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?