The Role of Family Support in Moderating Mental Health Outcomes for LGBTQ+ Youth in Primary Care

Joseph DelFerro; Joseph Whelihan; Jungwon Min; Maura Powell; Gabrielle DiFiore; Ari Gzesh; Scott Jelinek; Karen T G Schwartz; Molly Davis; Jason D Jones; Alexander G Fiks; Brian P Jenssen; Sarah Wood

doi:10.1001/jamapediatrics.2024.1956

. 2024 Jul 1;178(9):914–922. doi: 10.1001/jamapediatrics.2024.1956

The Role of Family Support in Moderating Mental Health Outcomes for LGBTQ+ Youth in Primary Care

Joseph DelFerro ¹, Joseph Whelihan ^2,^3,^4,^✉, Jungwon Min ^3,⁵, Maura Powell ³, Gabrielle DiFiore ³, Ari Gzesh ⁴, Scott Jelinek ^1,⁴, Karen T G Schwartz ⁶, Molly Davis ^1,^3,^6,⁷, Jason D Jones ^1,⁶, Alexander G Fiks ^1,^3,⁷, Brian P Jenssen ^1,^3,⁷, Sarah Wood ^1,^3,^4,^6,⁷

¹Perelman School of Medicine, University of Pennsylvania, Philadelphia

²Pediatric Residency Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

³Clinical Futures and PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

⁴Craig Dalsimer Division of Adolescent Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

⁵Data Science and Biostatistics Unit, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

⁶Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

⁷Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia

Accepted for Publication: May 3, 2024.

Published Online: July 1, 2024. doi:10.1001/jamapediatrics.2024.1956

^✉

Corresponding Author: Joseph Whelihan, MD, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, c/o Division of Adolescent Medicine, Philadelphia, PA 19104 (whelihanj@chop.edu).

Author Contributions: Drs DelFerro and Wood had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: DelFerro, Whelihan, Gzesh, Jelinek, Davis, Jones, Fiks, Wood.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: DelFerro, Whelihan, Min, Gzesh, Jelinek, Wood.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: DelFerro, Min, Jelinek, Jones, Fiks, Jenssen, Wood.

Obtained funding: Wood.

Administrative, technical, or material support: Whelihan, DiFiore, Jelinek, Fiks, Jenssen.

Supervision: Whelihan, Min, Fiks, Wood.

Conflict of Interest Disclosures: Dr Jelinek reported grants from the Maternal and Child Health Bureau, Health Resources and Services Administration and the Leonard Davis Institute for Health Economics, University of Pennsylvania during the conduct of the study. Dr Fiks reported salary support and honorarium from the American Academy of Pediatrics; honoraria from the American Medical Association, Atlantic Health Systems, Boston Medical Center, Emory University, New Jersey Manufacturers Insurance Company, PCORI, and University of North Carolina; and personal fees from Rutgers and the University of California, Los Angeles outside the submitted work. Dr Wood reported grants from Gilead Sciences during the conduct of the study. No other disclosures were reported.

Funding/Support: This work was supported by grant P30 AI045008 from the Penn Center for AIDS Research (Dr Wood); Career Development Award K23MH119976 from the National Institute of Mental Health (Dr Wood); and the Possibilities Project of the Children’s Hospital of Philadelphia (Dr Fiks).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

Additional Contributions: We thank Ashlee Murray, MD, MPH (Children’s Hospital of Philadelphia and University of Pennsylvania), and Allison E. Curry, PhD, MPH (Children’s Hospital of Philadelphia and University of Pennsylvania), for their assistance with project conceptualization and review of the manuscript. We also thank Jami Young, PhD (Children’s Hospital of Philadelphia), for their assistance with project conceptualization and design. Beyond usual salary, no one was financially compensated for their contribution.

^✉

Corresponding author.

PMCID: PMC11217892 PMID: 38949835

Key Points

Question

What is the association between lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+) status, family support, and mental health outcomes (as measured via electronic screeners) for adolescents attending primary care visits?

Findings

In this cross-sectional, primary care–based study of 60 626 adolescents, being LGBTQ+ was significantly associated with more depressive symptoms, recent suicidal ideation, and past suicide attempt. Parental support significantly moderated this association, protecting against these outcomes.

Meaning

Interventions targeting family support may help protect against negative mental health outcomes for LGBTQ+ adolescents presenting to primary care.

Abstract

Importance

Lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+) youth face worse mental health outcomes than non-LGBTQ+ peers. Family support may mitigate this, but sparse evidence demonstrates this in clinical settings.

Objectives

To compare depression and suicide risk between LGBTQ+ and non-LGBTQ+ youth in primary care settings and to investigate whether family support mitigates these negative mental health outcomes.

Design, Setting, and Participants

This cross-sectional study uses data from well care visits completed by adolescents aged 13 to 19 years from February 2022 through May 2023, including the Patient Health Questionnaire–9 Modified for Teens (PHQ-9-M) and the Adolescent Health Questionnaire (AHQ; an electronic screener assessing identity, behaviors, and guardian support), at 32 urban or suburban care clinics in Pennsylvania and New Jersey.

Exposures

The primary exposure was self-reported LGBTQ+ status. Family support moderators included parental discussion of adolescent strengths and listening to feelings. Race and ethnicity (determined via parent or guardian report at visit check-in), sex, payer, language, age, and geography were covariates.

Main Outcomes and Measures

PHQ-9-M–derived mental health outcomes, including total score, recent suicidal ideation, and past suicide attempt.

Results

The sample included 60 626 adolescents; among them, 9936 (16.4%) were LGBTQ+, 15 387 (25.5%) were Black, and 30 296 (50.0%) were assigned female sex at birth. LGBTQ+ youth, compared with non-LGBTQ+ youth, had significantly higher median (IQR) PHQ-9-M scores (5 [2-9] vs 1 [0-3]; P < .001) and prevalence of suicidal ideation (1568 [15.8%] vs 1723 [3.4%]; P < .001). Fewer LGBTQ+ youth endorsed parental support than non-LGBTQ+ youth (discussion of strengths, 8535 [85.9%] vs 47 003 [92.7%]; P < .001; and listening to feelings, 7930 [79.8%] vs 47 177 [93.1%]; P < .001). In linear regression adjusted for demographic characteristics and parental discussion of strengths, LGBTQ+ status was associated with a higher PHQ-9-M score (mean difference, 3.3 points; 95% CI, 3.2-3.3 points). In logistic regression, LGBTQ+ youth had increased adjusted odds of suicidal ideation (adjusted odds ratio, 4.3; 95% CI, 4.0-4.7) and prior suicide attempt (adjusted odds ratio, 4.4; 95% CI, 4.0-4.7). Parental support significantly moderated the association of LGBTQ+ status with PHQ-9-M score and suicidal ideation, with greater protection against these outcomes for LGBTQ+ vs non-LGBTQ+ youth.

Conclusions and Relevance

Compared with non-LGBTQ+ youth, LGBTQ+ youth at primary care visits had more depressive symptoms and higher odds of suicidal ideation and prior suicide attempt. Youth-reported parental support was protective against these outcomes, suggesting potential benefits of family support–focused interventions to mitigate mental health inequities for LGBTQ+ youth.

This cross-sectional study compares depression and suicide risk between LGBTQ+ and non-LGBTQ+ youth in primary care settings and investigates whether family support mitigates these negative mental health outcomes.

Introduction

Lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+) adolescents face a disparate burden of negative health outcomes compared with their cisgender, heterosexual peers.^1,2 In particular, mental health conditions disproportionately impact LGBTQ+ adolescents, with recent prevalence of depression and anxiety reaching 58% and 73%, respectively.³ Nearly half of these youth seriously considered suicide in 2022, with 14% reporting a suicide attempt in the past year in a population-based survey.³ Certain LGBTQ+ groups experience amplified burdens, including increased thoughts of suicide among transgender individuals (59%) and depressive symptoms among bisexual youth.^3,4 Youth holding multiple marginalized identities, including LGBTQ+ youth of color, experience intersectional minority stress, which can further contribute to risks of depression.⁵ Importantly, LGBTQ+ identity in and of itself does not lead to negative health outcomes; structural, societal, and psychosocial factors drive these inequities, as detailed in previous research and framed by the minority stress model.^6,7,8,9,10

Family support is an important factor that mitigates negative health outcomes among LGBTQ+ adolescents.^{5,11,12,13,14,15} Family support is a broad concept, including emotional and instrumental support, affirmation, and positive social interaction. The family strengths model¹⁶ has been used to demonstrate associations between family beliefs or behaviors and positive mental health outcomes, including in a systematic review demonstrating the benefits of appreciation, affection, and positive communication within families of transgender and gender-diverse youth.^11,17,18,19 Studies demonstrate that LGBTQ+ adolescents with low family support report higher distress and worse mental health than those with supportive families.^12,14 One study found that LGBTQ+ youth who experience frequent family rejection were 8.4 times more likely to report attempted suicide and 5.9 times more likely to report high depressive symptoms compared with those with low family rejection.²⁰ Low family support is also a barrier to care, with 45% of treatment-seeking LGBTQ+ youth citing concerns with parental permission as an obstacle to mental health services.³

While ample evidence highlights the protective role family support plays in mitigating poor health outcomes among LGBTQ+ youth, our existing knowledge is largely based on nonclinical samples. As family support can be potentially modified through pediatrician-family interactions to improve mental health outcomes, there is a critical need to understand associations between these constructs in clinical settings.^5,13 Pediatricians operate longitudinally within a clinician-family-patient triad, annually assessing health vulnerabilities and intervening to support healthy family dynamics.²¹ Within primary care, brief electronic screeners can elicit youth-reported mental health, sexual orientation and gender identity (SOGI), and family support information, providing clinicians with real-time data that assist in practicing more efficiently and effectively.^22,23 Importantly, brief screeners also generate opportunities to delineate associations between these constructs, creating an opening for interventions to enhance family support and potentially improve short- and long-term mental health outcomes.

Our study uses Adolescent Health Questionnaire (AHQ)²⁴ screener data to (1) examine differences in mental health outcomes between LGBTQ+ and cisgender, heterosexual adolescents at primary care–based annual well care visits and (2) determine whether family support moderates associations between LGBTQ+ status and mental health outcomes. We hypothesized that positive family support mitigates the risk of negative mental health outcomes, specifically depressive symptoms and suicidality, in LGBTQ+ youth. This research aims to lay the foundation for developing primary care interventions enhancing family support in this population.

Methods

Study Design

This cross-sectional study used retrospective electronic health record (EHR) data from the Children’s Hospital of Philadelphia care network.²⁵ This network comprises 32 pediatric practices in urban and suburban southeastern Pennsylvania and New Jersey. Sites deliver primary care to more than 240 000 patients annually; 25% are Black and one-third are Medicaid insured. Three clinics are pediatric resident teaching sites. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. An exemption waiver was approved by the Children’s Hospital of Philadelphia Committees for the Protection of Human Subjects.

Participants and Setting

The initial study sample included 67 632 adolescents aged 13 to 26 years who collectively attended 72 619 annual well care visits and, at least partially, completed the AHQ and Patient Health Questionnaire–9 Modified for Teens (PHQ-9-M) between February 2022 and May 2023. For patients with multiple annual visits during the study period, visits were included as separate observations, with observations linked via randomly assigned study identification numbers.

Measures

Our primary independent variable was self-reported LGBTQ+ status (cisgender, heterosexual vs LGBTQ+) on the AHQ. The AHQ is an electronic health screener completed by all patients aged 13 years and older at well care visits, with results populated in the EHR to guide clinician practice. The AHQ includes 8 domains: strengths, nutrition and activity, school, family and friends, weapons and safety, tobacco use, substance use, and adolescent sexuality and development.²⁴ Respondents were categorized as LGBTQ+ if they responded to the prompt “Do you think of yourself as” with transgender male, transgender female, nonbinary, or other and/or responded to the prompt “Do you think you may be gay, lesbian, or bisexual?” with yes, not sure, or other (n = 9885). LGBTQ+ identity was also assigned if these criteria were not met but sex assigned at birth differed from self-reported gender identity (n = 51). We categorized remaining participants as cisgender, heterosexual (n = 50 690). We collapsed the LGBQ and transgender or nonbinary youth into a single category given substantial overlap, wherein 94% of transgender and nonbinary youth also identified as LGBQ.

Our primary outcome measures were derived from the PHQ-9-M. Based on the Patient Health Questionnaire–9 (PHQ-9),^26,27 the PHQ-9 Modified for Adolescents,²⁸ and the Columbia Depression Scale,²⁹ the PHQ-9-M measures depressive symptoms during the past 2 weeks. It maintains the PHQ-9’s 9 core items with minor changes to improve youth centeredness. The 9 core items are scored from 0 (not at all) to 3 (nearly every day). Two additional items assess suicide risk: (1) suicidal ideation in the past month, and (2) lifetime attempted suicide.

Our primary outcome was continuous PHQ-9-M score (range, 0-27), with higher scores indicating higher levels of depression symptoms. Secondary outcomes included recent suicidality and past suicide attempt. Recent suicidality was operationalized as affirmative responses to either item 9 (“In the last two weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way?”) or item 12 (“Has there been a time in the past month when you have had serious thoughts about ending your life?”). Past suicide attempt was operationalized as a response of yes to item 13 (“Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?”). Covariates derived from visit registration included age, race, ethnicity, preferred language, clinic site, and insurance status. Race and ethnicity were reported by parent or guardian at visit check-in and included as proxy markers of structural racism and discrimination rather than as biological variables.^30,31 Provided options for race were African American or Black, Asian or South Asian, Native Hawaiian or Other Pacific Islander, indigenous, multiracial, White, or other (including all racial groups not previously listed); options provided for ethnicity were Hispanic and non-Hispanic. Clinics were categorized as urban if located within Philadelphia, Pennsylvania; all others were classified as suburban per county-level rural-urban continuum codes.³²

Two AHQ items served as proxy measurements of family support based on alignment with the family strengths model.¹⁶ Grounded in this model, “Do your parents discuss your strengths?” (no or yes) served as a proxy for appreciation and affection, and “Do you think that your parent(s) or guardian(s) usually listen to you and take your feelings seriously?” (no or yes) served as a proxy for positive communication.

Statistical Analysis

We excluded participants older than 19 years (as importance of family support may change as adolescent-to–young adult autonomy increases) and observations with incomplete PHQ-9-Ms, missing data for either family support variable or LGBTQ+ identity, and/or a visit date less than 9 months from a prior visit (suggesting an erroneous AHQ administration outside of the annual well care visit) (n = 7006; Figure 1). Excluded patients, primarily for missing data, were more likely to be Black, publicly insured, and from urban practices (eTable 1 in Supplement 1). We assessed demographic characteristics using means with SDs for normally distributed variables and medians with IQRs for nonnormally distributed variables. We assessed associations between LGBTQ+ status and mental health outcomes using χ² and Wilcoxon rank sum tests.

Figure 1. — LGBTQ+ indicates lesbian, gay, bisexual, transgender, queer, and/or questioning; PHQ-9-M, Patient Health Questionnaire–9 Modified for Teens.

Multilevel mixed-effects linear regression analysis determined the association of LGBTQ+ status and family support with PHQ-9-M scores. Beta coefficients represented estimated mean differences in PHQ-9-M score by LGBTQ+ and family support statuses, accounting for patient-level random effects and adjusting for the covariates described earlier. We conducted separate logistic regression analyses to determine associations of LGBTQ+ status and family support with (1) recent suicidality and (2) prior suicide attempt. As recent suicidal ideation and lifetime suicide attempts were repeatedly collected within a brief period (mean [SD] of 12.2 [1.8] months, with all responses <15 months apart), with highly consistent responses (93% and 96% agreement, respectively), we used only data from the first visit in these models. We tested the associations of parental discussion of strengths (strengths models) and parental listening to feelings (feelings models) in separate models.

To test our hypothesis that family support would moderate the association between LGBTQ+ status and mental health outcomes, we repeated the models, including an interaction term in each model to assess moderation of the associations of LGBTQ+ status with family support measures (eg, LGBTQ+ × strengths). All hypothesis tests were 2-sided and considered significant at the .05 level. Analyses were completed in Stata version 18.0 statistical software (StataCorp LLC).

Results

After the exclusion of 5870 participants (8.7%) for missing data, the final study sample included 60 626 patients. Of these, 55 793 (92.0%) had 1 visit during the study period and 4833 (8.0%) had at least 2 visits. A total of 9936 adolescents (16.4%) identified as LGBTQ+, with 9782 (16.1%) reporting a sexual orientation other than heterosexual and 1826 (3.0%) identifying as transgender or nonbinary. Among the study sample, 15 387 (25.5%) identified as Black, 30 296 (50.0%) were assigned female sex at birth, 18 007 (29.7%) held public insurance, and 15 252 (25.2%) attended an urban clinic. Additional sample characteristics are shown in Table 1.

Table 1. Characteristics of the Study Sample of 60 626 Adolescents^a.

Characteristic	No. (%) (N = 60 626)		P value
Characteristic	LGBTQ+ (n = 9936)	Non-LGBTQ+ (n = 50 690)	P value
Age, y^b
13-14	3536 (35.6)	20 104 (39.7)	<.001
15-17	5202 (52.4)	25 034 (49.4)
18-19	1198 (12.1)	5552 (10.9)
Race^b^,^c
Asian American or Pacific Islander^d	522 (5.3)	2633 (5.2)	<.001
Black	2852 (28.8)	12 535 (24.8)
Multiracial	367 (3.7)	1381 (2.7)
Other^e	1195 (12.1)	6346 (12.6)
White	4962 (50.1)	27 603 (54.7)
Ethnicity^b^,^f
Hispanic	967 (9.8)	4186 (8.3)	<.001
Non-Hispanic	8909 (90.2)	46 206 (91.7)	<.001
Sex assigned at birth^g
Female	7884 (79.4)	22 412 (44.2)	<.001
Male	2048 (20.6)	28 278 (55.8)	<.001
Language^b^,^h
English	9482 (97.6)	47 798 (96.8)	<.001
Non-English	234 (2.4)	1566 (3.2)	<.001
Clinic setting^b
Suburban	6884 (69.3)	38 490 (75.9)	<.001
Urban	3052 (30.7)	12 200 (24.1)	<.001
Insurance^b^,ⁱ
Commercial	6474 (65.2)	35 236 (69.6)	<.001
MA or government	3299 (33.2)	14 708 (29.0)
Uninsured or other	160 (1.6)	711 (1.4)
PHQ-9-M score
Median (IQR)	5 (2-9)	1 (0-3)	<.001
Mean (SD)	6.2 (5.4)	2.4 (3.4)	<.001
Recent suicidal ideation
No	8368 (84.2)	48 967 (96.6)	<.001
Yes	1568 (15.8)	1723 (3.4)	<.001
Lifetime history of suicide attempt
No	8548 (86.0)	49 213 (97.1)	<.001
Yes	1388 (14.0)	1477 (2.9)	<.001
Do your parent(s) or guardian(s) talk with you about your strengths (like working hard, using your talents/skills, etc)?
Yes	8535 (85.9)	47 003 (92.7)	<.001
No	1401 (14.1)	3687 (7.3)	<.001
Do you think that your parent(s) or guardian(s) usually listen to you and take your feelings seriously?
Yes	7930 (79.8)	47 177 (93.1)	<.001
No	2006 (20.2)	3513 (6.9)	<.001

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Abbreviations: LGBTQ+, lesbian, gay, bisexual, transgender, queer, and/or questioning; MA, medical assistance; PHQ-9-M, Patient Health Questionnaire–9 Modified for Teens.

^{^a}

The first observation per patient is displayed.

^{^b}

Denotes variables with data pulled from the patient’s existing electronic health record. All other variables are self-reported via the Adolescent Health Questionnaire.

^{^c}

Determined by parent or guardian report at visit check-in. Data are missing for 38 LGBTQ+ adolescents (0.4%) and 192 non-LGBTQ+ adolescents (0.4%).

^{^d}

Includes Asian or South Asian (518 [5.2%] LGBTQ+ and 2613 [5.2%] non-LGBTQ+) and Native Hawaiian or Other Pacific Islander (4 [0.04%] LGBTQ+ and 20 [0.04%] non-LGBTQ+).

^{^e}

Includes other (including all racial groups not otherwise listed) (1187 [12.0%] LGBTQ+ and 6308 [12.4%] non-LGBTQ+) and indigenous (8 [0.08%] LGBTQ+ and 38 [0.07%] non-LGBTQ+).

^{^f}

Determined by parent or guardian report at visit check-in. Data are missing for 60 LGBTQ+ adolescents (0.6%) and 298 non-LGBTQ+ adolescents (0.6%).

^{^g}

Data are missing for 4 LGBTQ+ adolescents (0.04%).

^{^h}

Data are missing for 220 LGBTQ+ adolescents (2.2%) and 1326 non-LGBTQ+ adolescents (2.6%).

^ⁱ

Data are missing for 3 LGBTQ+ adolescents (0.03%) and 35 non-LGBTQ+ adolescents (0.07%).

Bivariate analyses revealed that LGBTQ+ youth, compared with their cisgender, heterosexual counterparts, had significantly higher PHQ-9-M scores (median [IQR], 5 [2-9] vs 1 [0-3]; mean [SD], 6.2 [5.4] vs 2.4 [3.4]; P < .001) and proportions reporting both suicidal ideation (1568 [15.8%] vs 1723 [3.4%]; P < .001) and prior suicide attempt (1388 [14.0%] vs 1477 [2.9%]; P < .001). Furthermore, significantly fewer LGBTQ+ youth endorsed parental support than non-LGBTQ+ youth for both discussion of strengths (8535 [85.9%] vs 47 003 [92.7%]; P < .001) and listening to feelings (7930 [79.8%] vs 47 177 [93.1%]; P < .001). Bivariate analyses also revealed significant differences between the 2 groups with respect to race, ethnicity, sex assigned at birth, age, preferred language, clinic setting, and insurance (Table 1).

In the mixed-effects linear regression models (Table 2), LGBTQ+ identity was associated with higher PHQ-9-M scores (strengths model: 3.3 points; 95% CI, 3.2-3.3 points; feelings model: 3.0 points; 95% CI, 2.9-3.1 points). Across mental health outcomes, parental discussion of strengths and having a parent who listened to feelings were significantly protective. Having a parent who listened to feelings was associated with a 3.4-point reduction (95% CI, −3.5 to −3.3) in PHQ-9-M score. In logistic regression models (Table 2), LGBTQ+ youth had markedly increased adjusted odds of suicidal ideation (strengths model: adjusted odds ratio [aOR], 4.3; 95% CI, 4.0-4.7; feelings model: aOR, 3.9; 95% CI, 3.6-4.2) and prior suicide attempt (strengths model: aOR, 4.4; 95% CI, 4.0-4.7; feelings model: aOR, 4.0; 95% CI, 3.7-4.4). Across all 6 models, Black and publicly insured youth had higher mean PHQ-9-M scores and greater adjusted odds of suicidal ideation and attempt. Hispanic youth had higher mean PHQ-9-M scores and greater adjusted odds of suicide attempt (see eTable 2 in Supplement 1 for adjusted model outputs).

Table 2. Adjusted Associations Between Mental Health Outcomes, LGBTQ+ Status, and Parent or Guardian Support^a.

Variable	PHQ-9-M score, β coefficient (95% CI) (N = 60 626)^b	Adjusted OR (95% CI) (n = 58 574)^c
Variable	PHQ-9-M score, β coefficient (95% CI) (N = 60 626)^b	Recent suicidal ideation	Past suicide attempt
Models testing LGBTQ+ status and parent discussion of adolescent’s strengths
LGBTQ+ status
Non-LGBTQ+	1 [Reference]	1 [Reference]	1 [Reference]
LGBTQ+	3.3 (3.2 to 3.3)	4.3 (4.0 to 4.7)	4.4 (4.0 to 4.7)
Parents discuss strengths
No	1 [Reference]	1 [Reference]	1 [Reference]
Yes	−1.9 (−2.0 to −1.8)	0.5 (0.4 to 0.5)	0.5 (0.4 to 0.6)
Models testing LGBTQ+ status and parent listening to adolescent’s feelings
LGBTQ+ status
Non-LGBTQ+	1 [Reference]	1 [Reference]	1 [Reference]
LGBTQ+	3.0 (2.9 to 3.1)	3.9 (3.6 to 4.2)	4.0 (3.7 to 4.4)
Parents listen to feelings
No	1 [Reference]	1 [Reference]	1 [Reference]
Yes	−3.4 (−3.5 to −3.3)	0.3 (0.3 to 0.3)	0.4 (0.3 to 0.4)

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Abbreviations: LGBTQ+, lesbian, gay, bisexual, transgender, queer, and/or questioning; OR, odds ratio; PHQ-9-M, Patient Health Questionnaire–9 Modified for Teens.

^{^a}

Adjusted for race, ethnicity, sex, age, primary spoken language, insurance type, and suburban vs urban clinic.

^{^b}

Multivariate linear regression analysis. The β coefficient represents change in PHQ-9-M score associated with LGBTQ+ status or family support variable presence.

^{^c}

Multivariate logistic regression analysis.

In our moderation analysis, both parental support items significantly modified the association of LGBTQ+ status with PHQ-9-M score and suicidal ideation (Figure 2 and Figure 3). Both parental support items were more protective for PHQ-9-M score and suicidal ideation for LGBTQ+ youth than for cisgender, heterosexual youth. For suicide attempt, parents listening to feelings, but not parents discussing strengths, was more protective for LGBTQ+ youth than for cisgender, heterosexual youth.

Figure 2. — For interaction, P < .001 for Patient Health Questionnaire–9 Modified for Teens (PHQ-9-M) score (A), P = .007 for suicidal ideation (B), and P = .27 for suicide attempt (C). Error bars indicate 95% CI.

Figure 3. — For interaction, P < .001 for Patient Health Questionnaire–9 Modified for Teens (PHQ-9-M) score (A), suicidal ideation (B), and suicide attempt (C). Error bars indicate 95% CI.

Discussion

In this cross-sectional study of more than 60 000 adolescents attending annual well care visits, family support had a protective role against negative mental health outcomes for all youth. This finding emphasizes the critical importance of the strengths portion of the adolescent social history (ie, SSHADESS [strengths, school, home, activities, drugs, emotions/eating, sexuality, safety] or HEADSS [home, education, activities/employment, drugs, suicidality, and sex] assessment),³³ as pediatricians can use discussion of strengths to educate families on strengths-based communication, modeling this skill within the pediatrician-patient-parent triad.³⁴ Importantly, listening to an adolescent’s feelings had the largest protective role, suggesting that this skill should be incorporated into pediatricians’ modeling of family support. Notably, parents discussing their teen’s strengths and listening to their feelings was more protective for LGBTQ+ vs non-LGBTQ+ youth on PHQ-9-M score and suicidal ideation. This finding suggests that while interventions to enhance family support and strengths-based communication may be effective methods of mitigating stress and enhancing resilience for all youth, they may be particularly effective among LGBTQ+ youth. Notably, while family support was endorsed less frequently for LGBTQ+ youth vs non-LGBTQ+ youth, all youth reported fairly high levels of family support, as operationalized in our models. Previous studies assessing associations between family support and mental health have measured family support using extensive questionnaires that are impractical to integrate into clinical care, leaving a knowledge gap on how to succinctly assess, appraise, and intervene on familial support in clinical care settings. This study demonstrates that screeners using just 2 family support questions can provide actionable information.

Our second major finding was that compared with cisgender, heterosexual youth, LGBTQ+ youth had significantly higher median PHQ-9-M scores and higher odds of recent suicidal ideation and prior suicide attempt. Prior population-based survey studies demonstrate similar findings, but, to our knowledge, few have replicated these findings in a clinical setting.^1,2,3 Although median PHQ-9-M scores for both groups fell within the subthreshold range for depression symptoms, research suggests that the long-term mental health risks of subthreshold depression and major depression in adolescents are similar, highlighting the importance of preventive interventions for these adolescents.³⁵ We also identified higher depressive symptoms and probability of suicidal ideation or attempt in youth of racial and/or ethnic minoritized groups and youth with public insurance, emphasizing the importance of considering intersectional minority stress.

In the primary care setting, pediatricians and their allied health colleagues can immediately act to improve mental health outcomes through safety assessments, therapy referrals, and medication management per American Academy of Pediatrics guidelines.³⁶ Furthermore, adolescent depression prevention models have shown promise in the primary care setting.^37,38,39,40 These marked inequities for LGBTQ+ youth underscore a need for enhanced attention to mental health when evaluating these youth as well as the importance of integrating the collection and display of SOGI and mental health screening data in the primary care EHR to support patient-centered, timely, and safe care. While there is limited existing literature on primary care–based interventions to address mental health in these youth, strategies have involved addressing sexual, gender, and intersectional minority stress to promote resiliency and agency.⁴¹ Specifically, effective interventions have targeted internalized homophobia and/or transphobia, hopelessness, isolation, and maladaptive responses to minority stressors while affirming identities and promoting positive future orientation.⁴¹

While simple at face value, these recommendations are complex in implementation given limited visit time and challenges to follow-up. Delivering care will also require more than the pediatrician. Primary care systems can integrate allied health professionals, such as social workers or navigators, to streamline referrals to embedded or external mental health professionals with expertise working with LGBTQ+ youth. In addition, single-session online interventions that can be embedded within a primary care visit or provided as links to patients and families have been shown to improve depressive symptoms and perceived agency in adolescents.⁴² Implementing and sustaining evidence-based adolescent depression and suicide prevention programs in primary care, particularly for LGBTQ+ youth, will be critical for mitigating the likelihood that symptoms worsen.

Limitations

Our study has limitations. Our cross-sectional design does not allow inference of causal relationships between exposures and outcomes. These results come from a single regional health system serving primarily urban and suburban youth. We only included youth who were administered the AHQ and excluded 5870 patients (8.7%) from the observation period due to missing data for key measures. Generalizability should be considered given that significantly higher proportions of excluded patients were Black, did not speak English, attended urban clinics, or were publicly insured. The source of this disparity is unknown but may be due to the busy nature of urban practices (which, in our case, saw substantially higher daily patient volumes than suburban practices) and other sociostructural barriers to survey completion. Future research should focus on the complex intersectional nature of race, ethnicity, socioeconomic status, and LGBTQ+ identity on mental health outcomes. Given the sensitive nature of mental health and SOGI questions, nondisclosure and social desirability biases may have affected our results, with stigma leading to underreporting of LGBTQ+ status. We found an unexpectedly higher proportion of individuals assigned female sex at birth reporting LGBTQ+ status despite essentially equal distribution of patients by sex in the sample, which bears assessment in future research.⁴³ We measured parental support using 2 items chosen solely based on alignment with the family strengths model rather than using a validated instrument given the need for brief pragmatic measures in primary care. Last, depression may have affected participants’ perceptions of family support, meaning that observed associations between family support and mental health outcomes could be bidirectional or behave differently among adolescents with different clinical profiles. Future studies should further investigate the mechanisms for the protective role of family support and whether they differ for LGBTQ+ vs non-LGBTQ+ youth.

Conclusions

Our research demonstrates that LGBTQ+ status, mental health outcomes, and protective support factors can be identified in real time during routine clinical care. Further, in integrating these data elements, we identified marked mental health inequities for LGBTQ+ youth and highlighted family support as a modifiable factor to prevent negative mental health outcomes. These findings lay a path toward research to improve mental health outcomes and decrease mental health inequities for LGBTQ+ youth. Future work should focus on developing brief, culturally tailored interventions for LGBTQ+ adolescents with depression and suicide risk in primary care, training pediatricians to provide culturally humble and LGBTQ+-affirming care, and advocating for funding and resources to support allied health care team members, including nurse navigators and social workers, to facilitate close and frequent follow-up. Relatedly, given the documented benefits of integrated behavioral health models for youth, collaboration between pediatricians and behavioral health clinicians in promoting mental health among LGBTQ+ adolescents will be critical.⁴⁴ In summary, adolescent-reported information captured through previsit screenings may provide a foundation for targeted interventions to improve mental health outcomes, highlighting the importance of efforts to further this research in achieving health equity for LGBTQ+ youth.

Supplement 1.

eTable 1. Comparison Between Included and Excluded Groups

eTable 2. Adjusted Associations Between Mental Health Outcomes, LGBTQ+ Status, and Parent/Guardian Support With All Adjusted Variables

jamapediatr-e241956-s001.pdf^{(189.5KB, pdf)}

Supplement 2.

Data Sharing Statement

jamapediatr-e241956-s002.pdf^{(15.2KB, pdf)}

References

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eTable 1. Comparison Between Included and Excluded Groups

eTable 2. Adjusted Associations Between Mental Health Outcomes, LGBTQ+ Status, and Parent/Guardian Support With All Adjusted Variables

jamapediatr-e241956-s001.pdf^{(189.5KB, pdf)}

Supplement 2.

Data Sharing Statement

jamapediatr-e241956-s002.pdf^{(15.2KB, pdf)}

[poi240033r1] 1.Marshal MP, Dietz LJ, Friedman MS, et al. Suicidality and depression disparities between sexual minority and heterosexual youth: a meta-analytic review. J Adolesc Health. 2011;49(2):115-123. doi: 10.1016/j.jadohealth.2011.02.005 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r2] 2.Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health care disparities among lesbian, gay, bisexual, and transgender youth: a literature review. Cureus. 2017;9(4):e1184. doi: 10.7759/cureus.1184 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r3] 3.The Trevor Project . 2022 National Survey on LGBTQ Youth Mental Health. Accessed February 21, 2023. https://www.thetrevorproject.org/survey-2022/

[poi240033r4] 4.Chan RCH, Operario D, Mak WWS. Bisexual individuals are at greater risk of poor mental health than lesbians and gay men: the mediating role of sexual identity stress at multiple levels. J Affect Disord. 2020;260:292-301. doi: 10.1016/j.jad.2019.09.020 [DOI] [PubMed] [Google Scholar]

[poi240033r5] 5.Mereish EH, Fish JN, Watson RJ. Intersectional minority stress and alcohol, tobacco, and cannabis use among sexual and gender minority adolescents of color: moderating role of family support. LGBT Health. 2023;10(1):18-25. doi: 10.1089/lgbt.2021.0430 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r6] 6.Connors J, Casares MC, Honigberg MC, Davis JA. LGBTQ health disparities. In: Lehman JR, Diaz K, Ng H, Petty EM, Thatikunta M, Eckstrand K, eds. The Equal Curriculum. Springer Nature; 2020:13-31. doi: 10.1007/978-3-030-24025-7_2 [DOI]

[poi240033r7] 7.Moagi MM, van Der Wath AE, Jiyane PM, Rikhotso RS. Mental health challenges of lesbian, gay, bisexual and transgender people: an integrated literature review. Health SA. 2021;26:1487. doi: 10.4102/hsag.v26i0.1487 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r8] 8.Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674-697. doi: 10.1037/0033-2909.129.5.674 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r9] 9.Frost DM, Meyer IH. Minority stress theory: application, critique, and continued relevance. Curr Opin Psychol. 2023;51:101579. doi: 10.1016/j.copsyc.2023.101579 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r10] 10.Staufenbiel SM, Penninx BWJH, Spijker AT, Elzinga BM, van Rossum EFC. Hair cortisol, stress exposure, and mental health in humans: a systematic review. Psychoneuroendocrinology. 2013;38(8):1220-1235. doi: 10.1016/j.psyneuen.2012.11.015 [DOI] [PubMed] [Google Scholar]

[poi240033r11] 11.Brown C, Porta CM, Eisenberg ME, McMorris BJ, Sieving RE. Family relationships and the health and well-being of transgender and gender-diverse youth: a critical review. LGBT Health. 2020;7(8):407-419. doi: 10.1089/lgbt.2019.0200 [DOI] [PubMed] [Google Scholar]

[poi240033r12] 12.McConnell EA, Birkett M, Mustanski B. Families matter: social support and mental health trajectories among lesbian, gay, bisexual, and transgender youth. J Adolesc Health. 2016;59(6):674-680. doi: 10.1016/j.jadohealth.2016.07.026 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r13] 13.McConnell EA, Birkett MA, Mustanski B. Typologies of social support and associations with mental health outcomes among LGBT youth. LGBT Health. 2015;2(1):55-61. doi: 10.1089/lgbt.2014.0051 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r14] 14.Ryan C, Russell ST, Huebner D, Diaz R, Sanchez J. Family acceptance in adolescence and the health of LGBT young adults. J Child Adolesc Psychiatr Nurs. 2010;23(4):205-213. doi: 10.1111/j.1744-6171.2010.00246.x [DOI] [PubMed] [Google Scholar]

[poi240033r15] 15.Ford CA, Pool AC, Kahn NF, Jaccard J, Halpern CT. Associations between mother-adolescent and father-adolescent relationships and young adult health. JAMA Netw Open. 2023;6(3):e233944-e233944. doi: 10.1001/jamanetworkopen.2023.3944 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r16] 16.DeFrain J, Asay S. Strong Families Around the World: Strengths-Based Research and Perspectives. Vol 41. Haworth Press Inc; 2007. [Google Scholar]

[poi240033r17] 17.Sittner BJ, Hudson DB, DeFrain J. Using the concept of family strengths to enhance nursing care. MCN Am J Matern Child Nurs. 2007;32(6):353-357. doi: 10.1097/01.NMC.0000298130.16914.47 [DOI] [PubMed] [Google Scholar]

[poi240033r18] 18.Silberberg S. Searching for family resilience. Fam Matters. 2001;58:52-57. [Google Scholar]

[poi240033r19] 19.DeFrain J, Asay SM. Family strengths and challenges in the USA. Marriage Fam Rev. 2008;41(3-4):281-307. doi: 10.1300/J002v41n03_04 [DOI] [Google Scholar]

[poi240033r20] 20.Ryan C, Huebner D, Diaz RM, Sanchez J. Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009;123(1):346-352. doi: 10.1542/peds.2007-3524 [DOI] [PubMed] [Google Scholar]

[poi240033r21] 21.Fussell JJ, High PC, Donoghue E, et al. ; Committee on Early Childhood, Adoption, and Dependent Care . The pediatrician’s role in family support and family support programs. Pediatrics. 2011;128(6):e1680-e1684. doi: 10.1542/peds.2011-2664 [DOI] [PubMed] [Google Scholar]

[poi240033r22] 22.Farley AM, Gallop RJ, Brooks ES, Gerdes M, Bush ML, Young JF. Identification and management of adolescent depression in a large pediatric care network. J Dev Behav Pediatr. 2020;41(2):85-94. doi: 10.1097/DBP.0000000000000750 [DOI] [PubMed] [Google Scholar]

[poi240033r23] 23.Richardson LP, Zhou C, Gersh E, Spielvogle H, Taylor JA, McCarty CA. Effect of electronic screening with personalized feedback on adolescent health risk behaviors in a primary care setting: a randomized clinical trial. JAMA Netw Open. 2019;2(5):e193581-e193581. doi: 10.1001/jamanetworkopen.2019.3581 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r24] 24.DiFiore G, Wood S, Jenssen BP, Fiks AG, Mayne SL. Cumulative health vulnerabilities among adolescents by age and neighborhood opportunity. Pediatrics. 2023;152(6):e2023062657. doi: 10.1542/peds.2023-062657 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r25] 25.Fiks AG, Grundmeier RW, Margolis B, et al. Comparative effectiveness research using the electronic medical record: an emerging area of investigation in pediatric primary care. J Pediatr. 2012;160(5):719-724. doi: 10.1016/j.jpeds.2012.01.039 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r26] 26.Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. doi: 10.1046/j.1525-1497.2001.016009606.x [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r27] 27.Spitzer RL, Kroenke K, Williams JBW; Patient Health Questionnaire Primary Care Study Group . Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA. 1999;282(18):1737-1744. doi: 10.1001/jama.282.18.1737 [DOI] [PubMed] [Google Scholar]

[poi240033r28] 28.Johnson JG, Harris ES, Spitzer RL, Williams JBW. The Patient Health Questionnaire for Adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients. J Adolesc Health. 2002;30(3):196-204. doi: 10.1016/S1054-139X(01)00333-0 [DOI] [PubMed] [Google Scholar]

[poi240033r29] 29.Shaffer D, Fisher P, Lucas CP, Dulcan MK, Schwab-Stone ME. NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. J Am Acad Child Adolesc Psychiatry. 2000;39(1):28-38. doi: 10.1097/00004583-200001000-00014 [DOI] [PubMed] [Google Scholar]

[poi240033r30] 30.Flanagin A, Frey T, Christiansen SL; AMA Manual of Style Committee . Updated guidance on the reporting of race and ethnicity in medical and science journals. JAMA. 2021;326(7):621-627. doi: 10.1001/jama.2021.13304 [DOI] [PubMed] [Google Scholar]

[poi240033r31] 31.VanderWeele TJ, Robinson WR. On the causal interpretation of race in regressions adjusting for confounding and mediating variables. Epidemiology. 2014;25(4):473-484. doi: 10.1097/EDE.0000000000000105 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r32] 32.US Department of Agriculture Economic Research Service . 2023 Rural-urban continuum codes. Updated January 22, 2024. Accessed May 30, 2024. https://www.ers.usda.gov/data-products/rural-urban-continuum-codes

[poi240033r33] 33.Ginsburg K. The SSHADESS screening: a strength-based pyschosocial assessment. In: Ginsburg K, McClain Z, eds. Reaching Teens: Strength-Based, Trauma-Sensitive, Resilience-Building Communication Strategies Rooted in Positive Youth Development. 2nd ed. American Academy of Pediatrics; 2020:225-228. [Google Scholar]

[poi240033r34] 34.Dittus PJ. Promoting adolescent health through triadic interventions. J Adolesc Health. 2016;59(2):133-134. doi: 10.1016/j.jadohealth.2016.06.001 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi240033r35] 35.Fergusson DM, Horwood LJ, Ridder EM, Beautrais AL. Subthreshold depression in adolescence and mental health outcomes in adulthood. Arch Gen Psychiatry. 2005;62(1):66-72. doi: 10.1001/archpsyc.62.1.66 [DOI] [PubMed] [Google Scholar]

[poi240033r36] 36.Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D; GLAD-PC Steering Group . Guidelines for adolescent depression in primary care (GLAD-PC), part I: practice preparation, identification, assessment, and initial management. Pediatrics. 2018;141(3):e20174081. doi: 10.1542/peds.2017-4081 [DOI] [PubMed] [Google Scholar]

[poi240033r37] 37.Kanine RM, Bush ML, Davis M, Jones JD, Sbrilli MD, Young JF. Depression prevention in pediatric primary care: implementation and outcomes of interpersonal psychotherapy-adolescent skills training. Child Psychiatry Hum Dev. 2023;54(1):96-108. doi: 10.1007/s10578-021-01222-6 [DOI] [PubMed] [Google Scholar]

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PERMALINK

The Role of Family Support in Moderating Mental Health Outcomes for LGBTQ+ Youth in Primary Care

Joseph DelFerro, MD, MPH

Joseph Whelihan, MD

Jungwon Min, PhD

Maura Powell, MPH, MBA

Gabrielle DiFiore, MPH

Ari Gzesh, MSW

Scott Jelinek, MD, MPH

Karen T G Schwartz, PhD

Molly Davis, PhD

Jason D Jones, PhD

Alexander G Fiks, MD, MSCE

Brian P Jenssen, MD, MSHP

Sarah Wood, MD, MSHP

Key Points

Question

Findings

Meaning

Abstract

Importance

Objectives

Design, Setting, and Participants

Exposures

Main Outcomes and Measures

Results

Conclusions and Relevance

Introduction

Methods

Study Design

Participants and Setting

Measures

Statistical Analysis

Figure 1. Flow Diagram of Participant Selection and Analysis.

Results

Table 1. Characteristics of the Study Sample of 60 626 Adolescentsa.

Table 2. Adjusted Associations Between Mental Health Outcomes, LGBTQ+ Status, and Parent or Guardian Supporta.

Figure 2. Mental Health Outcomes Moderated by Interaction Between Lesbian, Gay, Bisexual, Transgender, Queer, and/or Questioning (LGBTQ+) Status and Parents Discussing Youths’ Strengths.

Figure 3. Mental Health Outcomes Moderated by Interaction Between Lesbian, Gay, Bisexual, Transgender, Queer, and/or Questioning (LGBTQ+) Status and Parents Listening to Youths’ Feelings.

Discussion

Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases

Table 1. Characteristics of the Study Sample of 60 626 Adolescents^a.

Table 2. Adjusted Associations Between Mental Health Outcomes, LGBTQ+ Status, and Parent or Guardian Support^a.