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. Author manuscript; available in PMC: 2025 Jan 1.
Published in final edited form as: J LGBT Youth. 2023 Jul 2;21(4):659–676. doi: 10.1080/19361653.2023.2230462

Protective factors associated with reduced substance use and depression among gender minority teens

Dina Burstein 1, Eliza Loren Purdue 2, Jennifer A Jones 3, Janis L Breeze 4, Ye Chen 5, Robert Sege 6
PMCID: PMC11580804  NIHMSID: NIHMS1920251  PMID: 39583960

Abstract

Gender minority (GM) students are at high risk for substance use and depression. This study explores the role of protective factors in reducing rates of substance use and depression based on high school surveys. Univariate and multivariate analyses were conducted to evaluate the association between exposures and outcomes. Youth completed surveys in 2018 (n=16,288) and in 2021 (n=10,792). GM students reported exposure to protective factors less frequently than their cisgender peers: good financial status (88.6% v 96.5% v in 2018 and 95% v 97.8% in 2021), feeling a sense of school/community membership, (mean score 2.7 v 3.0 in 2018 and 2.6 v 3.0 in 2021) or having two or more caring adults in their life (61.5% v 79.7% v in 2018 and 64.2% v. 80.6% in 2021). GM youth experienced risk factors more often than their peers including bias-based bullying (mean score: 0.6 v 0.2 in 2018, 0.5 v. 0.2 in 2021); peer victimization (0.5 v. 0.2 in 2018, 0.3 v 0.1 in 2021), and homelessness/foster care exposure (32.8% v 10.8% in 2018 and 15.8% v. 6.6% in 2021). Several factors mitigated depression and substance use among GM students. GM youth experienced these protective factors less frequently than their peers.

Keywords: gender minority youth, protective factors, risk factors, depression, substance use

Introduction

During middle and high school, adolescents explore, develop, and express their sexual identity (Gray & Squeglia, 2018; Kar et al., 2015). Adolescents who identify as transgender, non-binary, gender nonconforming, and/or do not identify with male or female gender (collectively gender-minority or GM), go through the same developmental processes. This normal process of identity formation can be difficult for adolescents who identify as GM. Previous research shows that GM youth have higher rates of substance use and mental health difficulties than their cisgender peers (Mereish, 2019; Russell & Fish, 2016). Strong parent-child relationships, a safe home, community and school environment, and positive social engagement protect against adolescent substance use and poor mental health in the general population (Allen et al., 2021; Rusby et al., 2018). In contrast, peer substance use, parent-adolescent conflict, child maltreatment and parental substance use increase these behavioral risks (Allen et al., 2021; Newcomb et al., 2020).

Safe school and home environments support healthy development for youth in general. Child maltreatment, poor parent-child relationships, and fear of being a crime victim undermine feelings of safety and are highly correlated with poor mental health in adolescence (Mueller et al., 2019; Yoon et al., 2017). Beyond these general risk factors affecting adolescent development, GM students face specific threats to feeling welcomed and safe at school including experiencing higher rates of bullying compared with cisgender peers. More than three-quarters of those who were openly transgender or perceived as transgender at some point between kindergarten and grade 12, experienced some form of mistreatment ranging from verbal harassment and stricter discipline to physical and sexual assault (Smith & Reidy, 2021) and seventeen percent faced such severe mistreatment that they left a K–12 school (James et al., 2016). These kinds of maltreatment at school have been correlated with higher rates of substance use (Coulter et al., 2019; Lowry et al., 2020; Reisner et al., 2015).

GM college students are more likely than their peers to have mental health challenges, with 4.3 times higher odds of experiencing depression, anxiety, eating disorders, nonsuicidal self-injury, suicidal ideation, or suicidal attempts (Lipson et al., 2019; Wyman Battalen et al., 2021). Transgender students have a 2.99 higher odds of past-year suicidal ideation than non-transgender students (Perez-Brumer et al., 2017). Forty percent of transgender adults reported a previous suicide attempt, and 34% of those respondents noted that their first attempt was at age 13 or younger. Thirty-nine percent reported the first suicide attempt between the ages of 14 and 17 (James et al., 2016).

The Healthy Outcomes from Positive Experiences (HOPE) framework extends insights drawn from the clear effects of adverse experiences on child development and has identified four key types of positive childhood experiences (PCEs) that function to create thriving, resilient children, even in the face of adversity (Sege, 2017). Adults who report higher numbers of PCEs are significantly less likely to report depression or poor mental health, (Bethell et al., 2019) and adolescents who had these experiences during childhood were less likely to have mental health problems as older teens (Guo et al. 2022) and adults.

These experiences cluster around the four building blocks of HOPE; relationships with adults and other children; safe, stable and equitable environments to live, learn and play; social/civic engagement, and opportunities for social/emotional development (Sege, 2017). This article explores the prevalence of protective factors, their relationship to these four building blocks, and their association with better mental health outcomes and lower rates of substance use among students. The study also explores the association between exposures to risk factors and substance use and other mental health problems. We were able to explore the durability of the relationships between exposures and outcomes prior to and during the pandemic.

Materials and Methods

Survey

The Dane County Youth Assessment (DCYA) is a web-based cross-sectional survey administered every three years to students in Dane County, Wisconsin. Dane County is the second largest county in Wisconsin with a population of 564,000. The population is majority White (85%) and 20% are age 18 or younger (United States Census Bureau, 2021). The Dane County Students Commission, United Way of Dane County, Public Health Madison & Dane County, the city of Madison, Wisconsin, K12 Associates Consulting of Middleton, WI, seventeen public school districts and one private high school collaborated to create this survey (Dane County Department of Human Services, 2021). A committee of educators, public health professionals, project funders, and parent representatives developed the survey questions. The survey consists of multiple choice questions on various protective and risk behaviors in regards to school, peer relations, family, and community. Developers extrapolated questions from the Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Surveillance System and other national surveys to allow for comparisons between national and Dane County students. Students in grades 7 to12 completed online surveys between January and April of 2018, and again between January and April of 2021.

Survey administration took place in classrooms, with designated time set for students to answer questions on a specialized survey link; the specialized link was deactivated following administration. Those who were unable to attend the designated survey time were offered a make-up schedule. Reading assistance was provided to students requiring this service by each participating school district. Student participation was voluntary and anonymous. Students were provided with instructions specifying that they could skip questions or opt-out of the survey at any point. No personal identifying information was collected as part of this survey, and student responses can and will not be connected to individual respondents at any time. Surveys were approved by each participating school district prior to administration, and followed Hatch Amendment protocols for human subjects under 18 (U.S. Office of Special Counsel). Populations or demographics reporting small numbers were grouped by district to maintain confidentiality. Legal guardians were given the opportunity to opt their child out of participating through a waiver letter sent to all parents and guardians 6–8 weeks prior to survey administration (Dane County Department of Human Services, 2021). This report only analyzed data from students in grades 9 to 12. The Tufts University School of Medicine Institutional Review Board granted this study exemption from review due to a determination that it was not classified as human studies research.

Gender identity

Gender identity was assessed with the following questions; “How do you describe your gender identity?” (Male, Female, Non-Binary, Gender Fluid, Other) and “Do you identify as transgender?” (Yes, No) Students who selected non-binary or gender fluid, or answered yes that they identify as transgender, were included in the GM group.

Exposures

All risk and protective factors were examined for both cisgender and GM students.

Protective factors items included:

  1. Environment: having a current stable financial status (based on family’s current situation), engaging in physical activity for 60 minutes or more three or more times per week,

  2. Relationships: connections to multiple adults outside the home, and

  3. Engagement: whether or not they felt connected to their school and/or community and, possibly engaging in physical activity for 60 minutes or more three or more times per week, if the respondent referred to team sports

Risk factors included experiencing bias or bullying in the past 12 months, frequency of experiences of peer victimization (i.e. being hit, picked on, made fun of, etc.) in the last 30 days, or having been either homeless or in foster care in their lifetime. We refer to protective and risk factors as “exposures.” Table 1 delineates survey items.

Table 1:

Analysis Question Text

Variable HOPE Building Block Question Response Options
Household Financial Status Environment How would you describe your family’s current financial situation? Not a problem, Tight but fine, Struggling with finances
Sense of School/Community Membership Agree or disagree with each of the following statements about your school.

  1. The rules and expectations are clearly explained.

  2. I feel close to people in my school.

  3. I feel safe at my school.

  4. Teachers and other adults treat students fairly.

  5. There are adults I can talk to at school if I have a problem.

  6. I feel like I belong at my school

 Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree
Environment Choose the option that best describes your neighborhood or community.

  1. I can ask my neighbors for help.

  2. If I had to move, I would miss my neighborhood.

  3. I feel safe in my neighborhood.

  4. My neighbors are friendly to me.

  5. I can count on the police if I need them.

  6. I help my neighbors.
Physical Activity Environment and Engagement During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? The physical activity could have happened a few times throughout the day at smaller amounts, adding up to 60 minutes as a total for the day. 0–7 days
Number of Caring Adults Relationships Not counting your parents, how many adults can you rely on if you have a problem and need help? No other adults, At least 1, At least 2, At least 3, 4+ Adults
Homelessness/Foster Care Exposure  RISK Factor Have you ever… Never; Yes, in the last 12 months; Yes, but not in the last 12 months

  • a) Run away from home for 1 or more nights?

  • b) Been homeless with your family?

  • c) Been homeless on your own?

  • d) Been in foster care?

  • e) Been kicked out of your house by your parents?
Experience of Bias-Based Bullying (BBB) RISK Factor In the past 12 months, how often have you been bullied, threatened or harassed… Never, Rarely, Sometimes, Often, Very Often

  • a) Through the internet or text message

  • b) By others thinking you’re gay, lesbian, bisexual, or transgender

  • c) About your race or ethnic background

  • d) About your immigration status

  • e) About your political views

  • f) About how you look
Experience of Peer Victimizationa RISK Factor How many times were you involved in any of these activities in the past 30 days? Never, 1 or 2 times, 3 or 4 times, 5 or more times

  • a) Someone made unwanted sexual comments to me.

  • b) I got hit and pushed by other students.

  • c) In a group I made fun of other students.

  • d) Other students picked on me.

  • e) I upset other students for the fun of it.

  • f) I started arguments or conflicts.

  • g) I spread rumors about other people.

  • h) I told someone to stop harassing another student.

  • i) Other students made fun of me.

  • g) I excluded other students from my group of friends.

  • k) Other students called me names.

  • l) I helped harass other students.
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This table depicts exact question text issued in the Dane County Youth Assessment survey in years 2018 and 2021. Questions reprinted and analyzed with permission of the Dane County Youth Commission, Madison, Wisconsin.15

a

Experience of Peer Victimization question text differed between 2018 and 2021 survey distribution. 2021 survey question text reads “How many times were you involved in any of these activities in the past 30 days?: (a) Someone made unwanted sexual comments to me; (b) I got hit and pushed by other students; (c) Other students picked on me; (d) I told someone to stop harassing another student; (e) Other students made fun of me; (f) Other students called me names.”

We calculated composite scores for peer victimization, sense of school and community membership, and bias-based bullying (BBB) based on prior data (Espelage D. L., 2001; Vigna, 2018, 2020). Total items answered for questions included in sense of school and community membership were scored so that a higher composite score indicated higher agreement with belonging. We calculated scores for BBB by scoring 0–4 for Never-Very Often. Higher composite scores therefore indicate a higher frequency of BBB (see Table 1). We calculated peer victimization scores by averaging experiences of victimization against experiences perpetrating victimization in order to create a composite score. Higher scores indicate more frequent experiences of victimization. We derived this score from a limited set of questions in 2021 relative to 2018 (See Table 1 footnote).

Notable outcomes were reports of depression and substance use, which were among the mental health conditions and health risk behaviors included in the survey.

Data analysis

We conducted separate analyses for the 2018 and 2021 surveys using SAS (SAS/STAT Software, 2022) and tabulated descriptive statistics on the samples’ demographic characteristics. We excluded respondents not reporting key demographic variables of grade, race, or GM status from subsequent analysis. Corresponding factors/outcomes in which responses were missing were also excluded from subsequent analysis. We used chi square tests for categorical variables, and t-tests for continuous variables to compare differences in the distribution of exposures between cisgender and GM students.

We initially used univariate logistic regression models to examine unadjusted associations between each of the demographic (grade [9, 10, 11, 12], race [white vs non-white], gender identity [cisgender/GM]) and exposure variables with the binary outcomes of interest (drinking, substance use, smoking, depression, suicidality, any mental health issues, use of mental health services). We used adjusted logistic regression models (for grade, race, and GM status) to test the associations between individual exposures and these outcomes. In models where GM status was significantly associated with the outcome, we added exploratory interaction terms to evaluate whether the association between the exposure of interest varied between those identifying as GM compared to cisgender students. As we aimed to identify possible exposures that may differ in their association with adverse outcomes for GM students compared to cisgender students, we retained interaction terms in the adjusted models with a liberal threshold for statistical significance (p<0.10). Otherwise, we used an alpha of 0.05 to define statistical significance for the association between exposures and outcomes. We calculated odds ratios and 95% confidence intervals for all associations.

Results

2018 yielded 16,288 completed surveys and 2021 yielded 10,792 completed surveys. Table 2 outlines response rates by grade, age, race, and gender identity. We excluded 538 (3.3%) and 111 (1.0%) participants due to missing demographic data (grade/race/gender) (Table 2).

Table 2:

Demographics of Survey Respondents

Variable Category 2018 Frequency (%) 2021 Frequency (%)
(N=16288) (N=10792)
Age 14 years old or younger 2597 (16.1) 1521 (14.1)
15 years old 4395 (27.2) 3017 (28.0)
16 years old 4126 (25.5) 2819 (26.2)
17 years old 3546 (21.9) 2440 (22.7)
18 years old or older 1513 (9.4) 973 (9.0)
Missing 111 22
Gender Minority Cisgender 15456 (96.5) 10228 (95.0)
Gender Minority 562 (3.5) 540 (5.0)
Missing 270 24
Grade 9th 4649 (29.0) 3050 (28.4)
10th 4256 (26.5) 2972 (27.6)
11th 3959 (24.7) 2604 (24.2)
12th 3183 (19.8) 2132 (19.8)
Missing 241 34
White 11417 (70.1) 8298 (77.0)
Race Non-White 4560 (28.0) 3413 (22.4)
Missing 311 81
Depression Yes 3819 (26) 3502 (32.5)
No 10832(74) 7072 (66.9)
Missing 1367 194
Substance Use  At least 1 substance 4311 (32) 3340 (31.8)
No substances 9219 (68) 7162 (68.2)
Missing 2488 266
Financial Status Good/Okay Yes 15095 (96.2) 9430 (97.6)
No 598 (3.8) 230 (2.4)
Missing 325 1108
Physical Activity 3+ days/week Yes 11555 (74.5) 7557 (70.8)
No 3947 (25.5) 3114 (29.2)
Missing 516 97
Two or More Caring Adults Yes 10863 (79.1) 8334 (79.7)
No 2868 (20.9) 2120 (20.3)
Missing 2287 314
Homelessness/Foster Care Exposure Yes 1807 (11.5) 761 (7.1)
No 13856 (88.5) 9950 (92.9)
Missing 355 57
Sense of School/Community Membership Score Mean (SD) 3.02 (0.52) 2.95 (0.48)
Missing 3062 720
Experience of Bias-Based Bullying Score Mean (SD) 0.23 (0.41) 0.25 (0.41)
Missing 2635 424
Experience of Peer Victimization Score Mean (SD) 0.25 (0.38) 0.13 (0.32)
Missing 2874 390
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SD stands for Standard Deviation from the mean where used.

There were significant differences in exposure to risk and protective factors between GM and cisgender students. GM students were significantly less likely to report exposure to any of the protective factors including good financial status, engaging in physical activity 3+ times per week, feeling a sense of school/community membership, or having two or more caring adults in their life (Tables 3, 4). Compared with cisgender students, GM students were significantly more likely to report risk factors including experience of BBB, experience of peer victimization, and experience with homelessness or being in foster care (Tables 3, 4).

Table 3:

Demographics of Survey Respondents, only Cisgender and Gender Minoritya

Variable Category 2018 Frequency (%)b 2021 Frequency (%)c
(N=16018) (N=10768)
Age 14 years old or younger 2563 (16.0) 1518 (14.1)
15 years old 4345 (27.2) 3013 (28.0)
16 years old 4072 (25.5) 2813 (26.2)
17 years old 3510 (22.0) 2436 (22.7)
18 years old or older 1495 (9.4) 972 (9.0)
Missing 33 16
Grade 9th 4596 (29.0) 3045 (28.4)
10th 4207 (26.5) 2965 (27.6)
11th 3912 (24.7) 2601 (24.2)
12th 3153 (19.9) 2130 (19.8)
Missing 150 27
Race White 11378 (71.0) 8290 (77.0)
Non-White 4515 (28.2) 2412 (22.4)
Missing 127 66
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a

This table above excludes records where gender minority variable is missing.

b

For 2018 data 538 are excluded due to any Missing in demographics variable (grade/race/gender for further analysis).

c

For 2021 data 111 are excluded due to any Missing in demographics variable (grade/race/gender for further analysis)

Table 4:

Factor Frequencies and Rate of Outcomes by Gender Identity: 2018 Data

Depression Substance Use
Variable Overall Freqency Frequency Cisgender (n=15456)a Frequency GM (n=562)a p-value aOR Overall p-value aOR Cisgender aOR GM aOR p aOR Overall p-value aOR Cisgender aOR GM aOR p
Protective Factors Financial Status Good/Okay 15095 (94.2) 14623 (96.5) 472 (88.6) <.0001 0.21 (0.17,0.25) <.0001 0.2 (0.17,0.24) 0.52 (0.25,1.08) 0.0142 0.44 (0.37, 0.54) <.0001 No Interaction
Physical Activity 3+ days/week 11555 (72.1) 11244 (75.1) 311 (59.6) <.0001 0.57 (0.52, 0.62) <.0001 0.56 (0.51,0.61) 0.81 (0.55,1.19) 0.0668 1.03 (0.94,1.12) 0.5302 1.00 (0.91,1.09) 1.85 (1.24,2.78) 0.0036
Sense of School/Community Membership (mean) 3.02 (0.52) 3.0 (0.5) 2.7 (0.6) <.0001 0.24 0.22,0.26) <.0001 0.23 (0.21,0.25) 0.47 (0.32,0.7) 0.0008 0.44 (0.41,0.48) <.0001 0.44 (0.40, 0.47) 0.67 (0.45,0.98) 0.0362
Two or more Caring Adults 10863 (79.1) 10596 (79.7) 267 (61.5) <.0001 0.40 (0.37, 0.44) <.0001 No Interaction 0.69 (0.59,0.71) <.0001 No Interaction
Risk Factors Experience of Bias-Based Bullying (mean) 0.23 (0.41) 0.2 (0.4) 0.6 (0.7) <.0001 4.53 (4.07,5.04) <.0001 4.81 (4.31,5.37) 2.03 (1.43,2.88) <.0001 2.62 (2.37,2.89) <.0001 No Interaction
Experience of Peer Victimization (mean) 0.25 (0.38) 0.2 (0.4) 0.5 (0.6) <.0001 3.75 (3.36,4.18) <.0001 3.87 (3.46,4.32) 2.01 (1.3,3.1) 0.0042 3.91 (3.5,4.38) <.0001 No Interaction
Homelessness/Foster Care Exposure 1807 (11.3) 1634 (10.8) 173 (32.8) <.0001 4.19 (3.75,4.68) <.0001 4.4 (3.93,4.93) 1.79 (1.15,2.78) 0.0001 4.01 (3.57,4.51) <.0001 3.91 (3.46, 4.41) 5.9 (3.7,9.42) 0.0936
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This table shows frequencies and odds ratios for both outcomes of interest among the study population, cisgender, and gender minority students. GM stands for gender minority where used. OR refers to the odds ratio for factor interactions, while aOR refers to adjusted odds ratio for said interaction. For each protective or risk factor row, frequencies of reporting the protective/risk factor are shown overall and for each gender group; p-value refers to significance in the difference between Cisgender and GM reporting of the factor. Columns 7–11 refer to odds ratios of reporting the row factor as well as depression among the population and gender groups; aOR p refers to the significance of difference in the odds ratios between cisgender and gender minority students for this outcome when reporting the row factor. Columns 12–16 refer to odds ratios of reporting the row factor as well as substance use among the population and gender groups; aOR p refers to the significance of difference in the odds ratios between cisgender and gender minority students for this outcome when reporting the row factor. “No Interaction” indicates that there was no significant difference between gender groups in reporting the row factor and outcome; these factors did not show different risk or protective effects among cisgender vs. gender minority respondents.

a

Total n includes missing values as represented in Table 2; missing values for each row factor are removed from frequencies and percentages.

Protective factor associations with depression

GM students were more likely to report depression compared to their cisgender peers. This was seen in both 2018 (297/562 (62.8%) vs. 3522/15456 (24.8%); p<0.0001) and 2021 (347/540 (65.2%) vs. 3155/10288 (31.4%); p<0.0001). All four protective factors were significantly associated with reduced reporting of depressive symptoms in the study population as a whole in both surveys (Tables 3, 4). The association between physical activity and depression did not reach statistical significance for GM students. Additionally, compared with cisgender students, physical activity 3+ times per week had lower protective effects against depression in GM students for both the surveys. Scores of sense of school and community membership showed a similar pattern, with cisgender students showing greater reduction in depression when reporting high sense of belonging in the school and community when compared to GM students (Tables 3, 4).

Protective factor associations with substance use

Substance use was also more common among GM students in 2018 (GM 189/562 (33.6%) vs. cisgender 4122/15456 (26.7%); p<.0001), while no significant difference was reported between cisgender and GM reports of substance use in 2021 (GM 181/549 (34.2%) vs. cisgender 3159/10288 (31.7%); p=0.2337). Three of the four protective factors (good financial status, sense of school/community membership, two or more caring adults) were significantly associated with reduced reported substance use in the population as a whole in both surveys. Physical activity 3+ times per week was not significantly associated with reduced substance use in either year for either group of students.

Having good financial status was significantly less protective for GM students when compared to cisgender peers in 2021 but not in 2018, while having a sense of school/community membership was significantly less protective for GM students compared to cisgender peers in 2018 but not in 2021 (Tables 3, 4).

Risk factors for depression

All three risk factors, experience of BBB, experience of peer victimization and homelessness/foster care exposure, were significantly associated with increased reported depression in the study population for both surveys (Tables 3, 4). Some risk factors were more strongly associated with depression in GM students in one survey, and did not show association in the other, including all three risk factors in 2018 and BBB and homelessness/foster care exposure in 2021 (Tables 3, 4).

Risk factors for substance use

All three risk factors were significantly associated with substance use in the overall population during both survey years. There were no consistent differences in the associations between any of the risk factors and reported substance use across both survey administrations. Two risk factors were significantly more strongly associated with reporting substance use among GM students; experiencing homelessness (2018 only), and experiencing peer victimization (2021 only). Experience of BBB, which includes bullying concerning race, sexuality, or other elements of personal identity, did not show a significant association with substance use and gender identity in either data set (Tables 3, 4).

Discussion

Adolescence is a dynamic developmental stage. Although gender minority youth have higher rates of depression and substance use (Connolly et al., 2016; Eisenberg et al., 2017; Mereish, 2019) than their peers, we found that the experience of protective factors (good financial status, sense of school/community membership, two or more caring adults) is associated with lower rates of both reported depression and substance use for GM adolescents. Recent research on the importance of protective factors and key PCEs have shed light on the power and importance of these factors in improving health outcomes (Bethell et al., 2019; Crandall et al., 2019; Crouch et al., 2021; Daines et al., 2021; Sege, 2017; Wang et al., 2021). A recently published systematic review demonstrated the important role that schools play in fostering positive relationships and a sense of belonging among LGBTQ+ students as an important and effective way to reduce suicidal thoughts and behavior in this population (Marraccini et al., 2022). Our study reaffirms the importance of key protective factors such as having a sense of school/community belonging and two or more caring adults, in reducing rates of depression and substance use in both cisgender and GM students.

In this study we found that in the survey population as a whole, all protective factors were associated with reduced reported depression and substance use and all risk factors were associated with increased reporting of depression and substance use. GM students were consistently less likely to report protective factor exposures and more likely to report risk factor exposures. Additionally, most of the protective factors (except physical activity) appeared to be less protective against depression. Several protective factors (financial status, sense of school/community membership) were less protective against substance use among GM students compared to cisgender students.

Previous research demonstrated that significant health disparities exist between GM adolescents and their cisgender peers (Eisenberg et al., 2017; Kann et al., 2018; Kann et al., 2016; Marshal et al., 2008; Perez-Brumer et al., 2017). This study demonstrates the importance of protective factors in protecting against depression and substance use. Although helpful, many protective factors may be less beneficial among GM compared to cisgender students. In this study, GM students were less likely to experience key protective factors than their cisgender peers.

Our study demonstrated that GM students are more likely to be exposed to risk factors and more likely to report exposure to BBB in both surveys compared with cisgender adolescents. The experience of BBB was associated with substance use in both cisgender and GM students, as all students who were subjected to BBB showed similarly elevated risk for substance use regardless of gender identity. GM students’ excess exposure to BBB disrupts their access to the HOPE building block of having a safe, stable and equitable environment for living and learning.

Previous research has examined specific categories of PCEs that are needed for healthy child development, (Bethell et al., 2019) including the four building blocks of HOPE (Sege, 2017). These results show that GM students have reduced access to these building blocks. GM students increased exposure to risk factors may in fact block access to key protective factors, for example bias based bullying may block access to a safe school environment. These differences in access to these building blocks may contribute to higher rates of poor health outcomes for GM students. The results of this study have implications for increasing access to building blocks for GM students, as the impact of such positive experiences is strong within this group. Policies limiting transgender youth from sports participation, making them feel less comfortable at school, would be expected to harm these vulnerable children by denying access to the engagement building block. This could have a detrimental effect on their sense of belonging within their school or community. GM youth are at risk for depression and substance abuse; inclusive policies that increase access to protective factors would lessen these risks. Further research is needed to determine why GM students benefit less from some protective factors so this disparity can be addressed.

Limitations

Study limitations include self-reported data which can introduce bias such as recall bias, selection bias, and social desirability bias, although the direction and magnitude impact of possible biases are unknown. Our study sample consists of in-school adolescents in one county in Wisconsin, therefore limiting generalizability. This is cross-sectional data not including information regarding the timing of risk and protective factors relative to the outcomes of interest. Additionally, the relatively high numbers of missing data may also lead to biased results if the missing results would have varied between the two groups.

Minor differences in the survey questions and methodology between the 2018 and 2021 surveys make direct comparisons less reliable (See footnote Table 1). In addition, the 2021 survey had fewer student respondents than the 2018 survey (16,288 vs. 10,792); this factor also suggested the inadvisability of developing detailed statistical comparisons between the two survey administrations. We attempted to disaggregate the data by both grade level and original 8-level racial / ethnic identity, and with a 5-level racial / ethnic identity grouping. However these groupings lead to zero/small number cells for the outcomes of interest, making reliable statistical testing impossible.

Future research, with larger sample sizes, could be directed to determine how grade level and racial/ethnic identity intersect with the overall results reported here.

Conclusion

This study provides a critical look into the effects of key protective factors for depression and substance use among cisgender and GM students. The limited access by GM students to these important protective factors and their greater exposure to risk factors is of concern. The apparent increased vulnerability of GM students to risk factors and the more limited effect of some protective factors is an interesting finding and more research is needed to further understand this phenomenon and how it may inform outreach to this vulnerable population. Future studies that focus on improving access to PCEs may reduce the risk of depression and substance use among GM students.

Table 5:

Factor Frequencies and Rate of Outcomes by Gender Identity: 2021 Data

Depression Substance Use
Variable Overall Frequency Frequency Cisgender (n=10228)a Frequency GM (n=540)a p-value aOR Overall p-value aOR Cisgender aOR GM aOR p aOR Overall p-value aOR Cisgender aOR GM aOR p
Protective Factors Financial Status Good/Okay 9430 (97.6) 8993 (97.8) 437 (95.0) 0.0002 0.24 (0.18, 0.33) <.0001 No Interaction 0.2906 0.31 (0.23, 0.41) <.0001 0.28 (0.21,0.38) 0.78(0.32,1.9) 0.0310
Physical Activity 3+ days/week 7557 (70.8) 7305 (72.1) 252 (47.0) <.0001 0.62 (0.57, 0.68) <.0001 0.61 (0.55,0.67) 0.91 (0.63,1.3) 0.0354 0.96 (0.88, 1.06) 0.4325 0.94 (0.85,1.04) 1.36 (0.94,1.97) 0.0613
Sense of School/Community Membership (mean) 2.95 (0.48) 3.0 (0.5) 2.6 (0.5) <.0001 0.23 (0.2, 0.25) <.0001 0.22(0.2,0.24) 0.35(0.23,0.52) 0.0273 0.50 (0.45, 0.54) <.0001 No Interaction 0.8072
Two or more Caring Adults 8334 (79.7) 7994 (80.6) 340 (64.2) <.0001 0.51 (0.46, 0.56) <.0001 0.49(0.44,0.54) 0.87(0.59,1.28) 0.0043 0.85 (0.77, 0.95) 0.0029 No Interaction 0.3090
Risk Factors Experience of Bias-Based Bullying (mean) 0.25 (0.41) 0.2 (0.4) 0.5 (0.6) <.0001 4.82 (4.28, 5.41) <.0001 4.96(4.39,5.6) 3.38(2.25,5.08) 0.0777 3.03 (2.72, 3.37) <.0001 No Interaction 0.1207
Experience of Peer Victimization (mean)a 0.13 (0.32) 0.1 (0.3) 0.3 (0.5) <.0001 4.55 (3.89, 5.33) <.0001 No Interaction 0.2235 2.97 (2.58, 3.42) <.0001 3.14(2.7,3.65) 1.95(1.31,2.91) 0.0296
Homelessness/Foster Care Exposure 761 (7.1) 676 (6.6) 85 (15.8) <.0001 4.32 (3.67, 5.08) <.0001 4.53(3.83,5.36) 2.18(1.21,3.9) 0.0179 4.56 (3.87, 5.37) <.0001 No Interaction 0.4811
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This table shows frequencies and odds ratios for both outcomes of interest among the study population, cisgender, and gender minority students. GM stands for gender minority where used. OR refers to the odds ratio for factor interactions, while aOR refers to adjusted odds ratio for said interaction. For each protective or risk factor row, frequencies of reporting the protective/risk factor are shown overall and for each gender group; p-value refers to significance in the difference between Cisgender and GM reporting of said factor. Columns 7–11 refer to odds ratios of reporting the row factor as well as depression among the population and gender groups; aOR p refers to the significance of difference in the odds ratios between cisgender and gender minority students for this outcome when reporting the row factor. Columns 12–16 refer to odds ratios of reporting the row factor as well as substance use among the population and gender groups; aOR p refers to the significance of difference in the odds ratios between cisgender and gender minority students for this outcome when reporting the row factor. “No Interaction” indicates that there was no significant difference between gender groups in reporting the row factor and outcome; these factors did not show different risk or protective effects among cisgender vs. gender minority respondents.

a

Total n includes missing values as represented in Table 2; missing values for each row factor are removed from frequencies and percentages.

Author Acknowledgements:

The authors would like to thank Amanda Winn, MSW and Laura Grubb, MD, MPH for their assistance in preparing this manuscript.

Funding source:

This work was supported by the National Center for Advancing Translational Sciences, National Institutes of Health. Award number UL1TR002544.

Footnotes

Declaration of Interest Statement: The authors report there are no competing interests to declare.

Data source: 2021 Dane County Youth Assessment, Dane County Youth Commission, Madison, Wisconsin. https://www.dcdhs.com/About-Us/Commissions-Boards-and-Committees/Youth-Commission/Youth-Assessment

Contributor Information

Dina Burstein, Center for Community-Engaged Medicine, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Boston, MA 02111 USA.

Eliza Loren Purdue, Center for Community-Engaged Medicine, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA 02111 USA.

Jennifer A. Jones, Prevent Child Abuse America, Chicago, Illinois, USA.

Janis L. Breeze, Clinical and Translational Science Institute, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA.

Ye Chen, Clinical and Translational Science Institute, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA.

Robert Sege, Center for Community-Engaged Medicine, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA 02111 USA.

References

  1. Allen JP, Loeb EL, Narr RK, & Costello MA (2021). Different factors predict adolescent substance use versus adult substance abuse: Lessons from a social-developmental approach. Dev Psychopathol, 33(3), 792–802. 10.1017/S095457942000005X [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bethell C, Jones J, Gombojav N, Linkenbach J, & Sege R (2019). Positive Childhood Experiences and Adult Mental and Relational Health in a Statewide Sample: Associations Across Adverse Childhood Experiences Levels. JAMA Pediatr, e193007. 10.1001/jamapediatrics.2019.3007 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Connolly MD, Zervos MJ, Barone CJ 2nd, Johnson CC, & Joseph CL (2016). The Mental Health of Transgender Youth: Advances in Understanding. J Adolesc Health, 59(5), 489–495. 10.1016/j.jadohealth.2016.06.012 [DOI] [PubMed] [Google Scholar]
  4. Coulter RWS, Egan JE, Kinsky S, Friedman MR, Eckstrand KL, Frankeberger J, Folb BL, Mair C, Markovic N, Silvestre A, Stall R, & Miller E (2019). Mental Health, Drug, and Violence Interventions for Sexual/Gender Minorities: A Systematic Review. Pediatrics, 144(3). 10.1542/peds.2018-3367 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Crandall A, Miller JR, Cheung A, Novilla LK, Glade R, Novilla MLB, Magnusson BM, Leavitt BL, Barnes MD, & Hanson CL (2019). ACEs and counter-ACEs: How positive and negative childhood experiences influence adult health. Child Abuse Negl, 96, 104089. 10.1016/j.chiabu.2019.104089 [DOI] [PubMed] [Google Scholar]
  6. Crouch E, Radcliff E, Merrell MA, Hung P, & Bennett KJ (2021). Positive Childhood Experiences Promote School Success. Matern Child Health J, 25(10), 1646–1654. 10.1007/s10995-021-03206-3 [DOI] [PubMed] [Google Scholar]
  7. Daines CL, Hansen D, Novilla MLB, & Crandall A (2021). Effects of positive and negative childhood experiences on adult family health. BMC Public Health, 21(1), 651. 10.1186/s12889-021-10732-w [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Dane County Department of Human Services. (2021). Youth Assessment. Retrieved September 7, 2021 from https://www.dcdhs.com/About-Us/Commissions-Boards-and-Committees/Youth-Commission/Youth-Assessment
  9. Eisenberg ME, Gower AL, McMorris BJ, Rider GN, Shea G, & Coleman E (2017). Risk and Protective Factors in the Lives of Transgender/Gender Nonconforming Adolescents. J Adolesc Health, 61(4), 521–526. 10.1016/j.jadohealth.2017.04.014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Espelage DL, K. HM (2001). Bullying and Victimization During Early Adolescence. Journal of Emotional Abuse, 2(2–3), 123–142. [Google Scholar]
  11. Gray KM, & Squeglia LM (2018). Research Review: What have we learned about adolescent substance use? J Child Psychol Psychiatry, 59(6), 618–627. 10.1111/jcpp.12783 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Guo S, O’Connor M, Mensah F, Olsson CA, Goldfeld S, Lacey RE, Slopen N, Thurber KA, Priest N. Measuring positive childhood experiences: testing the structural and predictive validity of the health outcomes from positive experiences (HOPE) framework. Academic Pediatrics. 2022. Aug 1;22(6):942–51. [DOI] [PubMed] [Google Scholar]
  13. James SE, Herman JL, Rankin S, Keisling M, Mottet L Anafi M. (2016). Executive Summary of the Report of the 2015 U.S. Transgender Survey.
  14. Kann L, McManus T, Harris WA, Shanklin SL, Flint KH, Queen B, Lowry R, Chyen D, Whittle L, Thornton J, Lim C, Bradford D, Yamakawa Y, Leon M, Brener N, & Ethier KA (2018). Youth Risk Behavior Surveillance - United States, 2017. MMWR Surveill Summ, 67(8), 1–114. 10.15585/mmwr.ss6708a1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Kann L, Olsen EO, McManus T, Harris WA, Shanklin SL, Flint KH, Queen B, Lowry R, Chyen D, Whittle L, Thornton J, Lim C, Yamakawa Y, Brener N, & Zaza S (2016). Sexual Identity, Sex of Sexual Contacts, and Health-Related Behaviors Among Students in Grades 9–12 - United States and Selected Sites, 2015. MMWR Surveill Summ, 65(9), 1–202. 10.15585/mmwr.ss6509a1 [DOI] [PubMed] [Google Scholar]
  16. Kar SK, Choudhury A, & Singh AP (2015). Understanding normal development of adolescent sexuality: A bumpy ride. J Hum Reprod Sci, 8(2), 70–74. 10.4103/0974-1208.158594 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Lipson SK, Raifman J, Abelson S, & Reisner SL (2019). Gender Minority Mental Health in the U.S.: Results of a National Survey on College Campuses. Am J Prev Med, 57(3), 293–301. 10.1016/j.amepre.2019.04.025 [DOI] [PubMed] [Google Scholar]
  18. Lowry R, Johns MM, & Robin LE (2020). Violence Victimization, Substance Use Disparities, and Gender-Nonconforming Youth. Am J Prev Med, 58(5), e159–e169. 10.1016/j.amepre.2019.12.021 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Marraccini ME, Ingram KM, Naser SC, Grapin SL, Toole EN, O’Neill JC, Chin AJ, Martinez RR Jr., & Griffin D (2022). The roles of school in supporting LGBTQ+ youth: A systematic review and ecological framework for understanding risk for suicide-related thoughts and behaviors. J Sch Psychol, 91, 27–49. 10.1016/j.jsp.2021.11.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Marshal MP, Friedman MS, Stall R, King KM, Miles J, Gold MA, Bukstein OG, & Morse JQ (2008). Sexual orientation and adolescent substance use: a meta-analysis and methodological review. Addiction, 103(4), 546–556. 10.1111/j.1360-0443.2008.02149.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Mereish EH (2019). Substance use and misuse among sexual and gender minority youth. Curr Opin Psychol, 30, 123–127. 10.1016/j.copsyc.2019.05.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Mueller MAE, Flouri E, & Kokosi T (2019). The role of the physical environment in adolescent mental health. Health Place, 58, 102153. 10.1016/j.healthplace.2019.102153 [DOI] [PubMed] [Google Scholar]
  23. Newcomb ME, Hill R, Buehler K, Ryan DT, Whitton SW, & Mustanski B (2020). High Burden of Mental Health Problems, Substance Use, Violence, and Related Psychosocial Factors in Transgender, Non-Binary, and Gender Diverse Youth and Young Adults. Arch Sex Behav, 49(2), 645–659. 10.1007/s10508-019-01533-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Perez-Brumer A, Day JK, Russell ST, & Hatzenbuehler ML (2017). Prevalence and Correlates of Suicidal Ideation Among Transgender Youth in California: Findings From a Representative, Population-Based Sample of High School Students. J Am Acad Child Adolesc Psychiatry, 56(9), 739–746. 10.1016/j.jaac.2017.06.010 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Reisner SL, Greytak EA, Parsons JT, & Ybarra ML (2015). Gender minority social stress in adolescence: disparities in adolescent bullying and substance use by gender identity. J Sex Res, 52(3), 243–256. 10.1080/00224499.2014.886321 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Rusby JC, Light JM, Crowley R, & Westling E (2018). Influence of parent-youth relationship, parental monitoring, and parent substance use on adolescent substance use onset. J Fam Psychol, 32(3), 310–320. 10.1037/fam0000350 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Russell ST, & Fish JN (2016). Mental Health in Lesbian, Gay, Bisexual, and Transgender (LGBT) Youth. Annu Rev Clin Psychol, 12, 465–487. 10.1146/annurev-clinpsy-021815-093153 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. SAS/STAT Software. (2022). Retrieved March 27, 2022 from https://www.sas.com/en_us/software/stat.html
  29. Sege R, Harper Brown C,. (2017). Responding to ACEs With HOPE: Health Outcomes From Positive Experiences. Academic Pediatrics, 17, S79–S85. [DOI] [PubMed] [Google Scholar]
  30. Smith AU, & Reidy D (2021). Bullying and suicide risk among sexual minority youth in the United States. Prev Med, 153, 106728. 10.1016/j.ypmed.2021.106728 [DOI] [PubMed] [Google Scholar]
  31. U.S. Office of Special Counsel. Hatch Act Overview. Retrieved June 30, 2022 from https://osc.gov/Services/Pages/HatchAct.aspx
  32. United States Census Bureau. (2021). Quick Facts, Dane County, Wisconsin. Retrieved June 2, 2022 from https://www.census.gov/quickfacts/danecountywisconsin
  33. Vigna AJ, Poehlmann-Tynan J & Koenig BW. (2018). Does self-compassion covary with minority stress? Examining group differences at the intersection of marginalized identities. Self and Identity, 17(6), 687–709. [Google Scholar]
  34. Vigna AJ, Poehlmann-Tynan J & Koenig BW. (2020). Is Self-Compassion Protective Among Sexual- and Gender-Minority Adolescents Across Racial Groups? Mindfulness, 11, 800–815. [Google Scholar]
  35. Wang D, Jiang Q, Yang Z, & Choi JK (2021). The longitudinal influences of adverse childhood experiences and positive childhood experiences at family, school, and neighborhood on adolescent depression and anxiety. J Affect Disord, 292, 542–551. 10.1016/j.jad.2021.05.108 [DOI] [PubMed] [Google Scholar]
  36. Wyman Battalen A, Mereish E, Putney J, Sellers CM, Gushwa M, & McManama O’Brien KH (2021). Associations of Discrimination, Suicide Ideation Severity and Attempts, and Depressive Symptoms Among Sexual and Gender Minority Youth. Crisis, 42(4), 301–308. 10.1027/0227-5910/a000718 [DOI] [PubMed] [Google Scholar]
  37. Yoon S, Kobulsky JM, Yoon D, & Kim W (2017). Developmental Pathways from Child Maltreatment to Adolescent Substance Use: The Roles of Posttraumatic Stress Symptoms and Mother-Child Relationships. Child Youth Serv Rev, 82, 271–279. 10.1016/j.childyouth.2017.09.035 [DOI] [PMC free article] [PubMed] [Google Scholar]

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