Abstract
Objectives. To provide population-representative estimates of US high school students’ exposure to adverse childhood experiences (ACEs), separately by sexual orientation, gender identity, and 3 demographic moderators: sex assigned at birth, race/ethnicity, and age.
Methods. Using data from the 2023 US National Youth Risk Behavior Survey (n = 12 131), this cross-sectional study calculated descriptive statistics, estimated multivariable regressions, and screened for mischievous respondents.
Results. Lesbian, gay, bisexual, transgender, and questioning (LGBTQ+) students reported elevated exposure to 8 separate ACEs, with a cumulative ACE score of 3.0 (95% confidence interval [CI] = 2.9, 3.1), compared with 1.8 (95% CI = 1.7, 1.9) among cisgender-heterosexual (cishet) students. This pattern held across all demographic subgroups and could not be explained by mischievous responders. Nearly half (46.1%; 95% CI = 39.7, 52.5) of all gender minorities reported 4 or more ACEs, compared with 34.5% (95% CI = 30.9, 38.0) of cisgender sexual minorities and 15.4% (95% CI = 14.2, 16.7) of cishet students.
Conclusions. The first national ACE prevalence data for US high school students show that LGBTQ+ youths—particularly transgender youths—face far greater levels of abuse, neglect, and other adversities than cishet youths. (Am J Public Health. 2025;115(7):1137–1145. https://doi.org/10.2105/AJPH.2025.308094)
Adverse childhood experiences (ACEs) are potentially traumatic events or conditions occurring before adulthood, such as abuse (physical, emotional, or sexual), neglect, and the experience of household challenges, such as intimate partner violence or parental incarceration. Although experiencing any single ACE can be detrimental, the negative effects of ACEs rise sharply as children’s total number of ACEs increases. A large body of research demonstrates a graded, dose–response relationship between cumulative ACE counts and increasingly negative health outcomes across the lifespan,1–3 including early mortality.4 The magnitude of these effects is often quite large. For instance, a 2016 meta-analysis estimated that, compared with those with no ACE exposure, adults who had experienced 4 or more ACEs had 2.3 times greater odds of being diagnosed with cancer, 10.2 times greater odds of developing a substance use disorder, and 30.1 times greater odds of attempting suicide.2 Research suggests that these negative effects result not only from maladaptive coping behaviors, but also from more fundamental changes in the nervous, endocrine, and immune systems triggered by chronic, toxic stress.5,6
Although all children may be exposed to ACEs, the burden of ACE exposure is unequally distributed. Recent Centers for Disease Control and Prevention (CDC) estimates suggest that about 17% of American adults have experienced 4 or more ACEs, with higher levels of exposure among females (19%), lower-income households (24%), and certain minoritized groups, such as American Indians and Alaska Natives (32%).7 Given ACEs’ wide-ranging consequences as well as their unequal distribution, there is growing interest in preventing ACEs as a way to target population health disparities.8,9
One group that has attracted particular concern with respect to ACEs exposure is lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) youths. Research using in-depth interviews,10 community-based surveys,11 and online nonprobability samples12,13 consistently finds that LGBTQ+ individuals report having experienced high levels of ACE exposure. For instance, in a large nonprobability sample of LGBTQ+ adolescents, 41% of all respondents reported experiencing 4 or more ACEs.13
Although studies like these play a vital role in illustrating the impact of ACEs for many LGBTQ+ young people, they cannot establish the full prevalence of ACE exposure within the population of LGBTQ+ youths at large. Population-representative research on ACE exposure among US LGBTQ+ individuals has primarily analyzed retrospective reports from LGBTQ+ adults,14–20 whose experiences with families of origin may have been very different from those faced by LGBTQ+ youths today. When population-based studies have examined direct reports from LGBTQ+ youths themselves, they have been limited to individual states.21,22 Moreover, much of the existing population-based research has been unable to specifically identify gender minorities17–21 or has only analyzed them as part of a broader LGBTQ+ group.15
For all of these reasons, research is needed to document the extent of ACE exposure among contemporary LGBTQ+ youths. Drawing on a nationally representative survey of US high school students, the current study aimed to provide new population estimates of ACE exposure by sexual orientation and gender identity as well as 3 potentially important demographic moderators: sex assigned at birth, race/ethnicity, and age.
METHODS
The current cross-sectional study took advantage of the important new possibilities created by the 2023 National Youth Risk Behavior Survey (YRBS). A biennial system of surveys sponsored by the CDC, the YRBS has tracked the health behaviors and experiences of US high school students since 1991. Employing a 3-stage cluster sampling design, the National YRBS is designed to generate a representative sample of students in grades 9 through 12 enrolled in public and private schools in all 50 states and the District of Columbia.23 The 2023 National YRBS consisted of 107 questions and was completed anonymously by students on provided tablet devices in the spring of 2023.23
For the purposes of examining LGBTQ+ students’ exposure to ACEs, the 2023 National YRBS marks a critical opportunity in 2 important regards. First, the 2023 survey introduced a new ACEs module designed to provide the first national prevalence estimates of self-reported ACEs among US high school students.23 Second, beyond these historic data on ACEs, 2023 was also the first year that the National YRBS assessed gender identity, generating the first nationally representative sample of transgender high school students in the United States.23 Together, these 2 new sets of items offer a unique opportunity to document ACE exposure among contemporary LGBTQ+ youths.
Measures
Adverse childhood experiences
This study analyzed responses to a set of 8 questions assessing lifetime exposure to ACEs. Designed to measure the same domains as the original ACEs study,1 the 2023 National YRBS ACEs module included 3 questions on abuse (physical, emotional, and sexual) by parents or other adults, 1 question on neglect (the absence of an adult working to meet the child’s basic needs), and 4 questions on household challenges (intimate partner violence, caregiver substance abuse, caregiver mental health challenges, and caregiver incarceration or detention). Physical abuse was assessed as whether “a parent or other adult in your home hit, beat, kicked, or physically hurt you in any way,” emotional abuse as whether “a parent or other adult in your home insulted you or put you down,” and sexual abuse as whether “an adult or person at least 5 years older than you made you do sexual things that you did not want to do.” Complete question wordings for all ACE items are provided in Appendix Table A (available as a supplement to the online version of this article at http://www.ajph.org). Notably, the YRBS did not assess 2 additional ACEs commonly included in ACE scales—parental separation or divorce and emotional neglect—nor did it assess any of the expanded ACE items recently designed to capture childhood adversities rooted in structural racism24,25 and cisheterosexism.26,27
Four of the ACE questions assessed the frequency of exposure and 4 only offered yes/no response options. To maintain consistency with prior ACE research, I dichotomized all items into binary indicators of any exposure or none. In addition to analyzing each exposure separately, I calculated students’ cumulative ACE scores and summarized them using the established cutoffs in this literature: zero, 1, 2 to 3, and 4 or more.
Sexual orientation and gender identity
I identified LGBTQ+ students using 2 separate survey items assessing sexual orientation and gender identity. For sexual orientation, students were asked, “Which of the following best describes you?” and provided with the following response options: “heterosexual (straight); gay or lesbian; bisexual; I describe my sexual identity some other way; I am not sure about my sexual identity (questioning).” For gender identity, students were given a definition of the word transgender and asked, “Are you transgender?” with the following response options: “no, I am not transgender; yes, I am transgender; I am not sure if I am transgender.” Both items also included the response option, “I do not know what this question is asking.”
The current study’s primary comparisons were between cisgender heterosexual (cishet) students—those who selected “heterosexual (straight)” and “no, I am not transgender”—and LGBTQ+ students—those who selected any other combination of sexual orientation and gender identity options, excluding those who selected “I do not know what this question is asking.” For space, results for students who answered “I do not know what this question is asking” are presented in the Appendix.
In addition to examining LGBTQ+ students overall, this study also documented the distinct experiences of cisgender sexual minorities and transgender or gender questioning students of all sexual identities. As shown in the Appendix, students who answered “Yes, I am transgender” and students who answered “I am not sure if I am transgender” reported ACE exposures that were statistically indistinguishable from one another; therefore, to maximize sample sizes and simplify the presentation of results, this study combined them into a single gender minority group. By separately analyzing cisgender sexual minorities and gender minorities in this way, this study followed the approach taken in prior research.11,12,14,22
Demographic controls and moderators
This study’s regression analyses control for 3 demographic characteristics of students: their sex assigned at birth, race/ethnicity, and age. To avoid sparse cell counts, I operationalized age in 3 categories—12 through 14, 15 and 16, and 17 years and older—and race/ethnicity in 6 categories—White (non-Hispanic), Black or African American, Asian and Pacific Islander, Hispanic or Latino, American Indian or Alaska Native, and Multiracial. Sex was assessed with the item, “What is your sex? Female; Male.” Although this item is imprecise in its wording, I interpret it as a measure of sex assigned at birth. After primary analyses that control for student demographics, this study also tested whether LGBTQ+ students’ ACE exposure varies across demographic groups, interacting LGBTQ+ identification and each demographic characteristic.
Statistical Analysis
Of the 20 103 students who participated in the 2023 National YRBS, 2166 did not answer the sexual orientation or gender identity items. Excluding these observations as well as those who didn’t report their age, race/ethnicity, or sex (n = 280) yields an initial analytic sample of 17 566 students. Within this sample, 69% (n = 12 131) provided complete responses for all ACE items. This degree of missingness on ACE questions is consistent with that found in nonprobability samples of LGBTQ+ adolescents12 and is only somewhat higher than that found among representative surveys of US adults.15
Analyzing the 12 131 students who provided complete data, this study reported descriptive statistics, calculated adjusted risk ratios using log-binomial regressions, and calculated adjusted ACE scores using Poisson regressions. To account for the multiple outcomes and comparison groups being analyzed in these regressions, a Bonferroni correction was applied and a new statistical significance cutoff of P < .001 was set. All results were calculated using CDC-provided weights to account for the YRBS’s complex sampling design and adjusted for school and student nonresponse.23
To adjust for potential mischievous respondents in the data,28–30 this study adopted Cimpian, Timmer, and Kim’s screening and reweighting approach.30 This approach, described more fully in the Appendix, trains a boosted logistic regression to predict students’ likelihood of mischievously identifying as LGBTQ+ based on their responses to 6 screener items. Unlike earlier approaches, which removed possible mischievous responders above a given threshold,28,29 this approach retains all observations but reweights LGBTQ+ students’ responses by their inverse probability of mischievous response.30 Raw results, unadjusted for mischievous response, are substantively similar and presented in the Appendix.
RESULTS
Table 1 reports the demographic characteristics of the sample. Overall, 24.2% (unweighted n = 2926) of students identified as LGBTQ+, with 19.3% (n = 2305) identifying as cisgender sexual minorities and 4.9% (n = 621) identifying as transgender or gender questioning. When demographic characteristics of LGBTQ+ students and cishet students were compared, the most pronounced difference was in sex assigned at birth. Consistent with prior years of the YRBS,31 LGBTQ+ identification was more common among those who reported that their sex was female. In an overall sample in which 47.7% of students reported being female, female students constituted 73.9% of the LGBTQ+ sample but only 39.7% of the cishet sample. These and other demographic differences across groups illustrate the potential importance of adjusting for demographic characteristics when estimating LGBTQ+ and cishet students’ patterns of ACE exposure.
TABLE 1—
Demographic Characteristics of the Analytic Sample: United States, National Youth Risk Behavior Survey, 2023
| Overall Sample, No. (%) |
Cisgender Heterosexual, No. (%) |
LGBTQ+, No. (%) |
Cisgender Sexual Minority, No. (%) |
Transgender and Gender Questioning, No. (%) |
|
| Age, y | |||||
| 12–14 | 1 461 (12.7) | 1058 (12.6) | 360 (13.0) | 287 (13.4) | 73 (11.5) |
| 15–16 | 6 391 (50.4) | 4664 (50.6) | 1 561 (49.7) | 1 209 (49.5) | 352 (50.5) |
| ≥ 17 | 4 279 (36.9) | 3144 (36.8) | 1 005 (37.3) | 809 (37.1) | 196 (37.9) |
| Assigned sex | |||||
| Female | 5 986 (47.7) | 3 659 (39.7) | 2 214 (73.9) | 1 803 (75.6) | 411 (67.1) |
| Male | 6 145 (52.3) | 5 207 (60.3) | 712 (26.1) | 502 (24.4) | 210 (32.9) |
| Race/ethnicity | |||||
| Black or African American | 1 439 (15.4) | 1 031 (15.3) | 369 (15.8) | 322 (17.6) | 47 (8.6) |
| Hispanic | 593 (7.4) | 468 (8.2) | 99 (4.6) | 83 (5.1) | 16 (2.8) |
| White | 5 616 (47.2) | 1 348 (46.9) | 1 348 (49.6) | 1 001 (47) | 347 (59.7) |
| Asian American and Pacific Islander | 603 (4.4) | 455 (4.6) | 122 (3.3) | 101 (3.3) | 21 (3.3) |
| American Indian or Alaska Native | 847 (0.3) | 617 (0.2) | 182 (0.4) | 147 (0.4) | 35 (0.4) |
| Multiracial | 3 033 (25.3) | 2 138 (24.8) | 806 (26.2) | 651 (26.5) | 155 (25.2) |
| Unweighted sample size (weighted %) | 12 131 (100.0) | 8 866 (73.2) | 2 926 (24.2) | 2 305 (19.3) | 621 (4.9) |
Note. Data are from the 2023 National Youth Risk Behavior Survey. LBGTQ+ = lesbian, gay, bisexual, transgender, “I describe my sexual identity some other way,” or questioning sexual orientation/gender identity. Results for students who answered “I do not know what this question is asking” for sexual orientation or gender identity (n = 339) are presented in the Appendix (available as a supplement to the online version of this article at http://www.ajph.org). All percentages are calculated using Centers for Disease Control and Prevention–provided sampling weights that adjust for complex sampling design as well as school and student nonresponse.
Table 2 presents descriptive statistics on the estimated lifetime prevalence of ACE exposure across groups. In every category of ACE exposure, LGBTQ+ students reported experiencing greater adversity than cishet students. Although both cisgender sexual minorities and gender minorities reported an elevated prevalence of ACEs, ACE exposure was consistently highest among gender minority students. For instance, the estimates in Table 2 imply that nearly half (46.1%) of all transgender or gender questioning high school students in the United States had experienced 4 or more ACEs by the spring of 2023, compared with 34.5% of cisgender sexual minorities and 15.4% of cishet students.
TABLE 2—
Prevalence of Adverse Childhood Experiences (ACEs) Among High School Students: United States, National Youth Risk Behavior Survey, 2023
| Overall Sample | Cisgender Heterosexual | LGBTQ+ | Cisgender Sexual Minority | Transgender and Gender Questioning | |
| Physical abuse, % (95% CI) | 31.8 (29.7, 33.8) | 28.1 (26, 30.2) | 43.9 (41.4, 46.3) | 41.3 (38.4, 44.3) | 54.1 (48.6, 59.5) |
| Emotional abuse, % (95% CI) | 61.9 (59.3, 64.5) | 56.2 (53.7, 58.6) | 81.6 (78.9, 84.3) | 79.1 (76.3, 81.9) | 91.7 (88.1, 95.2) |
| Sexual abuse, % (95% CI) | 7.0 (6.1, 7.9) | 4.1 (3.4, 4.7) | 15.9 (12.9, 18.9) | 14.7 (11.5, 17.9) | 20.6 (15.2, 26) |
| Physical neglect, % (95% CI) | 23.3 (21.8, 24.9) | 20.7 (19, 22.3) | 29.7 (27.1, 32.2) | 27.8 (25.3, 30.3) | 37.3 (32.7, 41.9) |
| Witnessed intimate partner violence, % (95% CI) | 17.6 (16.4, 18.7) | 14.7 (13.5, 15.9) | 26.8 (24, 29.6) | 26.6 (23.5, 29.7) | 27.6 (22.8, 32.3) |
| Household substance use, % (95% CI) | 24.4 (22.3, 26.4) | 20.3 (18.4, 22.1) | 36.8 (33.3, 40.2) | 35.5 (32, 39) | 42 (36.7, 47.3) |
| Household poor mental health, % (95% CI) | 28.8 (26.5, 31.1) | 22.6 (20.8, 24.4) | 48.2 (44.4, 52.1) | 46.3 (42.2, 50.3) | 56.3 (49.7, 62.9) |
| Parent or guardian incarcerated or detained, % (95% CI) | 13.3 (11.8, 14.9) | 11.7 (10.2, 13.3) | 18.0 (15, 20.9) | 18.6 (15.3, 21.8) | 15.6 (10.8, 20.5) |
| No ACEs, % (95% CI) | 22.3 (20.5, 24.1) | 26.6 (24.8, 28.4) | 8.7 (7.3, 10.1) | 10 (8.4, 11.6) | 3.6 (1.8, 5.4) |
| 1 ACE, % (95% CI) | 24.1 (23.2, 24.9) | 26.0 (25.0, 27.1) | 17.6 (16, 19.2) | 18.1 (16.6, 19.6) | 15.6 (11.5, 19.6) |
| 2 or 3 ACEs, % (95% CI) | 32.8 (31.1, 34.6) | 32.0 (30.3, 33.6) | 36.9 (33.8, 39.9) | 37.4 (33.9, 40.9) | 34.7 (29.5, 40) |
| ≥ 4 ACEs, % (95% CI) | 20.8 (19.2, 22.3) | 15.4 (14.2, 16.7) | 36.8 (33.4, 40.1) | 34.5 (30.9, 38) | 46.1 (39.7, 52.5) |
| Cumulative ACE score, mean (95% CI) | 2.1 (2, 2.2) | 1.8 (1.7, 1.9) | 3 (2.9, 3.1) | 2.9 (2.8, 3) | 3.5 (3.2, 3.7) |
Note. Data are from the 2023 National Youth Risk Behavior Survey. LBGTQ+ = lesbian, gay, bisexual, transgender, “I describe my sexual identity some other way,” or questioning sexual orientation/gender identity. Results for students who answered “I do not know what this question is asking” for sexual orientation or gender identity are presented in the Appendix (available as a supplement to the online version of this article at http://www.ajph.org). All estimates calculated using Centers for Disease Control and Prevention–provided sampling weights that adjust for complex sampling design as well as school and student nonresponse. LGBTQ+, cisgender sexual minority, and transgender/gender questioning students’ responses are weighted by the inverse probability of mischievous response; further details and unweighted responses provided in the Appendix.
Focusing specifically on experiences of abuse underscores the magnitude of ACE exposure among contemporary LGBTQ+ high school students. Emotional abuse was reported by 81.6% of LGBTQ+ students compared with 56.2% of cishet students. Among gender minority students, emotional abuse was a nearly universal experience, reported by 91.7% of all respondents. Although emotional abuse was the most common form of abuse reported, experiences of physical and sexual abuse were also widespread. For instance, over half (54.1%) of all gender minority students reported physical abuse, compared with 41.3% of cisgender sexual minorities and 28.1% of cishet students.
To test whether these disparities were driven, in part, by compositional differences between those who did or did not identify as LGBTQ+ on this survey, Table 3 reports the results of log-binomial regressions controlling for students’ assigned sex, race/ethnicity, and age. In every ACE category, LGBTQ+ students were significantly (P < .001) more likely to report ACE exposure.
TABLE 3—
Regression Adjusted Risk Ratios for Adverse Childhood Experiences (ACEs) Exposure Among High School Students: United States, National Youth Risk Behavior Survey, 2023
| LGBTQ+ vs Cisgender Heterosexual, ARR (99.9% CI) | Cisgender Sexual Minority vs Cisgender Heterosexual, ARR (99.9% CI) | Transgender and Gender Questioning vs Cisgender Heterosexual, ARR (99.9% CI) | |
| Physical abuse | 1.57 (1.38, 1.77) | 1.46 (1.27, 1.68) | 2.00 (1.61, 2.48) |
| Emotional abuse | 1.37 (1.28, 1.46) | 1.33 (1.23, 1.43) | 1.53 (1.42, 1.65) |
| Sexual abuse | 2.71 (1.64, 4.47) | 2.48 (1.43, 4.28) | 3.69 (2.07, 6.59) |
| Physical neglect | 1.43 (1.18, 1.72) | 1.33 (1.11, 1.59) | 1.85 (1.39, 2.47) |
| Witnessed intimate partner violence | 1.63 (1.28, 2.08) | 1.60 (1.24, 2.07) | 1.75 (1.20, 2.56) |
| Household substance use | 1.61 (1.32, 1.97) | 1.57 (1.28, 1.93) | 1.76 (1.35, 2.28) |
| Household poor mental health | 1.90 (1.64, 2.19) | 1.83 (1.57, 2.13) | 2.14 (1.70, 2.70) |
| Parent incarcerated or detained | 1.49 (1.12, 1.98) | 1.53 (1.12, 2.08) | 1.35 (0.79, 2.29) |
| No ACEs | 0.37 (0.27, 0.49) | 0.42 (0.31, 0.57) | 0.15 (0.06, 0.35) |
| 1 ACE | 0.68 (0.57, 0.80) | 0.70 (0.60, 0.82) | 0.59 (0.38, 0.93) |
| 2 or 3 ACEs | 1.16 (1.01, 1.33) | 1.17 (1.00, 1.38) | 1.10 (0.85, 1.42) |
| ≥ 4 ACEs | 2.12 (1.74, 2.58) | 1.98 (1.62, 2.43) | 2.66 (1.94, 3.65) |
Note. ARR = adjusted risk ratio; CI = confidence interval; LBGTQ+ = lesbian, gay, bisexual, transgender, “I describe my sexual identity some other way,” or questioning sexual orientation/gender identity. Statistical significance cutoffs were established applying Bonferroni correction for multiple comparisons. All estimates are exponentiated coefficients from log-binominal regressions controlling for students’ sex, race/ethnicity, and age, calculated using Centers for Disease Control and Prevention–provided sampling weights that adjust for complex sampling design as well as school and student nonresponse. LGBTQ+, cisgender sexual minority, and transgender/gender questioning students’ students’ responses are weighted by the inverse probability of mischievous response; further details and unweighted responses provided in the Appendix (available as a supplement to the online version of this article at http://www.ajph.org). Results for students who answered “I do not know what this question is asking” for sexual orientation or gender identity are presented in the Appendix.
Of all forms of ACE exposure, sexual abuse stands out as exhibiting the largest disparities between cishet and LGBTQ+ students. Compared with demographically similar cishet students, LGBTQ+ students were an estimated 2.71 times as likely to report having experienced sexual abuse. Here, too, gender minority students faced the most pronounced disparities. Compared with demographically similar cishet students, gender minorities were an estimated 3.69 times as likely to report sexual abuse.
Whereas the results in Table 3 controlled for student demographic characteristics, it is also possible that LGBTQ+ students’ risk for ACEs may vary across demographic groups. To explore this possibility, Figure 1 presents the results of 3 separate Poisson regressions modeling students’ cumulative ACE counts, allowing the effect of LGBTQ+ identity to vary by each demographic characteristic. Sample size constraints prevented an analysis of interaction effects among cisgender sexual minorities and gender minorities separately.
FIGURE 1—
Regression Adjusted Cumulative Adverse Childhood Experiences (ACE) Scores Across Demographic Subgroups: United States, National Youth Risk Behavior Survey, 2023
Note. AAPI = Asian American or Pacific Islander; AIAN = American Indian and Alaska Native; Black = Black or African American; Cishet = cisgender and heterosexual; Latino = Latino or Hispanic; LBGTQ+ = lesbian, gay, bisexual, transgender, “I describe my sexual identity some other way,” or questioning sexual orientation/gender identity; MU = Multiracial. Estimates from 3 separate Poisson regressions, interacting LGBTQ+ identity with highlighted demographic characteristic, controlling for the other 2 demographic characteristics, calculated using Centers for Disease Control and Prevention–provided sampling weights that adjust for complex sampling design as well as school and student nonresponse. LGBTQ+ students’ responses are weighted by the inverse probability of mischievous response; further details and unweighted responses provided in the Appendix (available as a supplement to the online version of this article at http://www.ajph.org).
Figure 1 illustrates that LGBTQ+ students experienced a greater cumulative total of ACEs within every demographic group analyzed. Even so, there is variation in ACE counts across groups, particularly by race/ethnicity. Consistent with recent CDC estimates for the US adult population overall,7 Figure 1 shows that the cumulative burden of ACE exposure was highest among American Indian or Alaska Native students. The estimates in Figure 1 imply that American Indian or Alaska Native high school students who identified as LGBTQ+ had experienced, on average, 3.5 ACEs by the spring of 2023. Notably, these estimates revealing the distinctly high burden of ACEs among LGBTQ+ American Indian or Alaska Native students were made possible by the fact that the 2023 National YRBS was the first ever to include a large oversample of American Indian or Alaska Native students.23
DISCUSSION
Drawing on the first CDC data designed to provide national prevalence estimates of self-reported ACEs among American high school students,23 this study documented that LGBTQ+ students face substantially greater exposure to ACEs than their cishet peers. LGBTQ+ students reported a higher prevalence on all 8 items in the YRBS ACEs module, cumulatively reporting an ACE score of 3.0 compared with the 1.8 reported by cishet students. LGBTQ+ students’ elevated exposure to ACEs was reported across all demographic subgroups, with the highest ACE scores being reported by LGBTQ+ American Indians and Alaska Natives. With nearly 1 in 4 students in this sample identifying as LGBTQ+, these widespread ACE exposures could forebode substantial population health challenges as this cohort ages into adulthood.
Although elevated levels of ACE exposure were reported by both cisgender sexual minorities and gender minorities, gender minorities consistently reported the highest levels of ACEs of all groups. In analyses made possible by the first gender identity item ever included in a nationally representative survey of current US high school students,23 this study underscored the importance of analyzing the distinct experiences of gender minorities over and above those of LGBTQ+ youths overall.
Troublingly, the levels of abuse reported by LGBTQ+ high school students in this nationally representative sample surpass those previously reported in nonprobability samples of LGBTQ+ adolescents.12,13 For instance, in a sample of adolescents recruited through social media and community organizations, Thoma et al.12 found that 71% of gender minorities reported emotional abuse, 40% reported physical abuse, and 19% reported sexual abuse. By contrast, in the 2023 National YRBS, 92% of gender minorities reported emotional abuse, 54% reported physical abuse, and 21% reported sexual abuse. As such, the United States’ first nationally representative sample of gender minority high school students didn’t just affirm the results of prior nonprobability samples; if anything, it indicated that prior samples had underestimated the full extent of abuse that gender minority youths face.
These results have important implications for broader understandings of LGBTQ+ health and well-being. They suggest that many LGBTQ+ population health disparities may reflect not just minority stress and discrimination experienced in adulthood, but also the longer shadow of adversities endured in childhood. Indeed, it is notable that LGBTQ+ students’ ACE scores increased only slightly across age groups, with large disparities already firmly established among those aged 12 to 14 years. This fact emphasizes the importance of understanding LGBTQ+ youths’ earliest experiences, identifying common sensitive periods when intervention could occur. This study’s results also underscore the central role of families of origin in shaping LGBTQ+ well-being.32 The widespread abuse and disproportionate exposure to household challenges reported by the LGBTQ+ youths in this study illustrate the necessity of analyzing the family as a key social institution implicated in the production of LGBTQ+ health disparities, alongside other institutions like schools, health care providers, and religious institutions.
Limitations
Despite the unique strengths of the 2023 National YRBS data, this study’s conclusions come with important limitations.
First, although the amount of missing data in this study is consistent with that found in other research on LGBTQ+ ACE exposure,12,15 the overall reduction in sample size makes it difficult to be certain how the results reported here would generalize to the full population of US high school students. Moreover, even if this study’s sample were to be representative of all US high school students, the YRBS is not designed to be representative of all US adolescents more broadly. To the extent that LGBTQ+ youths—particularly those experiencing high levels of ACEs—are less stably connected to school attendance, this study’s sample will systematically understate the true prevalence of ACEs among LGBTQ+ youths in the United States.
Second, and relatedly, although this study analyzed students’ responses to every survey question included in the YRBS ACEs module, these items do not exhaust the traumatic stressors to which LGBTQ+ youths are disproportionately exposed. As emphasized by the sexual and gender minority ACEs framework,26,27 there are many LGBTQ+ specific adversities—such as “conversion therapy” and homophobic or transphobic religious teachings—that affect LGBTQ+ well-being over and above traditional ACEs. In this regard as well, this study’s results reflect a lower bound estimate on the full burden of ACEs among contemporary LGBTQ+ youths.
Third, although the inclusion of a gender identity item in the 2023 National YRBS marks a critical milestone in the recognition of transgender students, the item itself may fail to capture gender diverse students who did not identify with the specific term “transgender.” This study’s results for transgender and gender questioning students cannot be assumed to reflect the potentially distinct experiences of gender nonbinary, genderfluid, or genderqueer students.33
Finally, although the YRBS data allow for new estimates of ACE prevalence, the YRBS is unable to address the specific mechanisms through which LGBTQ+ youths come to experience ACEs. No research has found that ACEs “cause” LGBTQ+ identities.17,19 However, more research is needed to explore how LGBTQ+ youths come to experience, for example, elevated levels of parental incarceration or detention. Understanding the specific social processes by which LGBTQ+ youths come to face higher levels of ACEs—particularly household challenge ACEs—should be an important priority for future research.
Public Health Implications
The results reported in this study emphasize the importance of working to prevent, monitor, and mitigate the impact of ACEs in the United States. Although there is debate regarding the wisdom of universal ACE screening by pediatric care providers,34 the historic inclusion of an ACEs module in the 2023 National YRBS illustrates the viability and value of large-scale public surveillance efforts in this area. To track trends and allow comparisons across contexts, ACE items should become an ongoing component of existing national, state, and local public health surveillance systems. Amid a political and policy environment that is growing increasingly hostile to LGBTQ+ youths, monitoring LGBTQ+ youths’ exposure to abuse is likely to become even more important in the years to come.
The breadth of ACEs reported by the LGBTQ+ youths in this study indicates that the particular needs of this population must be an essential part of any broader strategy for addressing ACEs in the United States. With 37% of all LGBTQ+ students enrolled in US high schools currently reporting 4 or more ACEs, this study’s results emphasize the importance of preventing ACEs as a way to address LGBTQ+ population health disparities. This study’s results also underscore the importance of a trauma-informed approach to care and services for LGBTQ+ populations, particularly gender minority populations.35
Acknowledgments
This study was supported through the University of Pennsylvania’s Population Studies Center, National Institute of Child Health and Human Development (grant P2CHD044964).
I thank 3 anonymous reviewers for their insightful feedback and recommendations.
CONFLICTS OF INTEREST
The author has no conflicts of interest to disclose.
HUMAN PARTICIPANT PROTECTION
Because it used de-identified, publicly available data, this study was deemed exempt by the institutional review board of the University of Pennsylvania.
See also Cimpian and McQuillan, p. 982.
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