Abstract
Interpersonal supports are protective against multiple negative health outcomes for youth such as emotional distress and substance use. However, finding interpersonal support may be difficult for youth exposed to intersecting racism, heterosexism, and cisgenderism, who may feel they are “outsiders within” their multiple communities. This study explores disparities in interpersonal supports for youth at different sociodemographic intersections. The 2019 Minnesota Student Survey includes data from 80,456 high school students, including measures of four interpersonal supports: feeling cared about by parents, other adult relatives, friends, and community adults. Exhaustive Chi-square Automatic Interaction Detection analysis was used to examine all interactions among four social identities/positions (racialized/ethnic identity, sexual identity, gender identity, sex assigned at birth) to identify groups who report different rates of caring from each source (Bonferroni adjusted p<.05). In the overall sample, 69.24% perceived the highest level of caring (“very much”) from parents, 50.09% from other adult relatives, 39.94% from friends, and 15.03% from community adults. Models identified considerable differences in each source of support. For example, more than 72% of straight, cisgender youth reported their parents cared about them very much, but youth who identified as LGBQ and TGD or gender-questioning were much less likely to report high parent caring (less than 36%) across multiple racialized/ethnic identities and regardless of sex assigned at birth. Findings highlight the importance of better understanding the ways interpersonal support might differ across groups, and underscore a need for intersectionality-tailored interventions to develop protective interpersonal supports for LGBTQ+ youth, rather than one-size-fits-all approaches.
Keywords: LGBTQ+, adolescents, protective factors, intersectionality, social support, CHAID
Introduction
Protective factors are the circumstances, qualities, and supports that characterize resilience – the process by which individuals avoid risk or overcome negative experiences to achieve a healthy developmental trajectory.1–3 Many scholars have prioritized this strengths-based focus, given the potential of protective factors to buffer youth against a wide variety of adverse outcomes.3 Although powerful protective factors exist across multiple social ecological levels, the bulk of research in this area has focused on interpersonal protective factors, such as connection, caring, and support from family members and other adults.4,5 Research has also identified these protections among youth who are marginalized (e.g. due to race or ethnicity), or who experience poverty, homelessness, or trauma.5–8
A substantial body of research has shown protective associations for interpersonal factors among LGBTQ+ youth regarding emotional health and distress, substance use, and violence involvement.9–17 For example, a study of LGB youth who were diverse with regards to racialized/ethnic identity and sexual identity compared several sources of social support in association with depression and self-esteem.17 They found that parent support was consistently associated with higher self-esteem and lower depression for all except lesbian youth, whereas teacher and classmate support were associated with greater psychosocial adjustment for some groups compared to others.17 Further, in a previous study of transgender and gender diverse youth in Minnesota, connectedness to parents, adult relatives, friends, and adults in the community were each inversely associated with substance use, depression, and suicidality; even after adjusting for multiple types of protective factors simultaneously, connection to parents remained protective against each outcome and connection to community adults remained protective against depression and suicidality.10 However, there is also evidence that a variety of interpersonal protective factors are less prevalent among LGBTQ+ youth than among heterosexual and/or cisgender youth, 9,12,18 suggesting that efforts to expand and strengthen interpersonal protective factors for LGBTQ+ youth may be warranted.
Intersectionality is a framework that explicitly considers intersections of multiple marginalized social positions and the experience of living within overlapping systems of privilege and oppression.19,20 With this lens, we posit that finding interpersonal support may be more difficult for youth exposed to intersecting racism, heterosexism, and cisgenderism, who may feel they are “outsiders within” multiple communities.21 Research specific to youth experiences of heterosexism within racial and ethnic communities or racism within the LGBTQ+ community is sparse,22 but some reports highlight this intersectional stigma and discrimination. For example, young Latino men were more likely than non-Latino white men to report negative reactions from family members when they disclosed their gay or bisexual identity.23 Likewise, LGBTQ+ people of color often experience erasure/invisibility and microaggressions based on their racialized/ethnic identities from within the LGBTQ+ community.21,24,25 Encountering barriers to accessing interpersonal support systems that have long been demonstrated to help young people of diverse backgrounds and circumstances build resilience and navigate challenges may manifest in emotional distress and related behaviors (e.g., substance use, violence involvement).5–17 We are not aware of research that has explored disparities in these supports across intersecting LGBTQ+ and racialized/ethnic social positions.
This study utilizes data from a large statewide sample to explore disparities in several types of interpersonal supports at the intersections of racialized/ethnic identity, sexual identity, gender identity, and sex assigned at birth. Findings are expected to inform further work in this field, to identify areas where interpersonal supports can be expanded and bolstered.
Methods
Data sources and sample
The present analysis uses data from an existing, large statewide sample of adolescents: the 2019 Minnesota Student Survey (MSS). The MSS has been conducted every three years since 1989 by state-level government agencies. All school districts in the state are invited to participate, as are all students in participating schools. In 2019, 81% of school districts participated, and 80,456 students in grades 9 (mean age=14.61, range=13–17) and 11 (mean age=16.61, range=15–19) provided online survey data; this sample includes approximately 66% of all 9th grade and 54% of all 11th grade students enrolled in public or charter schools in the state. Due to the high participation rates at the district and student levels, the MSS sample closely mirrors the demographics of statewide school enrollment with regards to assigned sex and racialized/ethnic identities. Additional details about the MSS are available elsewhere.26 Approximately 2% of cases were deleted during data cleaning to remove suspected mischievous responders (e.g., highly improbable or impossible response combinations).
The University of Minnesota Institutional Review Board determined that the present analysis was not human subjects research, and therefore was exempt from review, due to the use of existing, anonymous data.
Survey measures
We utilized measures of four social identities and positions in this analysis. Six sexual identity categories were created from one item, “How do you describe yourself?” with response options of: “heterosexual (straight),” “bisexual,” “gay or lesbian,” “questioning/not sure,” “pansexual,” “queer,” “I don’t describe myself in any of these ways,” and “I am not sure what this question means.” Based on previous findings of similarities between pansexual and queer youth,27 these groups were combined to maximize statistical power and comparability to previous work.28 Those giving the final response option were included in a “missing/other” category (1.48%, n=1,192), along with those who did not answer this question (0.82%, n=663). In addition, 8.29% (n=6,671) of participants (the largest group besides heterosexual) gave the response “I don’t describe myself in any of these ways.” Previous research suggests that those giving this response may be a combination of students who were straight but did not notice or understand the “heterosexual (straight)” option, those who use sexual orientation labels not listed on the survey (e.g. demisexual, asexual), and those who chose this response for other reasons. Therefore, they were also included in the “missing/other” category for this analysis.
One item regarding gender identity was used to create three categories: “Are you transgender, genderqueer, or genderfluid?” Those who answered no were considered cisgender; yes were considered transgender/gender diverse (TGD), and those who responded “I am not sure about my gender identity” were considered questioning their gender. Participants who responded, “I am not sure what this question means” (3.24%, n=2,609) and those who did not answer the question (0.38%, n=307) were coded as missing.
Six racialized/ethnic identity categories were created based on responses to one survey item, “How do you describe yourself (If more than one describes you, mark ALL that apply)” with responses of “American Indian or Alaskan Native,” “Asian or Asian American,” “Black, African or African American,” “Hispanic or Latino/Latina,” “Native Hawaiian or Other Pacific Islander,” and “White.” Those who did not respond were included in the “missing” category (0.68%, n=545). Assigned sex was measured with the item “What is your biological sex” (male/female). A small proportion of the sample did not respond and were categorized as missing (0.21%, n=172).
The MSS included measures of interpersonal protective factors, operationalized here as feeling cared for by various people. One question stem asked “How much do you feel…” with separate items for 1) Your parents care about you, 2) Other adult relatives care about you, 3) Friends care about you, and 4) Adults in your community care about you. Response options for each included not at all, a little, some, quite a bit, and very much. Due to high skewness in responses to three of the four sources of caring, responses were dichotomized as the top category (i.e. very much) vs. all other responses.
Data analysis
Descriptive analyses included calculating prevalences of each social identity/position and each protective factor. Exhaustive Chi-square Automatic Interaction Detection (CHAID) was used for the primary analysis, as recommended for quantitative studies of intersecting identities.29,30 Exhaustive CHAID is a descriptive, data-driven decision tree algorithm that iteratively tests multiple categorical inputs (social identity/position variables, in this case) with regards to prevalence of the dichotomous dependent variable. Categories with significantly different prevalences (Bonferroni-adjusted p-value <.05) are split; then additional category splits are tested until no significant differences within group are detected or specified model constraints have been met, resulting in a set of “terminal nodes.” Exhaustive CHAID permits re-testing for significant differences when categories are combined in a previous branch (e.g. if racialized/ethnic identities split into two groups in the first “branch,” then one of those groups was split by sexual identity in the next branch, previously combined racialized/ethnic identities are then re-tested for significant differences within sexual identity groups). For this analysis, a minimum node size of 40 was specified to avoid overfitting. Ten-fold cross-validation was conducted to ensure robust results.
Separate exhaustive CHAID models were run for each protective factor. Four social identities and positions included racialized/ethnic identity, sexual identity, gender identity, and sex assigned at birth. Youth with missing data on social identities and positions were retained in the exhaustive CHAID models, as a “missing” category. Rates of “very much” perceived caring from each source for all intersections of the four social identities and positions are shown in a supplemental table. For each source of caring, the five terminal nodes with the highest prevalence and five with the lowest prevalence are described below (within the highest 5 and lowest 5, nodes were not directly compared to one another statistically).
Results
Participants were approximately evenly divided by grade (56.22% 9th grade, n=45,232), and half were assigned female at birth (49.92%, n=40,163; Table 1). Two-thirds (69.81%; n=56,163) identified as non-Latina/x/o White. 11.35% (n=9131) of the sample identified their sexual identity as one of the four LGBQ+ categories and 2.89% (n=2,320) identified their gender identity as either TGD or questioning.
Table 1:
Characteristics of the MSS sample (N=80,456)
| N | % | |
|---|---|---|
|
| ||
| Demographic characteristics | ||
|
| ||
| Sex assigned at birth | ||
| Male | 40,121 | 49.87 |
| Female | 40,163 | 49.92 |
| Missing | 172 | 0.21 |
| Racial/ethnic identity | ||
| NL American Indian/Alaska Native | 941 | 1.17 |
| NL Asian/Pacific Islander | 5390 | 6.70 |
| NL Black, African, African American | 5966 | 7.42 |
| Latina/x/o | 6826 | 8.48 |
| NL White | 56,163 | 69.81 |
| NL multiracial | 4625 | 5.75 |
| Missing | 545 | 0.68 |
| Sexual identity | ||
| Straight | 62,799 | 78.05 |
| Gay or lesbian | 1253 | 1.56 |
| Bisexual | 4515 | 5.61 |
| Questioning | 1662 | 2.07 |
| Pansexual/queer | 1701 | 2.11 |
| Missing/Other | 8526 | 10.60 |
| Gender identity | ||
| Cisgender/not transgender | 75,220 | 93.49 |
| Trans/gender diverse | 1141 | 1.42 |
| Questioning | 1179 | 1.47 |
| Missing | 2916 | 3.62 |
|
| ||
| Protective factors – “very much” | ||
|
| ||
| Parents care | 51,311 | 69.24 |
| Other relatives care | 37,062 | 50.09 |
| Friends care | 29,531 | 39.94 |
| Community adults care | 11,101 | 15.03 |
NL: Non-Latina/x/o
Exhaustive CHAID models identified considerable disparities in the prevalence of each protective factor among MSS participants; Table 2 presents the 5 highest and 5 lowest prevalence subgroups. Although 69.24% (n=51,311) of the total sample felt their parents cared about them very much, this proportion ranged from 30.18% to 78.65% across intersecting social identities and positions, with many significant splits between nodes (p<.05 with Bonferroni correction). For example, 72.32% of Latina/x/o straight youth assigned male at birth (regardless of gender identity) reported parent caring, which was significantly different from lower-prevalence groups that include non-Latina/x/o American Indian/Alaska Native straight youth assigned male (63.39%), Latina/x/o gay/lesbian youth assigned male (50.94%), Latina/x/o straight youth assigned female (65.84%), etc; a complete list of prevalences is shown in the supplemental table). Likewise, the perception that other adult relatives care very much ranged from 12.00 – 56.18% (50.09% of total sample), friends from 21.31 – 48.22% (39.94% of total), and community adults from 5.37 – 25.65% (15.03% of total).
Table 2:
Intersecting social identities and positions with five highest and five lowest prevalences of each type of caring (MSS)
| Parents care – very much (69.24%) | ||||
|---|---|---|---|---|
|
| ||||
| Prev, % | Racialized/ethnic identity | Sexual identity | Gender identity | Assigned sex |
|
| ||||
| Highest 5 | ||||
|
| ||||
| 78.65 | Black | Missing/other | Cisgender/missing | -- |
| 75.53 | White, Black | Straight | -- | Male |
| 73.16 | White, Latina/x/o, missing | Missing/other | Cisgender/missing | Male |
| 72.62 | White, Black | Straight | Cisgender | Female, missing |
| 72.32 | Latina/x/o | Straight | -- | Male |
|
| ||||
| Lowest 5 | ||||
|
| ||||
| 45.91 | -- | Missing/other | TGD/quest | -- |
| 35.79 | -- | Pan/queer | TGD/quest | -- |
| 35.64 | -- | Gay/lesbian | TGD/quest/missing | -- |
| 35.36 | -- | Bisexual | TGD/quest/missing | -- |
| 30.18 | Latina/x/o, AIAN, Asian/PI, Multiracial | Pan/queer | -- | -- |
|
| ||||
| Other adult relatives care – very much (50.09%) | ||||
|
| ||||
| Prev, % | Racialized/ethnic identity | Sexual identity | Gender identity | Assigned sex |
|
| ||||
| Highest 5 | ||||
|
| ||||
| 56.18 | White | Straight | Cisgender | -- |
| 54.91 | White, Black, missing | Missing/other | Cisgender/missing | -- |
| 52.56 | Black | Straight | -- | -- |
| 50.17 | White | Straight | TGD/quest/missing | -- |
| 46.66 | Multiracial, Latina/x/o, AIAN | Missing/other | -- | Male |
|
| ||||
| Lowest 5 | ||||
|
| ||||
| 22.24 | Multiracial, AIAN, Asian/PI | Bisexual | Cisgender | -- |
| 15.70 | -- | Bisexual | TGD | -- |
| 15.46 | -- | Gay/lesbian | TGD/quest/missing | Female, missing |
| 15.33 | -- | Pan/queer | TGD | -- |
| 12.00 | -- | Questioning | TGD | -- |
|
| ||||
| Friends care – very much (39.94%) | ||||
|
| ||||
| Prev, % | Racialized/ethnic identity | Sexual identity | Gender identity | Assigned sex |
|
| ||||
| Highest 5 | ||||
|
| ||||
| 48.22 | White | Straight | -- | Female |
| 45.43 | White | Missing/other | -- | Female |
| 43.56 | Black | Straight, missing/other | -- | Female, missing |
| 38.44 | Black | Straight, missing/other | -- | Male |
| 38.42 | White | Straight, gay/lesbian, missing/other | Cisgender | Male, missing |
|
| ||||
| Lowest 5 | ||||
|
| ||||
| 29.12 | White | Bisexual, pan/queer, questioning | -- | Male, missing |
| 28.76 | Multiracial, missing | Bisexual, questioning | -- | -- |
| 26.48 | White | Gay/lesbian, bisexual, pan/queer, questioning | Questioning, missing | Female |
| 26.05 | Latina/x/o, Asian/PI, AIAN | Gay/lesbian, pan/queer, questioning | -- | Female |
| 21.31 | Black | Pan/queer, questioning | -- | -- |
|
| ||||
| Adults in community care – very much (15.03%) | ||||
|
| ||||
| Prev, % | Racialized/ethnic identity | Sexual identity | Gender identity | Assigned sex |
|
| ||||
| Highest 5 | ||||
|
| ||||
| 25.65 | Black, AIAN | Missing/other | -- | -- |
| 21.12 | Black | Straight | -- | Male |
| 18.97 | White, missing | Missing/other | -- | -- |
| 17.49 | White | Straight | -- | Male, missing |
| 16.18 | Black | Straight | -- | Female, missing |
|
| ||||
| Lowest 5 | ||||
|
| ||||
| 13.34 | Latina/x/o, AIAN, missing | Straight | -- | Male, missing |
| 11.36 | Asian/PI, multiracial | Straight | -- | Female, missing |
| 9.23 | Latina/x/o, AIAN, missing | Straight | -- | Female |
| 8.75 | -- | Gay, lesbian, bisexual, pan/queer, questioning | -- | Male |
| 5.37 | -- | Gay, lesbian, bisexual, pan/queer, questioning | -- | Female, missing |
Within this intersection of identities, there were no significant differences by the column variable.
Black, African, African American: PI: Pacific Islander; AIAN: American Indian/Alaska Native; Pan: pansexual; TGD: transgender/gender diverse; quest: questioning gender
Some consistent patterns emerged across the four sources of caring. In general, youth who were straight (or missing/other sexual identity) and cisgender (or missing gender identity), across several different racialized/ethnic identities and assigned sexes, were more likely to report feeling very cared about. Youth who identified as both LGBQ and TGD or questioning were less likely to report feeling very cared about by parents and other relatives. This trend is illustrated clearly in the findings specific to parent caring. More than 72% of straight, cisgender youth reported their parents cared about them very much (including those who identified as Black, White, and Latina/x/o). In contrast, youth who identified as LGBQ and TGD or questioning were much less likely to report high parent caring (less than 36%) across multiple racialized/ethnic identities and regardless of sex assigned at birth. Reflecting a slightly different pattern, youth who identified as LGBQ – across several racialized/ethnic identities and regardless of gender identity, in most cases – were less likely to report feeling very cared about by friends and community adults. For example, less than 9% of LGBQ youth reported feeling that other adults cared about them very much, in contrast to Black or White youth whose sexual identity was straight (or missing/other), where this prevalence was almost twice as high.
Discussion
Interpersonal protective factors are important for reducing adverse health outcomes such as emotional distress, substance use, and violence involvement among adolescents.1–8 Given potential challenges youth face in the form of intersecting racism, heterosexism, cisgenderism, and sexism, it is important to identify areas where interpersonal supports can be strengthened. This study found significant and substantial disparities in four protective factors across intersecting social identities and positions. Generally, straight and cisgender youth tended to report higher rates of feeling cared about by parents, other adult relatives, friends, and community adults, while LGBTQ+ youth reported lower rates. These findings were consistent for various racialized/ethnic identities and assigned sexes.
An intersectionality framework,19,20 supported by empirical research,21–25,31 describes ways in which multiple forms of oppression interact and multiply, leading to adverse effects for individuals, particularly those who may be targeted due to their marginalized identities. In the present study, perceptions of LGBTQ+ youth were largely similar across racialized/ethnic identities. This difference may be due to differences in the constructs being assessed across this nascent literature. For example, previous research has described experiences with structural racism (e.g., in policing, employment),31 racism in same-gender romantic/sexual relationships,24 and family acceptance of sexual identity.23 In contrast, the present study focuses on parental, family, friend, and community caring. This particular protective construct (i.e., caring) may not be similarly affected by structural oppression (i.e., racism) in other social contexts. Additionally, the bulk of existing literature in this area uses qualitative methods that allow participants to articulate their experiences and viewpoints with depth and nuance; here we use a quantitative approach that has greater generalizability to the population, yet relies on brief survey questions and closed-ended responses. Prior studies also point to differences across racialized/ethnic identities in the meanings and measurement of constructs such as parental care;32,33 distinct experiences of caring across youth in different intersections may not be apparent from the wording of the measures used here. It is also important to note that additional forms of structural oppression (e.g., related to religion, immigration status, economic status) were not included here and may be relevant to interpersonal support. Additional research is recommended to further elucidate these issues.
Numerous public health implications arise from this work, at multiple ecological levels. Most directly, findings about the interpersonal supports examined here suggest a need to “support the supports,” by providing and expanding cultural humility training and other programs for adults who interface with youth – that is, focusing on acknowledging one’s own biases and understanding the complexity of identities and social positionalities.34,35 Parents, coaches, youth program leaders, and other adults may benefit from education particularly around sexual and gender identity, in order to feel confident as an ally and advocate. Organizational efforts to connect youth – especially pansexual, queer, and TGD youth – to affirming resources may be acutely needed, as supportive relationships with others in those settings can be beneficial for youth facing disempowerment, stigmatization, and oppression.36 Many youth organizations have historically focused on the needs of gay and lesbian young people; intentionally expanding the audience – for example, through outreach by adult facilitators or involved peers – can create more welcoming spaces for those with a wider variety of LGBTQ+ identities.
Research and intervention regarding protective factors must operate at the structural level as well as the interpersonal levels, and the ways in which they work in tandem.37 Federal and state laws and policies are important structural factors that might intersect with interpersonal factors (such as feeling cared about), and are an important target. For example, TGD young people in states that block gender affirming health care may feel de-valued by the communities in which they live. Likewise, discourse around such policies may also be a conduit of support or stress; hearing family members, friends, or community adults talk about policies regarding same-sex marriage, gender-affirming health care, or racial uprisings can profoundly affect an individual’s feelings of being valued and supported by those close to them. Public health applications include advocating for supportive policies as well as educating families about how to talk about these issues with their adolescents in a manner that conveys their love and support even in the context of hostile policies.
Limitations and strengths
We note several limitations in this study’s design. First, the school-based data collection excluded youth who were absent on the days of data collection, or were no longer enrolled due to drop out/push out. LGBTQ+ youth are more likely than straight cisgender youth to be out of school due to bullying victimization and feeling unsafe in school,38 and may therefore be under-represented in the current study. Second, all responses were self-reported and may therefore be subject to bias. As noted above, the survey measures of caring lack detail and nuance. While appropriate for a large-scale surveillance program, they do not delve into experiences that may be particularly relevant to youth who are marginalized at multiple intersections. Likewise, the MSS only included caring as an interpersonal protective factor. Other aspects, such as feelings of connection, trust, support, or communication were not assessed and could provide further insights into the protective nature of these interpersonal supports. Other youth characteristics, such as intersex identity, were also not assessed here. Finally, this study was conducted in a single state, and findings may not be generalizable to youth in other areas.
This study also has several strengths. The use of a very large, population-based survey provides adequate numbers of youth in most demographic intersections to allow for statistically valid analysis, and is not restricted to those who have accessed a service or program through which convenience samples are often recruited. The use of an innovative analytic method (i.e. exhaustive CHAID) is recommended for studies of intersectionality and allows for simultaneous examination of numerous intersections that would not be feasible with more traditional methods such as regression.
Conclusions
Across multiple racialized/ethnic identities, LGBTQ+ youth – particularly those who may face both heterosexism and cisgenderism – have lower than average rates of perceived caring from people close to them. Findings highlight the importance of better understanding how interpersonal support might differ across groups, and further research is recommended to explore ways in which LGBTQ+ youth obtain support and care (for example, if not from family members or community adults, perhaps from online contacts or other sources). Understanding interpersonal supports from an intersectionality lens can inform tailored protective interventions for LGBTQ+ youth that are not simply “one size fits all.” It is also important to examine ways in which different sources of interpersonal support may operate in different intersecting social positions and for different aspects of health, in order to maximize the effectiveness of these supports and the well-being of LGBTQ+ young people. Interventions to support interpersonal, organizational, and structural factors in being affirming and welcoming, particularly across diverse sexual and gender identities, are especially needed.
Supplementary Material
Statement of Public Health Significance:
Using an intersectionality framework, this article explores differences in levels of interpersonal support across groups of youth at the intersections of racialized/ethnic identity, sexual identity, gender identity and sex assigned at birth. Identifying these differences can support the development of more protective interventions for LGBTQ+ youth and their networks.
Financial support:
Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number R01MD015722. It was also supported by a grant awarded to the Population Research Center at the University of Texas at Austin (P2CHD042849) by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. 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 manuscript for publication.
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