The Influence of Families on LGBTQ Youth Health: A Call to Action for Innovation in Research and Intervention Development

Abstract

Lesbian, gay, bisexual, transgender, queer, questioning, and other sexual and gender minority youth (LGBTQ) experience myriad health inequities relative to their cisgender heterosexual peers. Families have a profound impact on adolescent health, but little is known about this influence on LGBTQ youth specifically. We draw on work presented at a public symposium that aimed to characterize existing scientific evidence, identify gaps in knowledge, and set priority areas for future research on the influence of family factors on LGBTQ youth health. We review the evidence in each identified priority area and propose promising avenues for future research and opportunities for innovation.

Introduction

Lesbian, gay, bisexual, transgender, queer, questioning, and other sexual and gender minority (LGBTQ) youth experience myriad health inequities relative to their heterosexual and cisgender (i.e., nontransgender) peers.^1–3 Positive parent–adolescent relationships and effective parenting practices promote health among adolescents generally,^4–9 but very little research has examined the influence of families on the health of LGBTQ youth specifically.² LGBTQ youth too often experience strained relationships with families due to stigma related to their sexual orientation and/or gender identity.^10,11 The family context is, therefore, especially important for the development and prevention of negative health outcomes. In this article, we summarize what is known about families of LGBTQ youth and issue a call to action for prioritizing research to promote healthier parent–child relationships to improve the health of LGBTQ youth.

In June 2017, the Northwestern Institute for Sexual and Gender Minority Health and Wellbeing hosted a public symposium titled, “The State of LGBTQ Youth Health and Wellbeing: Strengthening Schools and Families to Build Resilience.” In partnership with the Center for Prevention Implementation Methodology, Advocates for Youth, and the AIDS Foundation of Chicago, an expert consultation was held after the public symposium to characterize areas of strong and emerging scientific evidence, gaps in knowledge, and research priorities regarding HIV, substance use, mental health and suicide, and violence among LGBTQ youth.¹² Working groups were formed during the expert consultation to address two important systems in the lives of youth: schools and families. The consultation included 40 participants from academia, federal health agencies, youth serving organizations, advocacy organizations, foundations, and youth themselves. Writing groups were formed to draft findings for publication and these were prereviewed for feedback by working group members before submission for peer review. The present perspective article is one of the resulting articles.

This article summarizes existing areas of inquiry and future directions related to families and LGBTQ youth health that were identified during the expert consultation meeting. At that meeting, participants were asked to generate an exhaustive list of research topics related to families and LGBTQ youth health that were characterized by a strong evidence base, preliminary findings, or novel and promising areas of inquiry. The working group condensed this list into a group of broad research priorities, each of which we examine in the subsequent sections. We first review the limited existing evidence in each identified priority area (where available), and then discuss promising avenues for future research and opportunities for innovation (see Table 1 for a summary of the main points described in the next sections).^{5,6,8–11,13–32}

Table 1.

Existing Evidence and Future Research Directions in the Area of Family Influences on LGBTQ Youth Health

Research topic	Existing evidence base	Future research and opportunities for innovation
Family support and rejection	Parent and family rejection is strongly associated with mental health problems, substance use, and sexual risk.10,11,13 LGBTQ youth are overrepresented in the homeless youth population.14 Perceived family support is associated with better mental health and less substance use.10,11,15–20	Which factors contribute to resilience among LGBTQ youth with unsupportive or rejecting families? Does the presence of one supportive parent compensate for lack of support from another parent or guardian? Does the presence of a nonparental family member (e.g., sibling) compensate for the effects of unsupportive parents? Does having nonparental mentors improve health outcomes? Which factors contribute to change in parental or family support over time? Why do some initially unsupportive parents become supportive?
Parenting practices	Parental monitoring and communication are associated with better health among adolescents in general.5,6,8,9 Associations with health outcomes are less clear among LGBTQ youth.21–23 Some studies find that monitoring and communication are associated with less sexual risk among young gay and bisexual men.21,22 Monitoring and communication are likely more complex with LGBTQ youth.22,24 Not all youth are “out” to parents. Not all parents possess LGBTQ-specific health information.	How does parental monitoring differ for LGBTQ compared with cisgender heterosexual youth? Which strategies do parents use to communicate with their children about health when they lack LGBTQ-specific information (i.e., related to sex education)? How do parenting practices affect the health of LGBTQ youth who are not “out” to their parents? Which other parenting strategies affect LGBTQ youth health? Negotiation, control, warmth, and shared interests, etc.
Mechanisms linking family factors to LGBTQ youth health	Stress during critical developmental stages can alter psychological and physiological stress response systems.25,26 Both general and LGBTQ-specific stressors affect cognitive/affective/behavioral factors that increase the risk of negative health outcomes.27 There is a very small research base with LGBTQ populations.	Which cognitive, affective, and behavioral factors drive the link between family factors and health? How do early family relationships and attachments (e.g., perceived conditional love) influence longer-term health during adulthood? What is the long-term impact of family stress on the physiological stress response system?
Cultural and individual differences	Few existing studies have been able to enroll parents with varying cultural backgrounds. There is limited focus on race/ethnicity, religious background, rurality, and area of residence. There is limited existing evidence on differences in parental acceptance of LGBTQ teens across demographic factors.	How does culture influence parent–child relationships when the child identifies as LGBTQ? What are the strengths of varying cultural groups that improve parent–child relationships? Do parental influences on health differ within the LGBTQ youth population (e.g., are there sexual or gender identity differences)? What are the unique issues that parents face based on the specific sexual orientation or gender identity of their child?
Parent- and family-based interventions	Family- and parent-based interventions developed for adolescents, in general, enroll LGBTQ adolescents, but rarely conduct subgroup analyses based on sexual or gender minority status.28 A few existing family-based programs show initial promise in nonrandomized trials.29–31 There are no existing randomized trials of family-based interventions for LGBTQ youth.	Do family- and parent-based interventions designed for adolescents, in general, work equally well for LGBTQ adolescents? Which components of these interventions need to be adapted for LGBTQ adolescents to optimize efficacy? Which modality of family-based intervention is best for LGBTQ adolescents (e.g., online or group based)? Is it most efficacious to intervene with the parent(s), adolescent, or both?
Innovation in methods	Most existing studies have assessed family influences from the LGBTQ youth perspective.24 A small number of studies have enrolled parents.24,32 Parents in these samples are generally already supportive. These studies have most often used qualitative methods. There are very few quantitative studies of family influences on LGBTQ adolescent health.	What are effective strategies for enrolling unaccepting parents into research? What are the most effective strategies for enrolling parent–child dyads into research? Strategies for recruiting diverse parents and LGBTQ adolescents into research: Racial/ethnic minorities, religious affiliation, and rural families, etc. Longitudinal studies: How do parent–child relationships change over time and how does that affect LGBTQ adolescent health? How do we retain parents and/or parent–child dyads in longitudinal studies over time?

Family Support and Rejection

Family rejection is strongly associated with mental health problems and suicidality, substance use, and sexual risk.^10,11,13 However, research on the link between family rejection and exposure to violence in the home, after being expelled from the home, or in romantic relationships is limited. Youth with highly rejecting families are often forced to leave the home, leading to overrepresentation of LGBTQ teens in the homeless youth population¹⁴ and foster care system,³³ thus exposing these youth to myriad risky contexts. For example, parental rejection decreases instrumental (i.e., tangible and practical) support and social support from parents, which increases certain HIV risk behaviors (e.g., survival/transactional sex) among young gay and bisexual men.³⁴ Similarly, parental rejection has also been linked to increased depression, suicidality, and substance use among LGBTQ youth.^10,11,13 When two parents are present in a household, there are often differences between parents in levels of acceptance,²⁴ and the limited existing evidence suggests that mothers are more engaged with their LGBTQ children³⁵ and that LGBTQ youth who come out to their parents tend to come out to mothers before fathers.^35,36 Less clear is whether the presence of one supportive parent buffers the negative impact of having another unsupportive/rejecting parent.

It is important to note that those LGBTQ youth who do perceive strong support from their families tend to have better mental health and lower risk of substance abuse and (to a lesser extent) sexual risk behaviors.^10,15–18 Furthermore, these positive effects are also seen in studies of transgender and gender minority youth specifically.^11,19,20 The presence of parental support in the lives of LGBTQ youth indicates that parents and their children were resilient in the face of coming to terms with the teen's LGBTQ identity, which is often a significant stressor for both parents and teens. Unfortunately, very little research has examined how parents and their children cope with the coming out process or what makes some parents more supportive than others. Understanding the processes that lead to positive outcomes is essential to develop strategies for improving relationships between parents and their LGBTQ youth and mitigating health disparities.

Parenting Practices

There is a growing body of knowledge on specific parenting practices that influence the health of LGBTQ youth. Two key parenting skills have been found to be protective for adolescent health behaviors in the general literature: parental monitoring and parent–adolescent communication.^5,6,8,9 Interestingly, findings are mixed for their relationship with health outcomes among LGBTQ youth specifically. Some studies find that monitoring and communication are negatively associated with sexual risk in young gay and bisexual men,^21,22 whereas other studies find positive associations.²³ This suggests that the influence of parenting practices on health is more complex for LGBTQ youth compared with cisgender heterosexual youth as the success of these strategies requires that parents are aware of, and at a minimum tolerate, their child's LGBTQ identity and/or gender expression and provide accurate health information tailored to their needs. Nevertheless, supportive and accepting parent–child relationships that are characterized by open, mutual, and low-conflict communication have been found to be associated with better health outcomes, specifically in reducing sexual risk among young gay and bisexual men.^21,32

Importantly, research on the effects of parenting practices on LGBTQ youth health is scant and has focused largely on their effects on sexual health outcomes. The expert consultation identified several key opportunities for strengthening the research base. First, research is needed on a larger variety of parenting practices (e.g., negotiation and control) as well as the effects of parenting on a wider array of adolescent health behaviors beyond sexual risk (e.g., substance use, eating behavior, and violence). Second, the existing literature on these effects has generally been cross-sectional, and longitudinal research is needed to clarify the temporal ordering of parental influences on health. Third, our understanding is limited as to what education parents need to foster the health of their LGBTQ children. Finally, to identify what links family factors and LGBTQ youth health, more theoretical writing is needed on families, parents, and LGBTQ adolescent health outcomes. In particular, the field would benefit from understanding whether existing theoretical frameworks that describe family influences on adolescent health in the broader population need to be adapted for LGBTQ youth or whether novel theoretical models are needed to address the unique needs of this population.

Mechanisms Linking Family Factors to LGBTQ Youth Health

Central to theory development is exploring the cognitive, affective, behavioral, and biological mechanisms through which parents and families influence health. For example, we are only beginning to understand the underlying processes that link parental rejection to negative health outcomes.¹³ These processes might unfold acutely (e.g., coping through substance use) or over longer periods of time (e.g., developing rejection sensitivity). Furthermore, emerging research in the area of developmental psychopathology suggests that experiencing stress during critical developmental stages (e.g., adolescence) may alter psychological and physiological stress response systems in a manner that increases vulnerability to adversities faced even later in life.^25,26 Identifying these varied mechanisms is critical to developing interventions to mitigate health disparities.

Cultural and Individual Differences

Most of the limited research on cultural differences in families of LGBTQ youth has examined mean differences in parental acceptance/rejection by sociodemographic characteristics (e.g., teen race/ethnicity and/or gender identity),^13,37 but there are limitations to this approach. First, sociodemographic factors are crude indicators of the beliefs, values, and meanings that comprise culture within and between families. Thus, there is a risk of conflating culture with race/ethnicity rather than acknowledging that cultural worldviews within each family are influenced by other factors.³⁸ There is a tremendous need to examine cultural factors that influence families of LGBTQ youth beyond race, including the influence of religion, urbanicity/rurality, and geographic region. Prior qualitative research with LGBTQ youth and families,³⁵ and the broader anthropological and sociological literature, may help to provide strong starting points. Finally, it is critical to examine and identify cultural strengths (not just deficits)³⁹ as these will be integral to engaging parents with varying levels of acceptance.

With regard to individual differences beyond those described in the prior section, it is imperative that future research recognizes the diverse experiences of individuals within the LGBTQ community. Experiences and stressors may differ substantially based on other factors, including sex assigned at birth, gender identity, and sexual orientation, to name a few. It is likely that these individual differences among LGBTQ adolescents influence their relationships with their parents and families, and understanding these influences is critical to understanding the health needs of these youth. For example, emerging research has found that parents of transgender and nonbinary youth have unique concerns related to their adolescents' health that may not be addressed by programs developed for cisgender LGB adolescents.²⁴

Parent- and Family-Based Interventions

Family-based interventions are efficacious and effective in preventing and reducing problem behaviors, including substance use and sexual risk, among (presumably heterosexual) adolescents.^40–42 These programs often have been found to have crossover effects on outcomes other than the ones that were targeted in the intervention.^43,44 Unfortunately, family-based interventions have rarely been evaluated among LGBTQ youth specifically. To our knowledge, no studies on family-based interventions for adolescents in general (i.e., not selected on the basis of sexual orientation or gender identity) have examined the potential for differential effects between cisgender heterosexual and LGBTQ youth. Researchers who have access to data on multiple trials of the same family-based intervention could synthesize datasets across trials to yield a sufficiently large sample of LGBTQ youth to make meaningful comparisons with cisgender heterosexual youth,²⁸ but this requires that researchers in this area consistently assess sexual orientation and/or gender identity in their trials.

Although it is important to assess LGBTQ identities in ongoing trials and examine differential effects between LGBTQ youth and their cisgender heterosexual peers, LGBTQ youth and their families encounter various stressors that differ from those of cisgender heterosexual youth,^24,27 and these unique stressors can affect LGBTQ youth health. Thus, existing interventions will likely need to be tailored, or new programs will need to be developed, to address certain health issues among LGBTQ youth (e.g., sexual health promotion, mental health, and violence prevention).²⁴ It is encouraging that existing practice and emerging research have laid the foundation for such programs. Peer-led support groups for parents (e.g., Parents and Friends of Lesbians and Gays and Parents of Transgender Individuals) are the most widely adopted programs, but no research points to their efficacy in improving parent or child outcomes. The Family Acceptance Project^® is an initiative that provides research-grounded psychoeducational resources to both parents of LGBTQ youth and practitioners who serve these families.²⁹ It has yet to be manualized or evaluated for efficacy, but the program has informed guidelines for best practices in working with families of LGBTQ youth endorsed by the Substance Abuse and Mental Health Services Administration.⁴⁵

Lead with Love, a documentary-style education–entertainment video that aims to improve parents' behaviors toward their LGB children by providing evidence-based information and support, has found that parents can be feasibly reached online and given support, information, and behavioral guidance after a child comes out.³⁰ Attachment-Based Family Therapy has also been adapted for parents of LGB youth. Preliminary studies suggest that it can engage struggling parents and reduce suicidal ideation among LGB youth.³¹ Finally, a small number of programs have been developed to help LGBTQ youth in the foster system strengthen relationships with their foster and/or birth parents that have shown initial promise.^46,47 Unfortunately, no randomized controlled trials have been conducted to date to evaluate the efficacy of family-based health programs for LGBTQ youth.

Evidence indicates that parents want support and guidance when a child comes out³⁰ and in addressing their adolescent's health,²⁴ but there are several areas of particular need. First, many parents have strong negative emotional reactions when a child comes out^24,48,49 and may interact with their children more effectively if they have assistance managing this stress.⁵⁰ Second, some parents are unaware of the negative impact that rejecting behaviors have on their children, including behaviors that may be well intentioned (e.g., encouraging a child to act more gender-typical to protect them from harm).¹³ Finally, most parents want their children to be healthy, but many lack the skills to help their children (e.g., knowledge of LGBTQ safer sex and coping with bullying).^24,35 Supporting, educating, and providing behavioral guidance for families of LGBTQ youth must be a priority of intervention research, including aiding parents in helping their children navigate other systems relevant to their health (e.g., patient–provider relationships and schools).² Schools may also be well positioned to provide support to parents, and a companion article in this issue reviews the influence of schools on LGBTQ adolescent health in greater detail.⁵¹

Innovation in Methods

Research on families of LGBTQ youth hinges on methodological innovation. Most studies have assessed family influences from youths' perspectives or have used samples of parents who are already accepting, leading to potential bias.² The field would benefit greatly from identifying innovative methods to (1) engage less accepting parents/families; (2) recruit minority families (e.g., racial/ethnic minority and rural families); (3) enroll parent–adolescent dyads and use dyadic analysis to model family effects; (4) enroll large enough samples to allow for examining differences in effects by subgroups within the LGBTQ youth population (e.g., bisexual individuals and gender minority individuals); and (5) engage nonparental family members (e.g., other caregivers and heterosexual siblings). These methodological innovations are reviewed in greater detail in this issue.⁵²

Conclusion

We are only beginning to understand the many ways in which families influence the health of LGBTQ youth. Furthermore, what little we know about these family influences has focused largely on their impact on sexual health and to a lesser degree substance use and mental health. However, very little research has examined the influence of families on suicidality and violence, highlighting a need to broaden into other health domains. There is also a need to examine whether there are differences between sexual and/or gender identity groups in family influences on adolescent health, as most existing studies have focused on specific populations (e.g., young gay men) or LGBTQ youth as a whole.^{10,13,15–18,21–24,32,34–37} Given the robust literature demonstrating the promotive effects of effective parenting on the health of cisgender heterosexual youth,⁴ it is clear that the lack of literature on the influence of families on the health of LGBTQ youth is a major gap. If we hope to mitigate the vast health inequities experienced by these young people^1–3 by developing effective interventions and policies, it is imperative that we push this nascent field of research forward through innovative empirical research, including (but not limited to) longitudinal studies of diverse LGBTQ youth and their parents that track the influence of family factors on adolescent health over time. In this article, we have drawn on expert consultation to provide a perspective on priorities for advancing the field.

Disclaimer

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, the National Institute on Drug Abuse, or the National Institutes of Health.

Author Disclosure Statement

No competing financial interests exist.