bisexual (LGB) adolescents reported significantly worse outcomes across an array of suicidality behaviors. Overall, 76% of LGB adolescents had persistent feelings of sadness or hopelessness as compared to 37% of heterosexual respondents; 47% of LGB adolescents had seriously considered attempting suicide as compared to 14% of heterosexual respondents. Most concerning, 26% of LGB adolescents had attempted suicide in the past year, a rate five times that of heterosexual adolescents (5%).³ Suicide attempt rates may be even higher among transgender and gender-diverse adolescents.⁴

The mental health and well-being of LGBTQ+ adolescents is under further threat amid a barrage of newly proposed state laws, some of which have already passed. According to the American Civil Liberties Union,⁵ state lawmakers across the country introduced 201 anti-LGBTQ+ bills in the 2022 legislative session. The vast majority (170) target transgender and gender-diverse youth: 43 bills would restrict gender-affirming healthcare, 9 bills would prevent adolescents from using the bathroom matching their gender identity, 72 bills would exclude transgender youth from athletics, and 46 bills would restrict the ability of teachers to discuss gender identity or sexual orientation.⁵ These state bills mirror several bills proposed at the federal level.⁶

The hypocrisy of these bills is blatant. In the case of laws that would prevent adolescents from receiving gender-affirming care, lawmakers would, under the guise of “protecting” children, interfere in adolescents’ and families’ access to potentially lifesaving medical care recommended by the American Medical Association,⁷ American Academy of Pediatrics,⁸ and the American Psychological Association.⁹ Contrary to beliefs in limited government espoused by many of the policymakers supporting these laws, such policy would have the government interfere with family-centered medical decision-making, with some bills making gender-affirming care a felony for physicians and tantamount to ‘child abuse’ for parents.¹⁰

Similarly, education bills like Florida’s HB 1557 (which critics have dubbed the “Don’t Say Gay” law) restrict teachers’ ability to have developmentally-appropriate discussions regarding gender identity and sexual orientation, potentially including aspects of students’, families’, or teachers’ own lived experiences.¹¹ Reporting has shown that the vagueness of the law on what constitutes prohibited discussion has had a chilling effect on class conversations. LGBTQ+-identified teachers report ‘self-censoring’ when discussing topics such as their partner or family—topics commonplace and unremarkable for cisgender and heterosexual teachers to discuss with students.^12,13

Political opportunism, rather than sincere policymaking, is the likely motivation for this wave of anti-LGBTQ+ bills. Of the 201 bills introduced in 2022, only 19 went on to become law.^5,6 Anti-LGBTQ+ legislation likely serves to drive attention to a wedge issue—a constructed debate point intended to energize political bases and generate voter turnout in advance of elections.^6,14 Indeed, polls conducted in early 2022 showed large party-line differences in the acceptance of transgender and gender-diverse people. Among adults identifying as Republicans or Republican-leaning, 54% reported feeling that greater social acceptance for people who are transgender was “very” or “somewhat bad for society,” with 15% saying it was very or somewhat good. Among adults identifying as Democrats or Democrat-leaning, these percentages were 13% and 59%, respectively.¹⁵

Amid this coordinated and highly politicized national movement to limit clinical care and education for young people, already-vulnerable LGBTQ+ adolescents will experience mental and emotional harm. Identity-based victimization, discrimination, and stigma—which collectively contribute to “minority stress”—are risk factors for suicide and other mental health and substance use problems.^16,17 Discriminatory policies targeting LGBTQ+ individuals are a fundamental cause of health inequities.^19,20 As LGBTQ+ adolescents grow to adulthood, the toll of this chronic and internalized stress adds up. The trauma of stigmatization and any maladaptive behaviors (e.g., heavy substance use) that may develop to cope,¹⁸ contribute to chronic health conditions that disproportionately burden LGBTQ+ adults and require lifelong medical and mental healthcare.²¹

Conversely, clinical spaces and schools where LGBTQ+ youth feel safe and connected are associated with decreased suicidal ideation and attempts.^22–24 A recent, real-world example of the impact of state policies on adolescents’ health can be seen amid the state laws codifying same-sex marriage that were passed in the 2000s and early 2010s. States that passed laws allowing same-sex marriage experienced a 4% decline in suicide attempts among LGBTQ+ adolescents relative to states that did not.²⁵ More recently, in December 2022, President Biden signed into law the Respect for Marriage Act, which codifies same-sex marriage and interracial marriage at the federal level. This landmark legislation will likely be a positive external signal to LGBTQ+ people and could profoundly impact the health of this population nationwide.²⁶ While this recent development is promising, the damage of the ongoing debate over anti-LGBTQ+ state laws is taking its toll. A recent national survey by the Trevor Project showed that 51% of LGB young people had already experienced worsened mental health as they witnessed discriminatory state laws debated in the public sphere; this proportion was 85% among transgender and gender-diverse youth.²⁷ These data do not yet even capture the soon-to-come harms of laws that already gone into effect in some states. It stands to reason that implementing state policies that strip rights from LGBTQ+ people will have a deleterious effect on adolescents, especially since the latest spate of discriminatory policies are specifically targeted at young people.

In the case of Florida, lawmakers may be aware of the potential harms of their bill and appear to have taken preemptive steps to prevent any study of its adverse consequences. In 2022, Florida’s Department of Education elected to discontinue its cooperative agreement with the CDC that supports the Youth Risk Behavior Survey and School Health Profiles, survey instruments that are commonly used across the US to measure the mental health status of high school students, including LGBTQ+ adolescents.²⁹ This move ended decades of participation in the survey.

The harms of these bills and the rhetoric used to promote them are far-reaching and increasingly include interpersonal violence. The tragic November 2022 mass shooting at Club Q—an LGBTQ+-serving establishment in Colorado Springs, CO—which killed five and injured dozens more,³⁰ followed months of increased violence coinciding with the recent wave of anti-LGBTQ legislation and debate. Such violence may in part be related to discriminatory and harmful language wielded by politicians. For example, the repugnant term ‘grooming’, which refers to the idea that an adult develops a relationship with a young person with the ultimate goal of developing a sexual relationship with them,³¹ has increasingly and unfoundedly been applied to LGBTQ+ adult professionals (e.g., teachers, clinicians) who work with youth.³² Indeed, Florida Governor Ron DeSantis’s press secretary proudly described Florida’s HB 1557 as an “anti-grooming bill.”³²

Beyond the direct harm this rhetoric inflicts on the mental health of LGBTQ+ adolescents, its use normalizes increasingly violent reactions to LGBTQ+ people’s existence and use of health services.³³ In 2022, incidents of political violence targeting LGBTQ+ events and health centers increased to a rate four times that of 2021.³³ These incidents include the Club Q shooting in Colorado,³⁰ bomb threats to children’s hospitals providing gender-affirming care in Boston and Washington, D.C.,³⁴ a foiled raid by white nationalist group Patriot Front on a pride march in Idaho,³⁵ and harassment campaigns on drag shows.³⁶

America’s hospitals are already bearing the brunt of an enormous adolescent mental health crisis in the wake of the COVID-19 pandemic, with a lack of inpatient psychiatric beds contributing to widespread boarding of young people in emergency departments and inpatient medical units.³⁷ Given what is known about how non-affirming clinical and educational spaces for LGBTQ+ adolescents contribute to depression, anxiety, and risk for suicide, we predict this wave of anti-LGBTQ+ bills could turn a dire situation into a genuine crisis. For the lawmakers putting forward these bills, either the harm to LGBTQ+ adolescents was determined to be worth the political benefit, or worse, the harm may even be the point. The preventable deaths of thousands of LGBTQ+ adolescents and the widespread suffering of hundreds of thousands more hang in the balance of this debate.

Though they are downstream from socio-political origin of this harmful policy debate, hospitals and hospital-based providers have considerable power to advocate for the health and dignity of LGBTQ+ patients. We recommend the following actionable steps:

1. Advocate through professional organizations. Hospital-based providers are members of powerful professional societies, including the American Hospital Association and American Medical Association. These and other organizations have already begun to adopt evidence-based position statements and can advocate for policies to promote health and dignity of LGBTQ+ people. Additionally, we recommend applying internal pressure to professional organizations to cease donations to lawmakers who support anti-LGBTQ+ bills or use derogatory, violence-promoting rhetoric.

2. Engage in hospital decision-making. Not-for-profit hospitals receive billions of dollars each year in state and federal tax exemptions and safety-net policies to support care for marginalized patient populations. However, there are often few specific requirements for how this money is spent. Such funds could be dedicated to crucial but traditionally low-profit services such as primary care, sexual health clinics, and mental health and substance use disorder treatment, all of which would improve the health of LGBTQ+ people who experience disproportionate physical and mental health problems owing to stigma. We recommend providers hold hospitals to their charitable missions and advocate for improved health services for LGBTQ+ and other marginalized patient populations.

3. Set an example. Positive signals and affirming care environments are crucial to the health of LGBTQ people, especially following the trauma of a suicide attempt. We recommend clinicians organize and participate in continuing education on how to provide affirming care for LGBTQ+ people. Consider adding ‘ally’ labels and pronouns to name badges. Hold space for potentially difficult conversations about the culture of care for LGBTQ+ patients in your clinic. Hire staff from the LGBTQ+ community.

We urge clinicians from all specialties and settings to stand up against discriminatory anti-LGBTQ+ laws and advocate for rational, science-based clinical and educational policy. For the nation’s many LGBTQ+ adolescents at risk of suicide—and the families that will grieve their loss—the harm of these bills will be irreversible.