Exploring Bias-Based Bullying and Intersecting Social Positions as Correlates of Sexual Risk Behaviors Among Adolescents

Abstract

Purpose:

The current study extends the limited body of intersectional research on adolescents' sexual health by examining experiences of bias-based bullying and multiple intersecting social positions associated with engagement in sexual risk behaviors.

Methods:

Participants were 14,968 sexually active 9th and 11th grade students surveyed as part of the 2019 Minnesota Student Survey (15% lesbian/gay/bisexual/queer/pansexual/questioning [LGBQ] and/or transgender/gender diverse [TGD] or gender questioning). Exhaustive Chi-square Automatic Interaction Detection analysis was used to identify experiences (i.e., bias-based bullying victimization) and intersecting social positions (i.e., sexual orientation identity; gender identity/modality; race/ethnicity; physical disabilities/chronic illness; mental health/behavioral/emotional problems) associated with the highest prevalence of three sexual risk behaviors.

Results:

Overall, 18% of adolescents reported 3+ sex partners in the last year, 14% reported drug/alcohol use before last sex, and 36% reported not discussing protection from sexually transmitted infections with new sexual partners. Adolescents with 2+ marginalized social positions, some of whom also experienced bias-based bullying, were part of 53% of the highest prevalence risk groups. For example, 42% of Multiracial or Latina/x/o gender questioning adolescents who identified as LGBQ reported 3+ sex partners in the last year—twice the sample average. Adolescents who were Black, American Indian/Alaska Native, Latina/x/o, Multiracial, TGD, or gender questioning were in the highest prevalence nodes across all outcomes.

Conclusion:

Adolescents with multiple marginalized social positions and who experience bias-based bullying engage in high-risk sexual behaviors at higher-than-average rates. Findings underscore the importance of addressing intersecting experiences of stigma to reduce high-risk sex behaviors and promote health equity among adolescents.

Introduction

Disparities in sexual risk behaviors

Extant research documents disparities in sexual risk behaviors (i.e., behaviors that can increase one's risk of adverse health outcomes, such as contracting sexually transmitted infections [STIs]) among adolescents with diverse, marginalized social positions. For instance, compared with their heterosexual and cisgender peers, adolescents who identify as lesbian, gay, bisexual, queer, or questioning their sexual orientation and/or transgender, genderqueer, non-binary, or questioning their gender identity (LGBTQ) report higher rates of sexual risk behaviors, such as having sex while using substances, having unprotected sex, and having sex for the first time before age 13.^1–4

Despite increased research attention to heterogeneity of sexual risk behaviors among sexual minority adolescents,^2,5 few studies examine sexual risk behaviors among transgender and gender diverse (TGD) youth,^4,6,7 and even fewer consider multiple intersecting social positions and experiences of stigma that may heighten LGBTQ adolescents' vulnerability to sexual risk-taking.

Evidence suggests that sexual risk-taking may vary by other social positions such as race/ethnicity^8,9 and disability/chronic health condition status.^10–13 For instance, in a national study of high school students in the United States (U.S.), Black and Hispanic sexual minority youth reported higher rates of sexual risk behaviors, such as using drugs or alcohol at their last sexual encounter, compared with White sexual minority youth.⁹

Further, despite common misperceptions that individuals with disabilities engage in less sexual activity than their peers,¹⁴ nearly one in five high school students with physical disabilities or chronic health conditions in a U.S. national sample reported having four or more sex partners in their lifetime, compared with 13% of students without physical disabilities or long-term health problems.¹⁰

Adolescents with developmental disabilities (e.g., attention-deficit hyperactivity disorder) and mental health concerns (e.g., depression) may likewise engage in more sexual risk behaviors.^11,15 For example, young people with depressive symptoms were more likely than their peers without depressive symptoms to report using substances at last sex and, among boys but not girls, were less likely to use condoms.¹¹

The roles of minority stress and intersecting social positions

Myriad social and structural factors may underlie disparities in sexual risk behaviors. Minority Stress Theory^16–19 posits that LGBTQ individuals face unique stressors (e.g., bias-based bullying) that place them at risk for poor health.¹⁸ Bullying behaviors and experiences have been implicated in risky sex behaviors among diverse samples of adolescents and young adults.^20–24 Across several studies, adolescents involved in bullying were less likely to use condoms compared with their peers who were uninvolved in bullying.^21–23 Bullying that targets adolescents' marginalized identities may be particularly harmful for adolescents' well-being.^25–27 To cope with distressing experiences of bias-based bullying and other forms of identity-based discrimination, adolescents may engage in unhealthy behaviors, such as substance use concurrent with sex.^27,28

Importantly, LGBTQ adolescents are a heterogeneous group and may hold multiple intersecting social positions that confer unique health risks and protection. Intersectionality theory²⁹ accounts for mutually constitutive social positions as they operate to create complex individual experiences within broader systems of privilege and disadvantage.^30–32 An intersectional approach is key to better understanding and addressing sexual health risk disparities among adolescents.

The current study

Using a statistical approach recommended for quantitative intersectionality research³³ and a large, population-based sample, the current study aims to extend the limited body of intersectional research on adolescents' sexual health by identifying experiences of bias-based bullying and intersecting social positions (i.e., gender identity/modality; sexual orientation; racial/ethnic identity; physical disability/chronic illness; mental, behavioral, or emotional problems) associated with the highest prevalence of engagement in sexual risk behaviors (i.e., having had sex with three or more partners in the last year, using alcohol or drugs before last sex, and not discussing use of protection against STIs with every partner).

Methods

Participants and procedures

Data for this analysis were from the 2019 Minnesota Student Survey (MSS), an anonymous, online, school-based survey conducted statewide every 3 years with youth in grades 5, 8, 9, and 11.³⁴ All Minnesota school districts are invited to participate in the MSS and, in 2019, most districts (81%) had at least one school provide data. Because items related to sexual orientation identity and sexual behavior were only included in surveys for students in grades 9 and 11, the present analysis focuses on the 80,456 students in these grades (56% ninth graders) and, in particular, the 14,968 students who reported ever having had sex. The present analysis was deemed exempt from review by the University of Minnesota Institutional Review Board due to its use of existing anonymous data.

Measures

Social position variables

Students self-reported their gender identity/modality, sexual orientation identity, and race/ethnicity. Students also responded to two dichotomous items about long-term disabilities/health problems: one focused on physical disabilities and chronic illness, and the other focused on mental health, behavioral, or emotional problems. See Table 1 for more detailed information on social position variables.

Table 1.

Social Position Measures

Social position	Item(s)/response wordinga	Analytic categories
Race/ethnicity	How do you describe yourself? (If more than one describes you, mark ALL that apply) 1. American Indian or Alaskan Native 2. Asian or Asian American 3. Black, African or African American 4. Hispanic or Latino/Latina 5. Native Hawaiian or Other Pacific Islander 6. White	Recoded into six mutually exclusive racial/ethnic categoriesb: 1. NH American Indian or Alaska Native 2. NH Asian or Pacific Islander 3. NH Black or African American 4. Hispanic or Latina/x/oc 5. NH White 6. NH Multiracial
Sexual orientation	How do you describe yourself? 1. Heterosexual (straight) 2. Bisexual 3. Gay or lesbian 4. Questioning/not sure 5. Pansexual 6. Queer 7. I don't describe myself in any of these ways 8. I am not sure what this question means	Recoded into five mutually exclusive sexual orientation identity categoriesd: 1. Heterosexual (straight) 2. Bisexual 3. Gay or lesbian 4. Questioning/not sure 5. Queer/Pansexual
Gender identity/modality	What is your biological sex? 1. Male 2. Female Are you transgender, genderqueer, or genderfluid? 1. Yes 2. No 3. I am not sure about my gender identity 4. I am not sure what this question means	Responses across these two items were collapsed into four mutually exclusive gender identity/modality categoriese: 1. Cisgender boy 2. Cisgender girl 3. Transgender or gender diverse 4. Questioning gender
Long-term disability	Do you have any physical disabilities, or long-term health problems (such as asthma, cancer, diabetes, epilepsy or something else)? Long-term means lasting 6 months or more. 1. Yes 2. No Do you have any long-term mental health, behavioral or emotional problems? Long-term means lasting 6 months or more? 1. Yes 2. No	Physical disability/chronic illness 1. Yes 2. No Mental health, behavioral, or emotional problems 1. Yes 2. No

^a Items and response wording are from the 2019 Minnesota Student Survey.³⁴

^b This coding approach made Latina/x/o ethnicity primary, such that anyone indicating a Latina/x/o ethnicity, regardless of other race options, was considered Latina/x/o. Categorizing race and ethnicity in this way has limitations, including obscuring participants' intersecting racial and ethnic identities.

^c We refer to individuals with this ethnic identity as Latina/x/o to be more inclusive of gender diverse participants.³⁸

^d Participants who responded “I don't describe myself in any of these ways” or “I am not sure what this question means” were set to missing for this analysis.⁴¹

^e Participants who responded “I am not sure what this question means” were set to missing for this analysis.⁴¹

NH, non-Hispanic/Latina/x/o.

Bias-based bullying

Five types of bias-based bullying were assessed. Specifically, respondents answered the following question: “During the last 30 days, how often have other students harassed or bullied you for any of the following reasons?” about their (1) race/ethnicity/national origin, (2) gender, (3) gender expression, (4) sexual orientation, and (5) physical or mental disability. Students responded to each item on a 5-point scale ranging from Never to Every day. Experiences of bias-based bullying were collapsed into a single dichotomous variable representing whether or not participants had experienced any of these forms of bias-based bullying in the last 30 days.

Sex-related behaviors

All students were asked whether they had ever had sex (Yes/No). Students who answered yes (the analytic sample) then responded to several items related to sexual health, including: (1) number of sex partners they had in the last year, (2) alcohol or drug use before last sex, and (3) conversations with sex partners about protection from STIs (i.e., “Have you talked with your partner(s) about...Protecting yourselves from getting sexually transmitted infections/HIV/AIDS?”). Responses were dichotomized into three indicators of sexual risk: (1) having had sex with three or more partners in the last year, (2) using alcohol or drugs before last sex, and (3) not discussing use of protection against STIs with every partner.

Plan for analysis

Exhaustive Chi-square Automatic Interaction Detection (CHAID)—a non-parametric, data-driven, decision-tree approach—was used to examine the interaction effects of bias-based bullying experience and social position variables (six independent variables) on sex-related behaviors (three dependent variables).^35,36 Separate exhaustive CHAID models were conducted for each of the three sex-related behaviors of interest. Exhaustive CHAID systematically cycles through categorical independent variables, splitting between categories where significant differences are detected in prevalence of dichotomous dependent variables until reaching “terminal nodes.” Terminal nodes are the final groups in the decision tree that cannot be further split by independent variables given the established p-value (Bonferroni adjusted p < 0.05) and minimum node size (40).

Index scores were calculated for each terminal node to demonstrate the proportion of youth with those experiences and intersecting social positions engaging in risky sex-related behaviors compared with the overall sample mean. Groups with index scores above 120 (i.e., representing sexual risk behavior prevalence at least 20% higher than the sample average) were interpreted to have a high prevalence of sexual risk behaviors. This cut off was established a priori to identify adolescents with substantially elevated sexual risk. Analyses were conducted in SPSS v28.³⁷

Results

Characteristics of the sample

Overall, 22% of adolescent respondents (N = 80,456) had ever had sex and were included in the analytic sample (n = 14,968). About half of these adolescents were cisgender boys (48%), 46% were cisgender girls, and about 3% were TGD or questioning their gender identity. In terms of race/ethnicity, 71% of sexually active adolescents were non-Hispanic/Latina/x/o (NH) White and, in terms of sexual orientation identity, 14% of students were gay, lesbian, bisexual, queer, pansexual, or questioning.

Nearly one in five sexually active adolescents (17%) reported a long-term physical disability or chronic illness and 36% reported mental health, behavioral, or emotional problems. Finally, about one-third of sexually active adolescents reported experiencing bias-based bullying in the last 30 days. See Table 2 for complete information on adolescents' social positions and bias-based bullying experiences.

Table 2.

Characteristics of the Analytic Sample (N = 14,968 Sexually Active Adolescents)

	N	%
Social positions/experiences
Grade
9	4550	30.4
11	10,418	69.6
Gender identity/modality
Cisgender boy	7206	48.1
Cisgender girl	6823	45.6
Transgender/gender diverse	284	1.9
Questioning	226	1.5
Missing	429	2.9
Race/ethnicity
NH American Indian/Alaska Native	256	1.7
NH Asian/Pacific Islander	558	3.7
NH Black or African American	759	5.1
Hispanic or Latina/x/o	1511	10.1
NH White	10,681	71.4
NH Multiracial	1126	7.5
Missing	77	0.5
Sexual orientation identity
Straight	11,668	78.0
Gay or lesbian	309	2.1
Bisexual	1217	8.1
Questioning	176	1.2
Pansexual, queer	450	3.0
Missing	1148	7.7
Physical disabilities/chronic illness
Yes	2562	17.1
No	12,227	81.7
Missing	179	1.2
Mental, behavioral, or emotional problems
Yes	5339	35.7
No	9459	63.2
Missing	170	1.1
Experienced bias-based bullying (about race/ethnicity, sexual orientation, gender identity/expression, and/or disability)
Yes	4976	33.2
No	9846	65.8
Missing	146	1.0
Sex-related behaviors
Number of sex partners (in last year)
0–2	12,114	81.8
3+	2704	18.2
Missing	150	1.0
Alcohol/drugs before last sex
Yes	2043	13.8
No	12,732	86.2
Missing	193	1.3
Discuss protection from STIs
Never/not with every partner	5293	36.2
At least once with every partner	9323	63.8
Missing	352	2.4

STI, sexually transmitted infection.

Sexually active adolescents' sexual behaviors are also shown in Table 2. A minority of adolescents reported having three or more sex partners in the last year (18%) or using alcohol or drugs before last having sex (14%). Just over one-third of participants (36%) reported never or inconsistently discussing use of protection against STIs with every sex partner.

Bias-based bullying experiences and intersecting social positions associated with highest prevalence sexual risk

Several patterns were observed with respect to experiences and intersecting social positions consistently associated with high prevalence of sexual risk behaviors (Table 3). First, nearly all (94%) high prevalence risk groups were characterized by at least one marginalized social position, sometimes in conjunction with an experience of bias-based bullying. Multiply marginalized adolescents (i.e., adolescents with at least two marginalized social positions) were part of 53% of the terminal nodes with the highest prevalence of sexual risk behavior.

Table 3.

Groups with Highest Prevalence of Sexual Risk Behaviors (Index Scores >120)

Prevalence, %	Race/ethnicity	Sexual orientation identity	Gender identity/modality	Mental health, behavioral, or emotional problem	Physical disability or chronic illness	Bias-based bullying	Index score
3+ sex partners (overall = 18.2%)
49.2	—	Straight, Missing	Quest	—	—	—	269.6
41.5	Multiracial, Latina/x/o, Missing	LG, B, QP, Quest	Quest		—		227.2
38.0	—	—	Cis boy, TGD, Missing	Missing	—	—	208.2
33.8	Black, AIAN, Multiracial, Missing	—	Cis boy, TGD, Missing	Yes	—		185.2
24.7	White, AIAN, Asian/Pacific Islander	—	Cis boy, TGD, Missing	No	—	—	135.2
23.0	Black, Multiracial, Latina/x/o, Missing	—	Cis boy, TGD, Missing	No	—		126.1
22.2	White, AIAN, Asian/Pacific Islander	—	Cis girl	No	Yes	Yes	121.8
Alcohol/drug use at last sex (overall = 13.8%)
25.0	—	—	TGD, Quest	No	—	—	180.8
24.3	—	—	—	Missing	—	—	175.5
20.9	Black, AIAN, Multiracial, Latina/x/o, Missing	—	—	Yes	—	—	151.5
19.7	—	—	Cis girl	No	Yes	Yes	142.6
18.3	—	B	Cis girl	No	—	No	132.1
Never/inconsistently talking about protection from STIs with sex partners (overall = 36.2%)
52.9	White, Multiracial, Latina/x/o, Asian/Pacific Islander	LG	Cis girl	—	—	Yes	146.2
47.5	—	LG, Missing	Cis boy, Quest	—	—	—	131.1
46.5	—	—	TGD, Missing	—	—	—	128.5
45.2	Black, AIAN	—	Cis girl		—	—	124.7
44.9	Black, AIAN, Missing	Straight, Quest	Cis boy, Quest				123.9

AIAN, American Indian or Alaska Native; B, bisexual; Cis, cisgender; LG, lesbian or gay; QP, queer or pansexual; Quest, questioning; TGD, transgender/gender diverse.

For example, 42% of lesbian, gay, bisexual, queer, pansexual, or questioning sexual orientation (LGBQ), gender questioning, and Multiracial, Latina/x/o,* or missing race/ethnicity adolescents reported three or more sex partners in the last year—more than two times higher than the sample average. Likewise, 21% of Black, American Indian/Alaska Native, Multiracial, Latina/x/o, or missing race/ethnicity adolescents who had a long-term mental health, behavioral, or emotional problem reported using alcohol or drugs before last having sex—one-and-a-half times the sample average.

Second, TGD and/or gender questioning identities, in conjunction with numerous other social positions, emerged in 65% of the high prevalence risk groups—more often than any other social position or experience. Further, TGD and/or gender questioning adolescents were in the highest prevalence group for two of the three sexual risk outcomes: (1) 49% of straight (or missing sexual orientation identity), gender questioning adolescents reported three or more sex partners in the last year—more than two-and-a-half times the sample average, and (2) one in four TGD or gender questioning adolescents who reported no mental health, behavioral, or emotional problems used alcohol or drugs before last having sex—nearly two times the sample average.

Third, bias-based bullying and/or six social positions (TGD identity, gender questioning identity, NH Black race, NH American Indian/Alaska Native race, NH Multiracial race, and Latina/x/o ethnicity)—often in conjunction with other marginalized social positions—were associated with high prevalence of all three sexual risk outcomes assessed here. For instance, 53% of NH Multiracial, NH Asian American/Pacific Islander, NH White, or Latina cisgender girls who were gay or lesbian and who experienced bias-based bullying reported never or inconsistently talking about protection from STIs with new sex partners—nearly one-and-a-half times the sample average. No other social positions were associated with high prevalence of all three sexual risk outcomes.

Discussion

Research highlights persistent disparities in sexual health and risk behaviors among adolescents with marginalized social positions.^{1–4,6,8–10,12,13} These inequities can be tied to the long-standing stigma, discrimination, and oppression that marginalized youth may experience. However, despite calls for greater attention to intersecting social positions as they relate to health disparities,³⁹ little research considers the mutually constitutive effects of holding multiple marginalized social positions on adolescents' sexual health behaviors.

Those studies that do, typically only consider two intersecting social positions, such as race/ethnicity and sexual orientation.^9,40 Using Exhaustive CHAID, a quantitative approach recommended for intersectional research^33,36 and a large, population-based sample of adolescents, the present article extends the literature by simultaneously considering experiences of bias-based bullying and five intersecting social positions as they relate to three indicators of sexual risk. Findings provide novel insight into the ways in which intersecting experiences of interpersonal and structural stigma may contribute to high-risk sex behaviors among marginalized youth, and have implications for tailored, targeted intervention efforts.

In the present study, multiply marginalized youth were disproportionately represented in the highest prevalence sexual risk behavior groups. These results are consistent with prior intersectional research on other adolescent risk behaviors, such as substance use,^41,42 and health disparities more broadly.^43,44 Stigma has been identified as a fundamental mechanism underlying health inequities.⁴⁵

For adolescents with multiple intersecting marginalized identities, bias-based bullying, biased stereotypes about sexual behavior, exclusion from sexual education curricula, and other forms of interpersonal and structural stigma may converge in complex ways to confer sexual risk. Future research is needed to tease apart the nuances of multiply marginalized adolescents' experiences of stigma and health risk behaviors, and to identify structural barriers and sources of stigma to be eliminated, as well as protective factors interventions can leverage.

Findings also underscore the need for sexual health programs to not only be sensitive to sexual orientation and gender diversity, racial/ethnic and cultural differences, and disability, but to be sensitive to the intersection of these social positions and the unique risks they may confer.

Consistent with prior research,^4,6,7 TGD and gender questioning identities were reflected more often in the high prevalence risk groups than any other social position or experience. TGD and gender questioning adolescents may engage in risky sexual behaviors as unhealthy coping responses to experiences of identity-based stigma. Indeed, studies with TGD youth have linked TGD-identity-related discrimination to health risk behaviors, including substance use concurrent with sex.^27,28

These findings may also be indicative of a need for more comprehensive, LGBTQ-inclusive sex education for adolescents. Ample evidence indicates that provision of inclusive, comprehensive sex education benefits adolescents' well-being broadly, and sexual health in particular (e.g., increased use of condoms⁴⁶). However, research overwhelmingly documents shortcomings in sex education programs for LGBTQ adolescents, including providing heteronormative, cisnormative, or inaccurate information.⁴⁶

Finally, adolescents in 18% of the high prevalence risk groups in the present study experienced bias-based bullying in the past month, and bias-based bullying was one of only a handful of variables associated with high prevalence for all three sexual risk behaviors, in conjunction with social position variables. Participants in the high prevalence risk groups characterized by bias-based bullying were cisgender girls and most had physical disabilities, among other marginalized social positions (e.g., lesbian/gay sexual orientation).

Addressing experiences of bias-based bullying may be an important point for intervention among cisgender girls with physical disabilities and other marginalized social positions. For example, nearly twice as many cisgender girls with physical disabilities who experienced bias-based bullying reported using drugs or alcohol before last sex (20%) compared with cisgender girls with physical disabilities but no recent experiences of bias-based bullying (12%). This is consistent with prior work that implicates identity-based stigma and discrimination in risky coping responses.^26–28

Community- and school-based efforts to combat bias-based bullying may be important steps in reducing sexual risk disparities and promoting health equity among adolescents. Low-cost strategies to reduce bias-based bullying in schools include enumeration of characteristics often targeted for victimization (e.g., LGBTQ identity, disability) in anti-bullying policies^47,48 and the establishment of gender and sexuality alliances in schools.^49,50 Recent findings indicate that LGBTQ adolescents at schools with gender and sexuality alliances reported lower levels of several forms of bias-based bullying (e.g., based on disability, sexuality, gender⁵⁰).

Limitations and future directions

Using a large, population-based sample of adolescents, the current study extends the literature base by examining experiences of bias-based bullying and five intersecting social positions as they relate to sexual risk behaviors among adolescents. Despite this study's strengths, findings should be interpreted in light of several limitations. First, data were self-reported and cross-sectional, meaning they are subject to response bias and causality cannot be examined.

Specifically, as a result of social desirability bias, participants may have underreported or overreported sexual behaviors depending on cultural norms or perceptions of behaviors as stigmatized or socially desirable.^51,52 Second, students who were absent when these data were collected in schools were not represented in this sample and may differ significantly from those adolescents included in the study. Because some of the social positions and experiences characteristic of youth in high prevalence risk groups are also associated with school absenteeism (e.g., bias-based bullying, TGD identity^53,54), our findings may underrepresent prevalence of, or disparities in, sexual risk behaviors.

Third, the wording and categorization of some survey items used in this secondary data analysis may have limited this study's ability to fully capture adolescents' experiences and behaviors. For instance, using sex assigned at birth and gender modality (“Are you transgender, genderqueer, or genderfluid?”) to create a composite gender identity/modality variable provides gender identity information for cisgender youth, but only information on gender modality for TGD youth.

Likewise, recoding respondents into six mutually exclusive racial and ethnic categories cannot account for the diverse lived experiences of youth with intersecting identities (e.g., youth who select Latina/x/o and Black may vary, with some identifying as bi/Multiracial, some as Latina/x/o, and some as Black). Any attempt to reduce the whole group to a single code (e.g., Latina/x/o in this case) is inherently reductionist. Due to the limits of MSS measures, colorism could not be assessed.

In addition, the heteronormative wording of the item “Have you ever had sexual intercourse (‘had sex’)?” may have contributed to underreporting of sexual behaviors, especially among LGBTQ adolescents. This item's wording also precludes the possibility of distinguishing consensual sex from non-consensual sex. Similarly, the items assessing physical disability/chronic illness and long-term mental health, behavioral, and emotional problems were very broad and limit the assessment of intragroup variation in sexual risk-taking. Future research should use more specific and inclusive language related to participants' social positions and sexual behaviors, and they should operationalize terms such as “had sex” to minimize response bias.

Conclusion

TGD and gender questioning adolescents, adolescents with multiple marginalized social positions, and adolescents who experienced bias-based bullying—often overlapping categories—were consistently among those adolescents with the highest prevalence of sexual risk behaviors. These findings underscore the importance of understanding and addressing stigma experienced by youth with marginalized social positions to reduce high-risk sex behaviors and sexual health disparities, and to promote health equity among youth.

Future research, including qualitative research with adolescents whose social positions were represented in the highest prevalence risk categories, is warranted to elucidate additional social and structural factors that may underlie these disparities. In addition, schools should implement comprehensive sexuality education and health programming that attends to intersecting identities of sexual orientation identity, gender identity, racial/ethnic identity, and disability. At the same time, broader initiatives to promote more inclusive school climates and combat bias-based bullying are needed to dismantle systems of oppression that perpetuate sexual health inequities.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Sponsors had no role in the study design; collection, analysis, and interpretation of data; writing of the report; or decision to submit the article for publication.

Authors' Contributions

S.E.L.: Conceptualization, formal analysis (lead), writing—original draft (lead). A.L.G.: Writing—review and editing. H.-M.E.: Writing—review and editing. C.C.-C.: Conceptualization, writing—review and editing. D.T.: Writing—review and editing. M.S.: Writing—review and editing. A.M.d.R.-G.: Writing—review and editing. M.E.E.: Conceptualization, funding acquisition, resources, project administration, writing—review and editing.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities under award number R01MD015722.