Bullying Among Lesbian, Gay, Bisexual, and Transgender Youth

INTRODUCTION

Bullying of lesbian, gay, bisexual, and transgender (LGBT) youth persists in the United States, with harmful and sometimes fatal consequences. Media reports about LGBT youth who have died by suicide frequently describe experiences of bullying victimization. For example, after being the target of bullying for several years, Adam Kizer died by suicide at age 16, 6 months after coming out as bisexual. Adam’s father reported that he was bullied starting at age 9, when his peers identified him as “different.”¹ Adam suffered substantial mistreatment from his peers that was both verbal (eg, suggestions that he should kill himself) and physical (eg, tied to a tree, doused in gasoline, and almost set on fire). Another example is that of Taylor Alesana, a young transgender woman who experienced significant bullying victimization at school and online, and died by suicide at age 16.^2,3 She described social isolation and rejection on Transgender Day of Remembrance, stating in a YouTube video: “Finding friends when you’re transgender, that to me is one of the hardest parts because you don’t find a lot of friends. And when you do, a lot of them will leave you just because you’re different.”³ The ridiculing comments on YouTube continued even after Taylor’s suicide.⁴

Adam and Taylor’s experiences of bullying by peers are common among LGBT youth. Although extreme in their consequences, these examples underscore the need to address bullying of LGBT youth. Pediatricians can play an important role in preventing and reporting LGBT bullying, supporting LGBT youth who are bullied, and promoting the health and well-being of LGBT youth. In this article, we define key concepts relevant to LGBT bullying; discuss its prevalence in the United States; review evidence of its psychological, behavioral, and physical health consequences; and make recommendations for how pediatricians can address it.

KEY CONCEPTS

Sexual orientation is a relational construct involving a pattern of romantic relationships with, or desires for, people of a particular gender.⁵ Sexual orientation is inclusive of behavior (eg, whether individuals are sexually engaged with same-gender and/or opposite-gender partners), identity (eg, how individuals understand and represent themselves based on identities such as “gay,” “lesbian,” “bisexual,” or “heterosexual”), and/or attraction or desire.⁶ The first 3 letters of the LGBT abbreviation (LGB; lesbian, gay, bisexual) refer to a range of sexual minority orientations that are not exclusively heterosexual. We include individuals who are “queer” or “questioning” under the LGBT umbrella.

Gender identity is one’s internal sense of being male, female, or outside these categories, and gender expression is the manifestation of culturally defined feminine or masculine traits in personality, appearance, and behavior.^5,7 The last letter of the LGBT abbreviation (T; transgender) refers to a range of gender minority identities and expressions that are not aligned exclusively with one’s assigned sex at birth. Some LGBT people display a nonconforming gender expression during development; some do not. Children with a conforming gender expression may grow up to be LGB or heterosexual; they may be transgender or they may not. People have a sexual orientation, gender identity, and gender expression, and these are related in complex ways throughout youth development (for a discussion of the development of sexual orientation and gender, including their associations, see Stewart L. Adelson and colleagues’ article, “Development and Mental Health of LGBT Youth in Pediatric Practice,” in this issue).

Having perceived to have a minority sexual orientation, gender identity, and/or gender expression may increase youths’ risk of being bullying. Bullying is defined by the Centers for Disease Control and Prevention and US Department of Education as:

Bullying is any unwanted aggressive behavior(s) by another youth or group of youths who are not siblings or current dating partners that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated. Bullying may inflict harm or distress on the targeted youth including physical, psychological, or educational harm.⁸

This definition emphasizes that bullying behavior is unwanted, meaning that the bullied youth wants the behavior to stop. It is aggressive, meaning that it involves the intentional use of harmful behavior. A power imbalance refers to a real or perceived ability of the perpetrator to control the target’s behaviors or outcomes. Power can be drawn from a variety of sources, such as physical strength, popularity, or wealth. Incidents are considered repeated if they occur multiple times or there is a concern that they are likely to recur. Moreover, bullying may result in harm involving negative experiences or injuries.

Mistreatment of LGBT youth is also referred to by other terms in the literature, including discrimination and bias. Although we use the term bullying in this article, we acknowledge that LGBT bullying is stigma-based and therefore fundamentally discriminatory in nature.

SCOPE OF PROBLEM

Data from US national samples suggest that the majority of LGBT youth experience some form of bullying. In 2011, the Gay, Lesbian and Straight Education Network surveyed more than 8500 LGBT youth aged 13–20 years old in all 50 US states and Washington DC.⁹ All forms of bullying were prevalent among these youth (Table 1). Most (92.3%) reported experiencing verbal bullying, involving harmful oral or written communication including taunting, name calling, and threats. Close to one-half (44.7%) reported physical bullying, including the use of physical force such as hitting, kicking, tripping, and spitting. About one-fifth (21.2%) reported more extreme physical assault, such as being punched, kicked, or injured with a weapon. Most (89.5%) reported social or relational bullying, involving behavior intended to harm reputations and relationships including spreading rumors, posting embarrassing media content, and socially isolating the target. Nearly one-half (47.7%) reported damage to property, such as stealing, damaging, or altering property. More than one-half of youth (55.2%) reported bullying via technology, or cyberbullying. Although youth attributed experiences of bullying to multiple socially devalued characteristics (eg, religion, race/ethnicity, disability), they attributed the majority of bullying to their sexual orientation or gender expression. Other data sources suggest similarly high prevalence estimates of bullying among LGBT youth.¹⁰

Table 1.

Types of bullying and prevalence among LGBT youth in the United States

Type	Definition	Examples	Prevalence Among LGBT Youth in Past Year (%)a
Verbal	Harmful oral or written communication	Taunting, name calling, threatening	92.3
Physical	Use of physical force	Hitting, kicking, tripping, spitting	44.7
Social or relational	Behavior intended to harm reputations or relationships	Spreading rumors, posting embarrassing media content, isolating socially	89.5
Damage to property	Stealing, damaging, or altering property	Stealing or deleting electronic information	47.7

Abbreviation: LGBT, lesbian, gay, bisexual, and transgender.

^aEstimates of prevalence are from the US national 2011 National School Climate Survey conducted by the Gay, Lesbian, & Straight Education Network.⁹

LGBT youth generally experience more bullying than non-LGBT youth. In an online study of youth ages 13 to 18 years, LGB youth reported more than twice as much online and in-person peer victimization as heterosexual youth.¹¹ Moreover, these different rates of bullying seem to begin before youth generally identify as LGB: youth who identify as LGB in 10th grade are more likely to have reported bullying than non-LGB youth when they were in 5th grade.¹² Similar differences are documented for transgender youth: approximately 83% of transgender or gender nonconforming youth reported bullying victimization in the past year in comparison with 58% of cisgender (ie, nontransgender) youth in a recent study.¹³ Adolescent boys who are bullied because they are perceived to be gay owing to nonconforming gender expression (even if they do not identify as gay themselves) also experience more verbal and physical bullying than boys who are bullied for other reasons.¹⁴

Although understudied, some work suggests variability in the prevalence of bullying among LGBT youth. For example, LGBT youth who have disclosed their sexual orientation or gender identity to their peers or school staff report greater bullying relative to youth who have not disclosed their LGBT status,^9,15 although it is possible that LGBT youth who are bullied are more likely to disclose to adults and be discovered as being LGBT by peers. Youth who identify as bisexual also seem to report greater bullying.¹⁶ The prevalence of bullying also seems to vary by social context. LGBT youth report more bullying in states that do not have laws that prohibit bullying or harassment on the basis of sexual orientation or gender identity, and LGBT youth in the Midwest and South report more bullying than youth in the North and West.⁹ Moreover, LGB youth who live in neighborhoods with high rates of LGBT assault hate crimes are more likely to report relational and cyberbullying, possibly because violence toward LGBT adults in neighborhoods signals acceptance of LGBT bullying.¹⁷

CAUSES AND CONSEQUENCES OF LESBIAN, GAY, BISEXUAL, AND TRANSGENDER BULLYING

Multiple factors contribute to youths’ engagement in bullying against LGBT individuals. At the societal level, LGBT stigma (social devaluation and discrediting of LGBT people) leads to discrimination and bullying of LGBT youth (see Mark L. Hatzenbuehler and John E. Pachankis’ article, “Stigma and Minority Stress as Social Determinants of Health among LGBT Youth: Research Evidence and Clinical Implications,” in this issue). At the social level, youth socialize and influence LGBT bullying within their peer groups. Certain norms within peer groups contribute to greater LGBT bullying, including traditional masculinity norms, dominance norms, and overall aggression levels.^18,19 Having fewer LGBT friends is associated with greater engagement in LGBT bullying. At the individual level, a prominent contributing factor is prejudice, or negative attitudes toward others based on their minority sexual orientation and/or gender identity and expression that are rooted in LGBT stigma.^20,21 Greater engagement in LGBT bullying is also associated with holding stronger attitudes in support of social dominance, hierarchies, and power differentials among peers as well as at a broader societal level against socially devalued groups (eg, racial minorities, women).²² Heterosexual youth who place greater importance on their heterosexual identity as part of their overall sense of identity and those who are less empathic tend to perpetrate more LGBT bullying.²⁰ Boys tend to engage in LGBT bullying more than girls. Also, youth who engage in bullying in general are more likely to perpetrate LGBT bullying specifically.²⁰

LGBT bullying undermines the mental, behavioral, and physical health of youth, ultimately leading to health inequities for LGBT compared with non-LGBT youth that may last across the lifespan. As highlighted in the introduction, suicidal ideation and suicide attempts and completion are a concern for youth experiencing LGBT bullying. Sexual minority youth are more likely to think about and attempt suicide than non-LGBT youth, and bullying plays a role in these thoughts and behaviors.^23,24 Other mental health effects of LGBT bullying include greater symptoms of depression and anxiety, and lower self-esteem.^9,23,24 Longitudinal evidence among youth in general suggests that bullying is associated with worse mental health outcomes over time, with past experiences of bullying predicting worse psychosocial quality of life, more depression symptoms, and worse self-worth.²⁵ Some evidence suggests that youth who disclose their sexual orientation or gender identity to school peers and staff report greater psychological well-being than those youth who do not, despite experiencing greater bullying.⁹ It is possible that youth who choose to disclose a sexual or gender minority status at school gain resilience resources, such as social support, after disclosing. More research is needed to understand associations among disclosure, bullying, and well-being, including the ways in which resilience resources and supportive environments affect these associations.

Bullying plays a role in harmful health behaviors among LGBT youth. LGBT bullying is associated with greater engagement in substance use, including tobacco, alcohol, marijuana, and other illicit drugs (eg, methamphetamines, inhalants).^13,26 It is also associated with engagement in risk behaviors related to substance use, such as drunk driving.²⁶ Although the topic is understudied, LGBT youth who are bullied may engage in high levels of sexual risk behaviors (eg, condomless sex, substance use before sex, transactional sex), similar to LGBT adults.^27,28 Also of concern, LGBT middle and high school students who experience greater bullying have higher rates of school absenteeism (often related to fears of being bullied at school), lower grade point averages, and lower postgraduation educational aspirations.⁹

Bullying further affects the physical health of LGBT youth. LGBT youth who are physically bullied may suffer cuts, bruises, broken bones, and other direct health sequelae of physical violence. Other physical health outcomes are understudied among LGBT youth specifically, but a robust body of research describes outcomes of bullying among youth in general. Youth who experience bullying are more likely to experience a range of physical health symptoms, including increased abdominal pain, headache, poor appetite, sleeping problems, and skin problems, as well as greater body mass index, higher systolic and diastolic blood pressures, and decreased self-rated health, relative to youth who are not bullied.^29,30,31,32 These health outcomes seem to be driven, in part, by the mental and behavioral health consequences of bullying.³⁰ That is, similar to the ways in which discrimination affects health among adults,³³ depression, anxiety, and other poor mental health effects of bullying may lead to worse physical health. Additionally, youth may engage in harmful coping behaviors (eg, substance use to manage anxiety), which ultimately undermine physical health.

The consequences of bullying among LGBT youth seem to be worse than the consequences among non-LGBT youth. Youth who experience LGBT-based bullying engage in greater substance use and other risk behaviors (eg, drunk driving), and experience higher rates of depression than youth who experience bullying that is not bias-based.²⁶ Similarly, adolescent boys who are bullied because they are perceived to be gay experience greater anxiety and depressive symptoms than boys bullied for other reasons.¹⁴

Although rates of bullying among LGBT youth seem to decrease with age,^12,34 the mental, behavioral, and physical health consequences of bullying may last into adulthood. LGBT young adults who self-report frequent bullying as adolescents are more likely to be depressed, have had a suicide attempt, engage in sexual risk behaviors including condomless sex, and be diagnosed with a sexually transmitted infection.^15,34,35 Similarly, adults who experienced bullying associated with having a nonconforming gender expression as youth report greater depressive symptoms and lower life satisfaction as young adults.^36,37 LGBT adults who experienced greater bullying as youth are more likely to report posttraumatic stress disorder.³⁸

RECOMMENDATIONS FOR CLINICIANS

Pediatricians and other clinicians practicing pediatric care have an opportunity and professional responsibility to address LGBT bullying to improve the well-being of LGBT youth. Here, we make recommendations to pediatricians regarding how to address LGBT bullying with patients and parents as well as within communities. We focus on LGBT bullying, but many of these recommendations generalize to other forms of bullying. These recommendations are largely guided by the American Academy of Pediatrics,³⁹ American Medical Association,⁴⁰ and the US Department of Health and Human Services.^41,42 It may also be useful for pediatricians to learn about local policies on bullying to help individual youth and their families navigate bullying at school. Pediatricians may contact representatives of school districts (eg, principals, guidance counselors, school nurses) and explore school websites for more information on school bullying policies. Some states also have laws that protect students from bullying on the basis of sexual orientation and gender identity. The Gay, Lesbian and Straight Education Network maintains state-specific resource guides on local bullying policies that may be useful for pediatricians.⁴³ In addition, Title IX has been used in several legal cases related to students experiencing discrimination on the basis of gender expression.⁴⁴

Several of our recommendations encourage pediatricians to work with other adults, including parents, teachers, school administrators, and other community stakeholders, to address LGBT bullying. It is important for pediatricians to bear in mind that these other adults may actively or passively mistreat LGBT youth (eg, use antigay epithets to mock gay students, ignore bullying).⁴⁵ Societal LGBT stigma leads both youth and adults to discriminate against LGBT youth. Pediatricians must be sensitive to this issue. In some cases, it may be possible for pediatricians to identify and work with other accepting adults to support LGBT youth. In other cases, when accepting adults are not present within youths’ lives, it is critical for pediatricians to act as allies of and advocates for LGBT youth experiencing bullying to promote their well-being (eg, by connecting them to community-based health or social organizations that are LGBT affirming).

Box 1 suggests several steps that pediatricians can take to address bullying. Importantly, addressing bullying starts with prevention. Pediatricians can include bullying in anticipatory guidance by describing bullying and its consequences to parents and youth.⁴⁵ They can describe what bullying is, and what forms it may take. Pediatricians can also discuss techniques to address bullying with youth (eg, tell an adult) so that youth are prepared to respond to bullying should they witness or experience it. Pediatricians can also encourage parents to promote positive social skills among youth (eg, nonaggressive behavior).⁴⁶ Any youth may experience LGBT-related bullying—not only those who are LGBT—based on perceived sexual orientation or gender identity. Pediatricians therefore should not limit their discussion of LGBT bullying to youth who are LGBT themselves. Similarly, LGBT youth may experience many forms of bullying, such as based on race or disability. Pediatricians should not limit their discussions with LGBT youth to LGBT bullying, but instead discuss all forms of bullying.

Box 1. Steps for pediatricians to address LGBT bullying.

Prevent

• Describe bullying and its consequences to parents and youth.

• Discuss ways to safely respond to bullying.

Identify

• Create safe environment in which youth feel comfortable discussing sexual orientation and gender identity.

• Screen youth for bullying.

• Identify type of bullying and youth involved.

Counsel

• Help youth to identify accepting and supportive adults.

• Advise parents on how to advocate for youth in school.

Advocate

• Speak out against LGBT bullying and stigma.

• Advocate for policies to address LGBT bullying and stigma.

Abbreviation: LGBT, lesbian, gay, bisexual, and transgender.

Pediatricians should seek to identify youth who are targets of LGBT bullying. This is particularly important because many LGBT youth do not disclose their experiences of bullying to other adults, including teachers.⁹ LGBT youth report not telling teachers about bullying because they are concerned about teachers’ reactions, they fear making the situation worse, and they feel that teachers will not effectively address the situation.⁹

Pediatricians can contribute to the creation of safe and welcoming spaces wherein LGBT youth feel comfortable discussing LGBT bullying (see Scott E. Hadland and colleagues’ article, “Caring for LGBTQ Youth in Inclusive and Affirmative Environments,” in this issue). Although LGB youth often do not disclose their sexual orientation to their physicians, many report that they would be open to discussing it if the subject were raised by their physician.⁴⁷ When seeking to identify bullying, pediatricians should pay particular attention to LGBT youth, who are at increased risk of experiencing bullying, and youth exhibiting mental, behavioral, or physical symptoms of bullying (eg, anxiety, substance use, unexplained physical injury).⁴⁵ Physicians may ask both youth and parents about bullying. Example questions to identify bullying are included in Box 2. Direct questions ask about bullying explicitly, whereas indirect questions are meant to generate conversation that may provide insight into bullying. If patients or parents indicate that patients have experienced bullying, pediatricians may ask follow-up questions to gain more information and determine whether it is LGBT bullying. For example, they should listen to see whether homophobic epithets are involved in the bullying or whether the youth attributes bullying to their real or perceived sexual minority orientation, gender nonconforming behavior, or transgender identity.

Box 2. Suggested questions for pediatricians to ask youth and caregivers to identify youth who might be experiencing bullying.

Youth

Direct

• Have you been bullied by other kids?

• Have you been teased or left out by other kids?

• Have other kids spread rumors about you?

• Have you been hurt, punched, or kicked by other kids?

• Have other kids taken or damaged anything that belongs to you?

Indirect

• What is lunch time like at your school? Whom do you sit with?

• What is it like to ride the school bus?

Follow-up

• Could you describe a time when you were bullied?

• What did the other kids say?

• What did the other kids do?

• Why do you think that they are treating you this way?

Caregivers

Direct

• Do you suspect that your child is being bullied or harassed?

• Is your child bothered by other kids?

• Does your child have problems with other kids?

Indirect

• How does your child get along with other kids?

• Does your child have many friends?

• Is your child nervous about going to school?

Adapted from Get Help Now. Stopbullying.gov Web site. Available at: http://www.stopbullying.gov/get-help-now/index.html. Accessed October 26, 2015; and Glew G, Rivara F, Feudtner C. Bullying: children hurting children. Pediatrics Rev 2000;21(6):183–9.

Pediatricians should provide counsel to youth who are experiencing LGBT bullying. Pediatricians can advise youth regarding how to react if they are bullied, including by staying calm, walking away, and telling an adult.⁴¹ Pediatricians can help youth to identify supportive adults (eg, parents, teachers, school administrators) to whom they can turn when bullied. Teachers involved in gay—straight alliances, for example, may be advocates for LGBT students. LGBT youth report that social support received from these adults at school helps them cope with bullying.⁴⁸ In addition, pediatricians can provide support for youth who decide to tell their parents or other adults about experiences of LGBT bullying. Pediatricians can further encourage youth to join safe and supportive extracurricular activities to reduce social isolation and strengthen their relationships with others.

Pediatricians can also counsel parents of youth who are experiencing LGBT bullying. If the pediatrician has learned of the bullying through a private, confidential conversation with the youth, he or she cannot tell parents about a patients’ experiences of bullying without permission unless the patient is in danger. Moreover, it is worth bearing in mind that many LGBT youth (28.4% in a recent survey)⁹ have not disclosed their sexual minority orientation or transgender identity to either one or both of their parents. Some parents, however, may raise concerns about LGBT bullying to pediatricians. Pediatricians can encourage parents to regularly speak about bullying with their children to identify experiences of bullying and provide support if children are bullied. For example, parents can provide emotional support by emphasizing to youth that they do not deserve to be bullied. Pediatricians can also advise parents on how to report bullying to school officials and connect parents with resources on bullying. If bullying is not handled by school authorities, parents may be able to file a formal grievance with the US Department of Education’s Office for Civil Rights and/or the US Department of Justice’s Civil Rights Division.⁴⁹

Pediatricians may engage in advocacy in their local schools and communities to address LGBT bullying. For example, pediatricians may voice support for enumerated laws that protect students from bullying and discrimination on the basis of sexual orientation and gender identity in states where they do not yet exist. They may also speak out against LGBT bullying to school officials and parents. Efforts to reduce LGBT bullying victimization should include addressing LGBT stigma in the broader community context. For example, physicians can advocate on behalf of transgender individuals by weighing in on bathroom use controversies in legislative hearings and amicus briefs.⁷ LGBT bullying will likely persist as long as LGBT stigma exists within society.

DISCUSSION

LGBT bullying is prevalent among LGBT youth, with significant mental, behavioral, and physical health consequences. LGBT youth may be denied support from parents, teachers, and school administrators. Pediatricians therefore have a vital role to play in promoting the well-being of LGBT youth by preventing bullying, identifying bullying, offering counsel to youth who experience bullying and to their parents, and advocating for programs and policies to address LGBT bullying. Pediatricians have the power, ability, and responsibility to contribute to destigmatizing sexual and gender minority youth in their communities, thereby making the world a healthier place for their LGBT patients.

KEY POINTS.

• Bullying of lesbian, gay, bisexual, and transgender (LGBT) youth is prevalent in the United States; the majority of LGBT youth experience some form of bullying.

• Bullying undermines the mental, behavioral, and physical health of LGBT youth, with consequences lasting into adulthood.

• Pediatricians can play a vital role in promoting the well-being of LGBT youth by preventing and identifying bullying, offering counsel to youth and their parents, and advocating for programs and policies.