“Trying my best”: Sexual minority adolescents’ self-care during the COVID-19 pandemic

Abstract

Purpose.

The COVID-19 pandemic has resulted in major life disruptions for sexual minority adolescents (SMA), who already face and cope with pervasive and disproportionate rates of social, behavioral, and mental health challenges. Current research suggests that SMA are struggling with COVID-19-related shelter in place orders navigating family proximity and dynamics, and experiencing isolation from SMA specific supports. Given identified challenges that may exacerbate known mental health disparities in SMA, this work explores self-care practices among SMA during the COVID-19 pandemic.

Methods.

The present study uses data from open-ended questions to understand SMA experiences of self-care within a nationwide sample of SMA (N=770; M=17.48 years, SD=1.00) who are part of an ongoing prospective study. Data were collected via online questionnaire between May 13-31, 2020. Thematic analysis guided data exploration.

Results.

Thematic analysis revealed five self-care practices among SMA: (1) relationships, (2) routines, (3) body and mind, (4) rest and reset, and (5) tuning out. SMA engaged in many positive coping strategies (i.e., exercise, establishing routine) and often linked these activities to positive wellbeing. Other SMA engaged in activities to distract or disengage from stressors (i.e., excessive TV and alcohol and drug use).

Conclusions.

These findings highlight the resiliency of SMA during the current pandemic, opportunities for providers to emphasize adaptive coping skills with youth, and the need for more research on adolescent self-care practices.

The COVID-19 pandemic disrupted the lives of people throughout the U.S. and worldwide. Researchers globally note that these disruptions uniquely affect adolescents^1–3 who are in a developmental stage marked by increased autonomy, reorientation from family to peer networks,⁴ and risk-taking.⁵ Adolescents in the U.S. face stressors specific to their development, including challenges with maintaining supportive peer relationships in the context of social distancing, school closures, cancelled plans, and changes in housing.^6–8 COVID-19-related school closures disproportionately affect adolescents who rely on the physical school context for social bonding and support from peers.⁷ Isolation from peers may have profound effects on sexual minority adolescents’ (SMA) wellbeing due to their reliance on these social networks and supports.^{9, 10}

Many of the challenges faced by SMA, including lesbian, gay, bisexual, pansexual, queer, questioning, and non-identifying youth (LGBQ), are considered unique.¹¹ SMA are more likely than heterosexual youth to have unsupportive families¹² and rejecting practices are linked with disparities in SMA mental and behavioral health¹³ including suicide ideation and substance use.^{11, 14, 15} The pandemic may present particular challenges for SMA. During shelter in place, SMA may be confined with unsupportive family and lose connections with LGBQ friends, communities, and resources. These experiences may exacerbate disparities in anxiety, depression, and suicide ideation burdening SMA.¹⁶ In fact, peer support buffers the effects of family rejection on anxiety and depression symptomology,¹⁷ so SMA may be coping with the combined effects of confinement with potentially unsupportive family, school closures, diminished access to peers, school-based supportive adults, and LGBQ-affirming clubs (e.g., gender and sexuality alliances; GSAs).

While peer support,^{17, 18} GSAs,¹⁹ and supportive online LGBQ-specific networks ^{20, 21} appear to buffer or reduce exposure to stress, little is known of SMA self-care. Even less is known about SMA self-care practices during the COVID-19 pandemic, when such supports may be harder to maintain. Indeed, youth report spending less time with peers and more time with parents during the COVID-19 pandemic, and most youth were benefitting from this increased time with parents.²² While greater parent support is associated with higher self-esteem and lower risk for mental health challenges,^{13, 23} this increased time with parents could conversely be stressful for SMA who experience rejection or are not out to family. For example, SMA in a focus group indicated that they were struggling with confinement with family, and that LGBQ-specific online supports helped them cope with sheltering in place with family.²⁰ Information about SMA subjective lived experiences during the pandemic is limited, and scholarship on SMA self-care practices is necessary to understand and address the unique challenges experienced by SMA. Thus, the current study sought to understand self-care practices among SMA during the COVID-19 pandemic to inform points of intervention for increasing SMA wellbeing.

Method

Participants

A nationwide sample of 770 SMA residing in the U.S., ages 15-19, completed a COVID-19 online survey delivered between assessments of a longitudinal parent study (Adolescent Stress Experiences Over Time). Most participants (91.8%, n=707) reported living with family. At the parent study’s baseline, all participants self-identified as cisgender; at the 18-month follow-up, a small number of participants self-identified as trans or nonbinary (TNB). Because gender was not explicitly assessed within the COVID-19 survey, TNB responses are not disaggregated. Respondents lived across 47 states (no responses from Delaware, North Dakota, or Wyoming), the District of Columbia, and Puerto Rico. Demographics are presented in Table 1.

Table 1.

Sample Demographics (N = 770)

	N / M	% / SD
Age	17.53	1.02
Sex assigned at birth
Female	544	70.6
Male	226	29.4
Sexual orientation
Gay / Lesbian	291	37.8
Bisexual / Pansexual	394	51.2
Queer	20	2.6
Complex / Multiple identities	29	2.6
Mostly straight	9	1.2
Questioning or another identity	36	4.6
Race and Ethnicity
White	449	58.3
Asian / Pacific Islander	58	7.5
Black or African American	60	7.8
Native American, American Indian, or Alaskan Native	21	2.7
Latino / Hispanic	111	14.4
Multiracial	71	9.2
Current housing situation / Living with:
Immediate family	681	88.4
Other relatives	26	3.4
Friends	13	1.7
Independently	9	1.2
Non family housemates	23	3.0
College dormitory	6	0.8
Other unspecified location	11	1.4
Declined to answer	1	0.1

Procedure

Online data collection occurred between May 13-31, 2020. Institutional review board approval was obtained at the host university. Respondents gave informed assent or consent online prior to completing the questionnaires and received a $20 e-gift card for their participation.

Measures

Three open-ended questions were asked at the end of the quantitative survey. Respondents were presented with an open textbox to share thoughts, feelings, and behaviors. Responses from the first question - “What have you been doing to care for yourself in these difficult times?” — were analyzed to understand the self-care behaviors of SMA during the COVID-19 pandemic. Responses ranged from a single word to multiple paragraphs of text. Given the nature of questions (open-ended questions as part of a larger quantitative study) and the size of the sample, deductive analysis was selected. This approach yields systematic procedures for the generation of codes and themes²⁴ and allows for the identification of patterns within a topic related to personal or social meaning and the implications of these experiences. Methods set forth in a thematic approach were undertaken by two coders (First and Third Author; nonbinary and cisgender female, respectively). First, coders did an initial reading to familiarize themselves with the data.²⁵ Next, initial codes were independently generated and discussed; a codebook was created based on discussions. Co-coders then reconvened multiple times to discuss their process and resolve coding differences. Codes were specified, collapsed, added, and removed as coders gained greater familiarity and understanding of the data and coding scheme. Themes were then identified and reviewed for quality and boundaries.²⁵ Finally, themes were named and reported below.

Results

Thematic analyses yielded five themes pertaining to SMA self-care practices: (1) relationships, (2) routines, (3) body and mind, (4) rest and reset, and (5) tuning out.

Relationships

Spending time with others was perhaps the most important form of self-care mentioned by SMA in this study. This is unsurprising given the primacy of relationships to adolescents, generally, and the benefits of peer relationships for SMA wellbeing, specifically. Where some SMA were caring for themselves by “staying in my basement mostly away from my parents,” others found that their family relationships were beneficial and improving. One youth shared that “me and my family…have been taking walks every other day or so. I think I’ve actually gotten closer to my parents from this.” Pets also featured strongly in responses as SMA cared for themselves by “being with my french bulldog,” “fostering cats,” “training my puppies,” “spending time with my lizard,” and, in one case, “taking care of my pet snails.”

Many SMA shared the importance of peer and friend support. Many SMA mentioned “talking to my girlfriend over facetime every night” or “talking to my boyfriend on the phone.” Sometimes friends helped to just pass the time, frequently via video games and social media. One youth spoke of “Playing Dungeons and Dragons with my friends, playing video games with my friends, browsing social media,” and another shared that “I talk to my friends often, and play a LOT of animal crossing with or without them.” Other SMA linked their friendships to their mental health. For example, one SMA shared that “talking to my friends everyday also helps to calm me down when going through panic attacks.”

Some SMA spoke to the challenges to spending time with friends. One SMA said “My friends are all enjoying themselves and playing games, so I can never reach them. I’m always afraid to reach out for help, so I haven’t done that, but getting to talk to friends for a short period of time is nice but not enough.” Another respondent shared how “I’ve met up with friends in person, but only those who had isolated themselves during the pandemic like I had.” Quarantine clearly took a toll on many SMA, who spoke of the links between resiliency and relationships. As one youth shared:

Now that I am back home, I have been seeing my old friends to ‘self-care’. A very close friend to mine killed himself two weeks ago, in part because he was unable to socialize with his friends and felt lonely. I, also being a very social person, have been going out as often as possible to ensure to maintain my well-being.

Peer relationships were central to SMA wellbeing as they contended with the effects of isolation and new challenges to maintaining vital peer connections. SMA used many modes - phone, video chat, text, video games, and socially distanced time together - to maintain these ties.

Routines

Many participants noted setting routines as a method to promote stability and create some sense of normalcy. This quote captured this sentiment, “…trying to stay in a routine even though I’m not working or going to school.” Some routines focused more on daily tasks, while others were specific to increasing positive wellbeing. Those focused on daily tasks tended to highlight list making/organization and being organized and focused on school. A participant noted, “I’m keeping up on my school work and college business, waiting on news for scholarships and things. Keeping connected to my teachers and counselor for news about my graduation and prom. Maintaining a schedule for showers and homework and other things to keep me busy.” Individuals also used lists to “try to stick to them to give myself a routine,” “Making to do lists and following them…[to make] me feel like I am not wasting away,” and trying to “…keep my regular schedule to instill a sense of normalcy and stability.”

Some individuals noted that keeping a routine supported positive wellbeing. This included, as one participant noted, “Making sure I have a routine even if it small like going to bed at a certain time if I can and showering every time I wake up.” Many SMA also talked about maintaining personal hygiene routines. One SMA said, “Maintaining a personal hygiene routine. Taking time to get ready some days even if I’m not going anywhere.” For some, routines specifically helped to combat despair, as well captured by the quote, “I make sure to keep a schedule so I don’t fall into a depression. Simple, like making sure I am awake around the same time every day and take care of myself.” Each of these motivations appeared to result in a similar benefit for SMAs; maintaining a routine was important for the promotion of positive wellbeing.

Body and Mind

Participants reported engaging in a wide variety of activities to promote positive wellbeing, noting the explicit benefits of these activities. Self-maintenance, including exercise, meditation, and makeup were a major component of SMA self-care during the pandemic. The following explores how respondents used these tools to care for their physical wellbeing and self-esteem.

Many SMAs reported using exercise and outdoor activities to destress and noted benefits to their mental health. One participant shared, “I’ve also been trying my best to eat well and get exercise, as the lack of sports has really had a negative impact on me. It’s hard to motivate myself, but I always feel better after exercising.” For some youth, like one who shared that “I am gardening a little everyday. It gets me out of the house, and gives me a break from family,” going outside provided a release from daily stressors.

Other participants engage in meditation and yoga to destress and spoke explicitly of the benefits of these activities on their wellbeing. Captured by one SMA, “I have found meditation and self introspection has been quite therapeutic and helps me realize the problems that are troubling me.” Another SMA noted how “Self-meditation allows me to control and pay attention to my mental health. I reflect over my life and be grateful and count my blessings.” Physical activity and meditation were frequently mentioned along with specific benefits to mind and body.

Besides previously mentioned adolescents who spoke of hygiene in terms of having routines, many youths spoke of maintaining their health through a focus on their hygiene and appearance. At a period when SMAs were spending a great amount of time at home, makeup, hair, and bathing remained important daily activities for maintaining positive wellbeing. Some examples include “making sure to shower every day, do my makeup whenever I feel my self-esteem go down,” “trying to bathe every other day or so (depression makes it hard for me to do it every day),” and “learning how to cut my hair at home.” Some participants more specifically linked such practices to their upkeep and future social engagement, like one SMA who shared “practicing doing my makeup and hair so I can at least be beautiful when I finally get to leave my house again.”

Rest and Reset

Many participants shared that they used music, art, and reading as ways to rest and reset during the pandemic. For some, such creative pursuits were a useful distraction to pass the time. One participant shared, “I got into some new activities so I have more creative outlets and I try to do simple activities that take a long time, like embroidery, to get my mind off of stuff.” Another SMA shared how writing served as an outlet from isolation, “I have been doing a lot of writing, currently working on a drafting a novel, just for fun. It’s kind of relaxing to create someone else’s story where they can move about the world in ways that I can’t.” Other youth spoke of how creative self-expression brought calm and joy, “I have been spending time doing my creative passions…These are really important to me because they help me relax and stay creative while also helping me express myself.” Another SMA shared that they used writing and music to support mental wellbeing, stating that they were, “Focusing on poetry and music, taking as much time as I can to keep my thoughts in check and my mind at ease.”

Many individuals also noted music as a source of relaxation. In this quote, the SMA connected listening and playing music and stress relief. “I’ve been spending a lot of time playing music, reading, writing, and making art. Music, both listening and playing, is very soothing for me when I’m stressed, so I’ve been shaping up my guitar and piano skills.” Last, methods used to create a soothing environment were described, including activities like lighting candles and decorating one’s space. This is captured by one SMA, “I listen to a lot of music and I clean and decorate my room often. I have been trying to make art for my walls and photo collages.” On the whole, SMA shared that expressive arts and the enjoyment of music enhanced their mood during this time.

Tuning Out

SMA commonly noted methods of escapism or tuning out, describing “binge watching” television and using videos and/or video games to escape. One person noted, “Lots of video games and YouTube videos to take my mind off of life.” Such examples were qualitatively different from youth, mentioned earlier, who spoke of their use of video games and social media to connect with friends and communities. Another shared, “I’ve discovered more TV shows and Animes that I’ve been watching and I’ve been playing more video games.” While some individuals shared that they did these activities to “relax,” for others it appeared to be a way to “escape.” This quote exemplifies this sentiment, “[I am] Playing video games, texting, watching Youtube videos, anything to try to ignore the stuff that’s going on. It works pretty well - I don’t think about all the bad stuff when I’m in the middle of a game of Mario Kart.” It was clear that many SMA knew this might be impacting their mental wellbeing. As noted by this quote, “I spend most of my time in my room, scrolling through the internet or reading books. I’ve just been…trying to pretend that everything is normal, even though I know that it’s not.”

A smaller proportion of participants discussed the use of alcohol or other drugs to escape. One person shared they were “doing nothing but watch things and vape.” Another shared they were, “Smoking weed…generally being too self-indulgent.” After describing what they were doing for self-care, a third noted that they could not type much because “my keyboard is broken because I drunkenly spilled a vodka cranberry on it the other day – apologies.” Someone who had been sober shared that they were “…going crazy.” They shared “I got sober from various drugs, and I relapsed a couple days ago on alcohol. I’m not doing so hot.” Each of these forms of escapism raise concern for wellbeing over time.

Discussion

SMA face unique daily stressors; prior research has noted the importance of supportive peer relationships in buffering the effects of stress on SMA health.^{17, 18} However, with the COVID-19 pandemic, schools closed and went online, events were cancelled, and relationships became more virtual than ever. While one study²⁰ has indicated the importance of online services to SMA health at this time, research on SMA self-care practices is otherwise lacking. Therefore, this study sought to understand SMA self-care practices in the context of the unprecedented COVID-19 pandemic. SMA shared a broad variety of activities they engaged in to maintain social ties, sustain their body and mind, distract themselves, avoid sadness, relax, and experience joy. Five general themes were identified, (1) relationships, (2) routines, (3) body and mind (4) rest and reset, and (5) tuning out. This study reveals the adaptive and risky activities that SMA use for self-care. These findings can inform the efforts of SMA service providers to work with SMA to identify and maintain healthy coping strategies as they adapt to sheltering in place with their families during the pandemic.

Findings in this study reflect much of what is known about the behaviors of adolescents, but also highlight the particular self-care behaviors of SMA. The overwhelming number of SMAs who spoke of maintaining peer ties underscores a hallmark of adolescence, the central role of the peer network.⁴ Peer networks are important to SMA wellbeing because they can provide a context for adolescents to explore their identities and learn to navigate their intra- and interpersonal social worlds.⁵ Methods SMA used to maintain these relationships, including via text, phone, online chat, and video games, reveal the many avenues available to youth to safely connect with one another while social distancing. Notably for SMA, many spoke of spending time with family; while some youth are struggling with heterosexism in the home during quarantine, examples in this work point to the importance of family relationships to SMA wellbeing.⁸

Youth in this study spoke of their efforts to create a regular schedule. Maintenance of routines may be important and beneficial to SMA wellbeing during the pandemic. The emphasis youth placed on maintaining routines, or social rhythm, during the pandemic, specifically the connection between routines and mental health, is supported by pre-pandemic work with youth²⁶ and adults,²⁷ and a recent study suggested that maintaining daily routines attenuated the association between community COVID-19 infections and depressive symptoms.³ Interventions focused on maintaining daily routines may be important to youth wellbeing during crises. Other approaches to self-care, including exercise, meditation, makeup, reading, and music reflect how SMA connect their interests and hobbies to stress relief. The variation in reported self-care practices attests to resiliency and adaptive coping behaviors employed in the face of major social upheavals. Some strategies like exercise have been specifically linked to reduced risk of depression among adolescents²⁸ and one study has shown that exercise during the pandemic also has a health enhancing role.³

To a lesser extent, respondents spoke of distracting themselves from their current circumstance by playing video games, watching TV, consuming alcohol and drugs, or otherwise sleeping and avoiding people. Prior research focused on SMA coping with minority stressors has found that SMA often report avoiding, dismissing, or seeking to escape from these stressors.^{29, 30} Research has highlighted persisting disparities in alcohol use burdening SMA, despite recent declines in alcohol use among adolescents more generally.^{31, 32} Further, research has specified that SMA use substances to cope with minority stress^{14, 15} and, concerningly, adolescent substance use frequency appears to have increased during the pandemic.³³ Findings that SMA use substances to cope during the pandemic provides further evidence for intervention efforts needed to support SMA in establishing healthier and more effective self-care behaviors. While avoidant coping behaviors may help to destress in the short-term, such coping strategies are associated with depression.³⁴ Some youth specified that they connected with peers while playing video games, and this study conceptualized such activity as a means of maintaining relationships, not tuning out. Providers may benefit from eliciting from youth whether they engage in such activities to connect with peers or as a form of escapism.

Limitations in the current study include its cross-sectional nature and variance in response depth by SMA to open-ended questions. The location of the self-care question at the end of a quantitative survey about mental health during the COVID-19 pandemic may have affected responses. Youth were not asked about frequency, relative benefit, or primacy of coping strategies, so analysis could not make claims that any particular strategy had differential effects on stress relief and wellbeing. Whether stressors noted existed prior to the COVID-19 pandemic are unknown. Qualitative analysis did not investigate sample demographic differences in selfcare behaviors; behaviors likely vary for youth already living with family pre-pandemic versus youth who moved in with family during the pandemic. Despite the limitations, this study uniquely assessed the self-care practices of a nationwide sample of SMA during a major public health crisis. Findings inform future research aimed at understanding self-care among youth generally and SMA in particular, and may support providers in considering and strengthening the tools that SMA use for self-care.

Implications and Contribution summary statement.

Sexual minority adolescents engage in a variety of coping skills during the COVID-19 pandemic, many of which are healthy behaviors that support their overall physical, mental, and developmental wellbeing. Providers may consider these coping behaviors while supporting youth in managing stress, and future research may further examine adolescent self-care practices.

Abbreviations

SMA

sexual minority adolescents

LGBTQ

lesbian, gay, bisexual, transgender, questioning, queer, or non-identifying

GSA

gender and sexuality alliances