Abstract
Purpose:
Existing evidence indicates significant threats against the mental health of sexual and gender minority (SGM) young adults as a result of the COVID-19 pandemic, including elevated rates of substance use, anxiety, depression, and traumatic stress. Therefore, it is imperative to understand the mechanistic identity-related factors that may influence the mental health needs of SGM young adults in the time of COVID-19. This study aims to examine the impact of increases in lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) identity-related victimization since the start of COVID-19 on psychological distress among SGM college students.
Methods:
A nonprobability, cross-sectional online survey was conducted between May and August 2020 to explore the psychological impacts of COVID-19 on U.S. SGM college students (N = 565). Previously validated scales were used to measure LGBTQ identity-related victimization and psychological distress. Chi-square tests of independence, independent samples T-tests, and adjusted logistic regression were used to examine the study aim.
Results:
Adjusted logistic regression findings revealed that reporting past year+more frequent LGBTQ identity-related victimization since the start of COVID-19 (compared to no report) was associated with over four times greater odds of experiencing moderate to severe psychological distress.
Conclusion:
Findings highlight the importance of research, practice, and policy stakeholders toward addressing the unique identity-related mental health needs and victimization experiences of SGM college students. Mental health, social service, and higher education practitioners have an important opportunity and responsibility toward identifying and intervening on SGM college students and young adults facing identity-related victimization amid the ongoing COVID-19 pandemic.
Keywords: college students, LGBTQ, mental health, minority stress, victimization, young adults
Introduction
The COVID-19 pandemic has severely affected the mental health of the U.S. population.1 Existing evidence further indicates similar threats against the mental health of sexual and gender minority (SGM) young adults as a result of the pandemic, manifested as elevated rates of substance use, anxiety, depression, and traumatic stress.2–7 Given that roughly 41% of all young adults in the United States are currently enrolled in college8 and the increased vulnerabilities faced by SGM young adults as a result of the pandemic, it is imperative to understand the factors that may influence the mental health needs of young SGM students in the time of COVID-19.
SGM college students face distinct challenges to their mental health and wellbeing during COVID-19.9–12 For example, since the start of the COVID-19 pandemic, many SGM students have faced a lack of stable access to affirming friends, therapists, advisors, teachers, and student organizations,9,10,13,14 which are common support systems in university settings that buffer against mental health burden for these populations.15–19 In addition, SGM students may find themselves in unsafe living arrangements during COVID-19,20 particularly those who experienced housing rearrangements as a result of pandemic-related changes to university operations (in-person vs. online), employment loss, and/or financial hardship.10,13,21 SGM students may have been forced to return to their parents or other family members' homes, where many are at risk for facing negative SGM-related outcomes.
For instance, SGM students may be facing increased risk for verbal and physical victimization due to rejection of their SGM identities,22,23 which are associated with negative mental health outcomes, including substance use, depression, and suicidality.24–26 In the current context and time, it is imperative to understand how SGM-related victimization during the ongoing COVID-19 pandemic relates to mental health among SGM students and young adults.
Current study
The current study is guided by the Minority Stress Theory,27,28 which emphasizes the role of SGM identity-related distal (e.g., SGM-related victimization, family rejection) and proximal (e.g., internalized homophobia) stressors and their impact on mental health. Although the negative mental health impacts of SGM stressors on SGM young adults and students are well-documented,17,25,29,30 SGM identity-related victimization and its effects on the mental health of SGM young adults and college students in the context of the ongoing COVID-19 pandemic specifically remains an understudied public health concern.
The current study aims to examine the impact of (1) past year lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) identity-related victimization and (2) more frequent LGBTQ identity-related victimization since the start of COVID-19 on psychological distress among SGM college students. We hypothesize that experiencing both types of LGBTQ identity-related victimization will be associated with greater psychological distress (compared to not experiencing these types of victimization). The information provided by this study may help to improve policies, practices, and programs to address the mental health of SGM young adults and students, particularly in the context of COVID-19, which will be relevant to future times of global distress.
Methods
Participants and procedures
This study was derived from nonprobability cross-sectional data collected from a sample of SGM students (N = 565) to explore mental health in the context of the COVID-19 pandemic. Eligibility criteria for the study were assessed using four presurvey questions and included being at least 18 years of age (1), identifying as a sexual (2) or gender (3) minority person, and being a full-time currently enrolled college student in the United States (4). Data were collected between May 27 and August 14, 2020 using an online survey. Participants were incentivized with a raffle for a $50 Amazon gift card. The University of Maryland Institutional Review Board granted approval for the study.
Participants were recruited using an electronic recruitment flyer distributed via multiple social media platforms that included a link to an online Qualtrics survey. Recruitment also occurred through email campaigns within our internal and external professional networks, and at historically Black colleges and universities, Hispanic serving university and college institutions, and LGBTQ+ university/college student centers across the United States.
Upon clicking the link to the survey, participants immediately underwent a self-administered electronic informed consent process. Survey duration was ∼20–25 minutes, with a total of 87 questions (including single-item and multi-item questions). Study participants had the right to skip or not answer any question in the survey. Upon completion of the survey, participants were provided with a listing of mental health and crisis management resources and contact information for the study principal investigator in case they had any questions.
Measures
LGBTQ identity-related victimization
LGBTQ identity-related victimization was measured using 4 items from the Daily Heterosexist Experiences Questionnaire (DHEQ)31 and 2 items from the LGBT Minority Stress Measure.32 To capture presence of past year victimization, students were asked to indicate whether they experienced each item in the past year (yes/no). To capture increased frequency of victimization since the start of the COVID-19 pandemic, students were asked to indicate whether they experienced each item more often since the start of the pandemic (yes/no).
Specifically, participants responded either 1 = yes or 0 = no to the following questions: (1) “Has this happened to you in the past year?,” and (2) “Have you felt this way more often since the start of the COVID-19 pandemic?” for each victimization item. Two composite scores were calculated by summing responses across the 6 items. However, due to the positive skew of distributions, the two composite scores were dichotomized. The first composite score was dichotomized to signify no presence of past year victimization (0), or presence of past year victimization (1). The second composite score was dichotomized to signify no presence of more frequent victimization since the start of COVID-19 (0), or presence of more frequent victimization since the start of COVID-19 (1).
Psychological distress
The previously validated Kessler-10 (K10)33 was used to measure current psychological distress among SGM students. The 10-item scale includes measures of depression and anxiety within the past 30 days. Item responses are coded on a 5-point Likert-type scale from none of the time (1) to all of the time (5). The measure showed strong internal consistency in the current sample (α = 0.921). The measure was dichotomized (healthy to mild psychological distress = 0, moderate to severe psychological distress = 1) using previously validated K10 cutoff scores34 to make interpretations about study participants suffering from the greatest levels of psychological distress.
Sociodemographic variables and social isolation
We collected information on gender identity, sex assigned at birth, sexual orientation, race, Hispanic/Latino ethnicity, nativity, outness to parents, living with parents' during COVID-19 status, parental financial dependence, age, undergraduate/graduate program, and social isolation.
Gender identity and sex assigned at birth
“Which term best describes your gender identity? (Please select the best answer).” Response options: nonbinary, Cisgender woman, Cisgender man, Trans woman, Trans feminine, Trans man, Trans masculine, Genderqueer, Two-spirit, Gender fluid, or Agender. “What is your sex assigned at birth?” Response options: Male, Female, or Intersex. Sex assigned at birth (1 = female, 0 = male) and gender identity (1 = noncisgender identity, 0 = cisgender identity; cisgender refers to gender identity that corresponds with sex assigned at birth) were recoded due to small group sample sizes and dummy coded for regression analysis.
Sexual orientation
“Which term best describes your current sexual orientation? (Please choose the best answer).” Response options: Asexual, Bisexual, Gay, Lesbian, Same-gender loving, Nonbinary, Pansexual, Queer, Questioning, or Heterosexual or Straight. Sexual orientation was recoded due to small group sample sizes and dummy coded for regression analysis: Gay (1 = Gay, 0 = bisexual), Lesbian (1 = Lesbian, 0 = bisexual), Queer (1 = Queer, 0 = bisexual), Pansexual (1 = Pansexual, 0 = bisexual), Asexual (1 = Asexual, 0 = bisexual), or another sexuality (1 = another sexuality, 0 = bisexual).
Race and ethnicity
“What is your race or ethnicity? (select all that apply).” Response options: American Indian or Alaskan Native, Native Hawaiian or other Pacific Islander, Asian, Black or African American, White, or another race not listed. “Are you Hispanic or Latino?” Response options: Yes (1) or No (0). Race was recoded due to small group sample sizes and dummy coded for regression analysis: Black (1 = Black, 0 = White), Asian (1 = Asian, 0 = White), another race (1 = another race, 0 = White), Multiracial (1 = multiracial, 0 = White).
Living with parents during COVID-19
Participants were asked about their main living situation before and during the COVID-19 pandemic. Respondents who were living with their parents before the pandemic and whose living arrangements did not change during the pandemic, as well as respondents who were not living with their parents before the pandemic but moved back in with their parents during the COVID-19 pandemic were coded affirmatively (1). Those who were not currently living with their parents at the time the survey was completed were coded as zero.
Social isolation
Social isolation was measured using the 3-item loneliness scale.35 The 3-item measure uses a 3-point ordinal-level scale (1 = hardly ever, 2 = some of the time, 3 = often) to assess current level of social isolation. A composite score (range = 3–9) was calculated by summing responses across the three items; a greater score indicated more social isolation. The measure demonstrated strong internal consistency in the current sample (α = 0.760).
Data analysis
First, we conducted descriptive analyses to identify the frequencies or means of psychological distress, social isolation, sociodemographic characteristics, and past year victimization and more frequency of victimization since the start of COVID-19 (raw scores; Table 1). Next, we recoded the past year victimization variable to signify those who solely experienced past year victimization (and not more frequent since COVID-19 victimization). This group is known as “past year victimization only” from this point onward. All participants who experienced more frequent victimization since COVID-19 also experienced past year victimization; therefore, this group is known as “past year + more frequent victimization since COVID-19” from this point onward.
Table 1.
Sample Sociodemographic Characteristics Among Sexual and Gender Minority College Students by Level of Psychological Stress
| |
Psychological distress |
|
||
|---|---|---|---|---|
| N (%) | Moderate-to-severe, N = 366, n (%) | Healthy-to-mild, N = 199, n (%) | p value (χ2/t) | |
| Sex assigned at birth | ||||
| Male | 117 (22) | 57 (11) | 60 (11) | <0.001 |
| Female | 428 (79) | 298 (55) | 130 (24) | |
| Gender identity | ||||
| Cisgender | 388 (69) | 227 (40) | 161 (29) | <0.001 |
| Transgender | 53 (9) | 39 (7) | 14 (3) | |
| Nonbinary | 67 (12) | 55 (10) | 12 (2) | |
| Another noncisgender identity | 57 (10) | 45 (8) | 12 (2) | |
| Sexual orientation | ||||
| Bisexual | 181 (32) | 112 (20) | 69 (12) | <0.001 |
| Gay | 77 (14) | 29 (5) | 48 (9) | |
| Lesbian | 102 (18) | 74 (13) | 28 (5) | |
| Queer | 89 (16) | 69 (12) | 20 (4) | |
| Pansexual | 49 (9) | 33 (6) | 16 (3) | |
| Asexual | 41 (7) | 28 (5) | 13 (2) | |
| Another sexuality | 26 (5) | 21 (4) | 5 (1) | |
| Age [M (SD)] | 21.97 (3.94) | 0.146 | ||
| 18–22 years old | 398 (73) | 269 (49) | 129 (24) | |
| 23–27 years old | 97 (18) | 56 (10) | 41 (8) | |
| 28+ years old | 51 (9) | 31 (6) | 20 (4) | |
| Hispanic or Latinx | ||||
| Yes | 80 (14) | 49 (9) | 31 (6) | 0.528 |
| No | 485 (86) | 317 (56) | 168 (30) | |
| Race | ||||
| Asian | 61 (11) | 29 (5) | 32 (6) | 0.025 |
| White | 388 (70) | 258 (46) | 130 (23) | |
| Black or African American | 49 (9) | 31 (6) | 18 (3) | |
| Multiracial | 39 (7) | 30 (5) | 9 (2) | |
| Another race | 21 (4) | 13 (2) | 8 (1) | |
| Nativity | ||||
| United States-born | 518 (92) | 339 (60) | 179 (32) | 0.339 |
| Foreign-born | 47 (8) | 27 (5) | 20 (4) | |
| Parental financial dependence | ||||
| Yes | 457 (84) | 304 (56) | 153 (28) | 0.221 |
| No | 88 (16) | 52 (10) | 36 (7) | |
| Living with parents | ||||
| Yes | 320 (57) | 213 (38) | 107 (19) | 0.329 |
| No | 245 (43) | 153 (27) | 92 (16) | |
| Out to parents | ||||
| Yes | 360 (72) | 229 (46) | 131 (26) | 0.298 |
| No | 141 (28) | 97 (19) | 44 (9) | |
| Educational program | ||||
| Undergraduate | 375 (70) | 255 (48) | 120 (23) | 0.090 |
| Graduate | 158 (30) | 95 (18) | 63 (12) | |
| Social isolationa [M (SD)] | 6.50 (1.71) | 6.83 (1.61) | 5.87 (1.70) | <0.001 |
| Past year victimization only | ||||
| Yes | 106 (20) | 80 (15) | 26 (5) | 0.016 |
| No | 422 (80) | 265 (50) | 157 (30) | |
| Past year+more victimization since COVID-19b | ||||
| Yes | 38 (7) | 33 (6) | 5 (1) | 0.004 |
| No | 490 (93) | 312 (59) | 178 (34) | |
The Social Isolation scores range from 3 to 9 with higher scores indicating more social isolation.
Participants in this group also reported past year victimization.
M, mean; SD, standard deviation.
Next, we conducted chi-square tests of independence and independent samples t-tests to examine the bivariate relationships between (1) sociodemographic characteristics/social isolation and psychological distress, (2) past year victimization only and psychological distress, and (3) past year+more frequent victimization since COVID-19 and psychological distress. Next, we conducted logistic regression analysis to examine the effects of past year victimization only and past year+more frequent victimization since COVID-19 on psychological distress, while adjusting for study covariates that demonstrated statistical significance in the previously described bivariate analyses. Alpha was set to 0.05, and all analyses were conducted using SPSS version 28.
Item missingness was handled using listwise deletion, with 0% missing on the study dependent variable (psychological distress), and 6.5% missing in the multivariable logistic regression model.
Results
Sociodemographic characteristics, LGBTQ identity-related victimization, and psychological distress
A summary of the frequencies or means for sociodemographic characteristics/social isolation, past year and more frequent since COVID-19 LGBTQ identity-related victimization, and psychological distress can be found in Table 1. A summary of the frequencies of each past year and more frequent since COVID-19 LGBTQ identity-related victimization item can be found in Table 2.
Table 2.
LGBTQ Identity-Related Victimization Items and Frequencies (Raw Scores; N = 565)
| Items | n (%) |
|---|---|
| Past Year Victimization Total a | 143 (27) |
| Past Year Victimization Item a | |
| 1. Being threatened with harm because I am LGBTQ32 | 66 (12.5) |
| 2. Being bullied by others because I am LGBTQ32 | 119 (22.5) |
| 3. Being punched, hit, kicked, or beaten because I am LGBTQ31 | 7 (1.3) |
| 4. Being assaulted with a weapon because I am LGBTQ31 | 6 (1.1) |
| 5. Being raped or sexually assaulted because I am LGBTQ31 | 19 (3.6) |
| 6. Having objects thrown at me because I am LGBTQ31 | 18 (3.4) |
| More Frequent Since COVID-19 Victimization Total b | 38 (7) |
| More Frequent Since COVID-19 Victimization Item b | |
| 1. Being threatened with harm because I am LGBTQ32 | 17 (3.2) |
| 2. Being bullied by others because I am LGBTQ32 | 29 (5.5) |
| 3. Being punched, hit, kicked, or beaten because I am LGBTQ31 | 5 (0.9) |
| 4. Being assaulted with a weapon because I am LGBTQ31 | 3 (0.5) |
| 5. Being raped or sexually assaulted because I am LGBTQ31 | 6 (1.1) |
| 6. Having objects thrown at me because I am LGBTQ31 | 8 (1.5) |
Past Year Base Question: “Has this happened to you in the past year?,” item response options: 1 = yes, 0 = no; if any item = 1, then total = 1, otherwise total = 0.
More Frequent Since COVID-19 Base Question: “Have you felt this way more often since the start of the COVID-19 pandemic?,” item response options: 1 = yes, 0 = no; if any item = 1, then total = 1, otherwise total = 0.
LGBTQ, lesbian, gay, bisexual, transgender, and/or queer or questioning.
Among the sample, more than half identified as female (79%), and 69% identified as cisgender, 9% as transgender, 12% as nonbinary, and 10% as another noncisgender identity. Although sexual orientation varied, bisexuality (32%) was the most prevalent, followed by lesbian (18%), queer (16%), gay (14%), pansexual (9%), asexual (7%), and another sexuality (5%). The majority of the sample were undergraduate students (70%) born in the United States (92%), and average age (range = 18–50) was 21.97 years (standard deviation = 3.94), with 73% of the sample being 18–22 years old, 18% being 23–27 years old, and 9% being 28+ years old.
A total of 14% of participants identified as Hispanic or Latinx. Participants identified their race as White (70%), Asian (11%), Black or African American (9%), multiracial (7%), or another non-White race (4%). The majority of the sample indicated that they were financially dependent on their parents at some level (84%).
Approximately 72% were out to their parents, and 57% were currently living with them during COVID-19. A total of 20% (n = 106) reported past year LGBTQ identity-related victimization only, and 7.2% (n = 38) reported past year+more frequent LGBTQ identity-related victimization since the start of COVID-19. Bullying due to LGBTQ identity was the most frequent type of victimization (past year = 22.5%, and increasing since COVID-19 = 5.5%), followed by being threatened with harm due to LGBTQ identity (past year = 12.5% and increasing since COVID-19 = 3.2%). A total of 65% of the sample (n = 366) suffered from moderate to severe psychological distress.
Impact of LGBTQ identity-related victimization on psychological distress
The bivariate relationship between past year LGBTQ identity-related victimization only and moderate to severe psychological distress was statistically significant (χ2 [1, N = 528] = 6.011, p = 0.014), such that participants who experienced an increase in the frequency of past year LGBTQ identity-related victimization only were more likely to experience moderate to severe psychological distress compared to those with healthy to mild levels of psychological distress and/or not experiencing past year LGBTQ identity-related victimization only.
The bivariate relationship between past year+more frequent LGBTQ identity-related victimization since the start of COVID-19 and moderate to severe psychological distress was statistically significant (χ2 [1, N = 528] = 8.359, p = 0.004), such that participants who experienced past year+more frequent LGBTQ identity-related victimization since the start of COVID-19 were more likely to experience moderate to severe psychological distress compared to those with healthy to mild levels of psychological distress and/or not experiencing past year+more frequent LGBTQ identity-related victimization since the start of COVID-19. In addition, social isolation, sex assigned at birth, gender identity, sexual orientation, and race were significantly associated with moderate to severe psychological distress (Table 1).
Finally, multivariable logistic regression revealed that reporting past year+more frequent LGBTQ identity-related victimization since the start of COVID-19 was associated with over four times greater odds of experiencing moderate to severe psychological distress compared to those who did not report past year+more frequent LGBTQ identity-related victimization since the start of COVID-19 (adjusted odds ratio = 4.209, confidence interval: 1.413–12.535, p = 0.010). Statistically significant covariates included social isolation, gay sexual orientation, and noncisgender identity (Table 3).
Table 3.
Logistic Regression Model Testing the Relationships Between LGBTQ Identity-Related Victimization and Sociodemographic/Social Isolation Covariates with Moderate-to-Severe Psychological Distress Among Sexual and Gender Minority College Students (N = 565)
| Variable | B | OR | 95% CI | P |
|---|---|---|---|---|
| Past year LGBTQ-related victimization only | 0.520 | 1.682 | (0.958–2.955) | 0.070 |
| No past year LGBTQ-related victimization only | Ref. | |||
| More frequent LGBTQ-related victimization since COVID-19a | 1.437 | 4.209 | (1.413–12.535) | 0.010 |
| No more frequent LGBTQ-related victimization since COVID-19 | Ref. | |||
| Social isolation (continuous) | 0.335 | 1.398 | (1.229–1.591) | <0.001 |
| Female assigned at birth | 0.197 | 1.218 | (0.624–2.378) | 0.564 |
| Male assigned at birth | Ref. | |||
| Noncisgender | 0.684 | 1.981 | (1.205–3.259) | 0.007 |
| Cisgender | Ref. | |||
| Gay | −1.015 | 0.362 | (0.162–0.810) | 0.013 |
| Lesbian | 0.582 | 1.790 | (0.973–3.294) | 0.061 |
| Queer | 0.298 | 1.347 | (0.681–2.667) | 0.392 |
| Pansexual | −0.101 | 0.904 | (0.414–1.972) | 0.799 |
| Another sexuality | 0.475 | 1.607 | (0.485–5.329) | 0.438 |
| Bisexual | Ref. | |||
| Undergraduate program | 0.230 | 1.258 | (0.746–2.123) | 0.390 |
| Graduate program | Ref. | |||
| Black | −0.271 | 0.762 | (0.374–1.554) | 0.455 |
| Asian | −0.524 | 0.592 | (0.313–1.121) | 0.108 |
| Multiracial | 0.565 | 1.760 | (0.675–4.587) | 0.248 |
| Another race | −0.054 | 0.948 | (0.302–2.974) | 0.927 |
| White | Ref. | |||
| Living with parents | 0.111 | 1.118 | (0.675–1.851) | 0.665 |
| Not living with parents | Ref. |
Participants in this group also reported past year victimization.
CI, confidence interval; LGBTQ, lesbian, gay, bisexual, transgender, and/or queer or questioning; OR, odds ratio.
Discussion
This study is among the first to explore SGM identity-related victimization in the context of COVID-19 and its impact on psychological distress among SGM college students. Our main study hypotheses were partially confirmed; multivariable analysis demonstrated that sample SGM students who reported past year+more frequent LGBTQ identity-related victimization since the start of COVID-19 had over four times greater odds of experiencing moderate to severe psychological distress compared to those who did not report such victimization experience. Experiencing past year LGBTQ identity-related victimization only was not significant in multivariable analysis, emphasizing the salient and unique impact of LGBTQ identity-related victimization, specifically in the context of COVID-19.
Findings are consistent with previous research on the negative effects of victimization on the mental health of SGM young adults,36,37 as well as recent theorizing about this pathway during COVID-19.22,38 Study results provide initial evidence revealing a strong impact of SGM-related victimization since the start of the COVID-19 pandemic on psychological distress among sample SGM college students.
In addition, study covariates revealed a negative effect of social isolation and noncisgender identity (compared to cisgender identity) on psychological distress. Covariate findings support existing evidence on the negative mental health impacts of the COVID-19 pandemic related to social isolation2 and transgender and nonbinary identities4,11 among SGM young adults and students during COVID-19. SGM young adults who feel more socially isolated might be more vulnerable to suffering from SGM-related victimization experiences,39 highlighting the need for future research to investigate social isolation levels in larger studies.
Public health implications amid the COVID-19 pandemic
Findings from the current study have several public health implications in the context of the ongoing COVID-19 pandemic. Given our finding that social isolation is a significant predictor of moderate to severe psychological distress among SGM college students, it is important to recognize the need for social support of SGM young adults.
Amid the ongoing COVID-19 pandemic, many SGM college students have been forced to leave the campus social environment, stay at their parents' homes, and generally isolate from others due to fully online or hybrid college education formats. Hence, access to diverse types of social support that are found on most college campuses have been lost or interrupted. This highlights the importance of unique social supports that are part of the college experience and that facilitate the mental health of SGM young adults. Social supports for SGM persons are needed both in and particularly away from the campus environment, especially during times of widespread social isolation such as during COVID-19.
As the types and mechanisms of mental health support that were in place before COVID-19 versus during COVID-19 have not been fully identified and examined, there is an important need for researchers to conduct longitudinal studies of SGM young adults to understand on-campus and off-campus facilitators and barriers, such as victimization, to the mental health of SGM young adults. Such research could facilitate SGM support programs in college and noncollege settings, as well as public health policy reform and interventions to mitigate victimization and mental health burden among SGM young adults. The COVID-19 pandemic will likely be followed at some point by another socially isolating widespread crisis and such research could inform how best to combat the special threats that such events hold for the mental health of SGM young adults.
Research reveals that compared to before the COVID-19 pandemic,40 SGM students are experiencing much greater levels of severe psychological distress during the COVID-19 pandemic.9,10 Therefore, there is a great need for mental health, medical, and higher education practitioners to implement competent and affirming practice to respond to the increasing SGM-related concerns in the time of COVID-19 (and beyond) to mitigate negative mental and physical health ramifications among SGM college students.41 Higher education, and medical and mental health entities could help address this concern by increasing SGM-affirmative practice training, capacity, and availability during the time of COVID-19.
SGM-affirmative practice requires providers to competently and sensitively screen for SGM-related concerns (e.g., SGM-related victimization) when providing care to SGM clients, and addressing these concerns and/or linking clients to affirming and competent resources.42–50 Availability of SGM-affirmative practice is especially important during widespread crises such as COVID-19 given the instability of health and mental health services amid this time.
Unfortunately, recent research reveals a deficit in the availability of culturally competent mental health services in the United States.51 Providers are encouraged to seek educational resources regarding the care of SGM young adults in general, but especially for bisexual,52–54 and transgender and nonbinary individuals,55–57 who have unique mental and physical health needs and have been found to be at increased risk for psychological burden when compared to SGM youth of other identities.
Providers should also ensure that existing client information collection procedures adequately capture sexual and gender identity information (e.g., bisexual, transgender, and nonbinary identities) needed to identify persons at high risk for identity-related stressors, such as SGM-related victimization, and prompt the provision of prevention and wellbeing practices.58,59 Such provider practice is especially needed during global-level crises such as COVID-19, which has often rendered invisible the experiences of SGM people (and other marginalized groups), and led to barriers toward adequate SGM population public health response.
It is important for health, mental health, and higher education stakeholders to advocate for the implementation of affirmative response practices and inclusive policy reforms that support the unique SGM identity-related needs (e.g., SGM identity-related victimization experience and mental health burden) of SGM college students and young adults,15,16,60 especially during the time of COVID-19.
Limitations and future directions
This study used a nonprobability and cross-sectional sampling strategy, which limits our ability to generalize findings to broader populations and make causal assessments. Sample eligibility criteria included self-identifying as SGM and a current college student, and while generalization of findings is made to SGM young adults and college students, there may be differences in these populations regarding key study factors, including victimization and psychological distress, which warrant further attention. The study also implemented a retrospective self-report data collection strategy, which presents risk for recall and social desirability biases.
Further, there was a relatively low prevalence (n = 38, 7.2%) of past year+more frequent LGBTQ identity-related victimization since COVID-19 in this study, which caused some confidence interval instability. In addition, the majority of the sample were U.S.-born (92%), female (79%), cisgender (69%), and White (70%); future studies with larger sample sizes are needed to continue to explore the impact of SGM-related victimization on the mental health of SGM young adults and college students during global-level crises, especially among those who hold other nonmajority and marginalized identities and statuses (e.g., nonbinary gender, racial minority, immigrant status).
Indeed, previous research has documented the dual and intersecting impact of racial and SGM stress experiences,61–64 highlighting the importance of implementing intersectionality,65,66 and anti-racism67,68 paradigms in social science research to more equitably understand the mental health needs of SGM young adults who are marginalized by multiple nonmajoritarian social identities, especially during the time of COVID-19 and future global-level crises.69,70
Moreover, items in this study did not differentiate between gender71 and sexual27 minority victimization stress experiences. Future studies should examine SGM stress experiences separately to provide more meaningful information that could increase the effectiveness of prevention practices and interventions to address SGM-related victimization among specific gender identity and sexual orientation subgroups. Despite these limitations, this study provides important higher education, mental health, and medical practice implications to consider in the context of COVID-19 related to the care of SGM college students and young adults.
Conclusion
This study found that reporting past year+more frequent LGBTQ identity-related victimization since the start of COVID-19 was associated with over four times greater odds of experiencing moderate to severe psychological distress. Results highlight the importance of practice and policy stakeholders toward addressing the unique identity-related mental health concerns and victimization experiences of SGM college students and young adults in the context of widespread crises that disrupt social connections, such as during the ongoing COVID-19 pandemic.
Acknowledgments
The authors are grateful to study participants for sharing their personal experiences amid COVID-19. The authors also express their gratitude to LGBTQ+ Students and Allies in Public Health at the University of Maryland (UMD) and various other UMD-affiliated individuals and organizations that supported this work. The authors are further thankful to the various student affairs and diversity offices, LGBTQ student centers, and professors and colleagues across the United States, who do deeply valuable work for marginalized folks in their communities and made this study possible. Finally, the authors thank Dr. Dayron Leon for his early work on this project as part of his Master of Public Health Capstone Project.
Authors' Contributions
J.P.S. conceptualized the study, conducted study recruitment, data collection, and data analysis, and drafted the first iteration of the article. B.O.B. provided extensive feedback on the conceptualization of the current analysis and on the original draft of the article. Both authors reviewed and approved the article before submission.
Disclaimer
Any interpretations and opinions expressed herein are solely the responsibility of the authors and do not necessarily represent the official view of the NIH or CDC.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This study was supported by the University of Maryland Prevention Research Center Cooperative Agreement Number U48DP006382 from the Centers for Disease Control and Prevention (CDC). J.P.S. acknowledges support from the National Institute of Mental Health (Award Number 1R36MH123043) of the National Institutes of Health (NIH).
References
- 1. Czeisler ME, Lane RI, Petrosky E, et al. : Mental health, substance use, and suicidal ideation during the COVID-19 pandemic—United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049–1057. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Fish JN, Salerno J, Williams ND, et al. : Sexual minority disparities in health and well-being as a consequence of the COVID-19 pandemic differ by sexual identity. LGBT Health 2021;8:263–272. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Kamal K, Li JJ, Hahm HC, Liu CH: Psychiatric impacts of the COVID-19 global pandemic on U.S. sexual and gender minority young adults. Psychiatry Res 2021;299:113855. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Hawke LD, Hayes E, Darnay K, Henderson J: Mental health among transgender and gender diverse youth: An exploration of effects during the COVID-19 pandemic. Psychol Sex Orientat Gend Divers 2021;8:180–187. [Google Scholar]
- 5. Moore SE, Wierenga KL, Prince DM, et al. : Disproportionate impact of the COVID-19 pandemic on perceived social support, mental health and somatic symptoms in sexual and gender minority populations. J Homosex 2021;68:577–591. [DOI] [PubMed] [Google Scholar]
- 6. Gato J, Barrientos J, Tasker F, et al. : Psychosocial effects of the COVID-19 pandemic and mental health among LGBTQ+ young adults: A cross-cultural comparison across six nations. J Homosex 2021;68:612–630. [DOI] [PubMed] [Google Scholar]
- 7. Rodriguez-Seijas C, Fields EC, Bottary R, et al. : Comparing the impact of CoViD-19-related social distancing on mood and psychiatric indicators in sexual and gender minority (SGM) and non-SGM individuals. Front Psychiatry 2020;11:590318. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Espinosa LL, Turk JM, Taylor M, Chessman HM: Race and Ethnicity in Higher Education: A Status Report. Washington, DC: American Council on Education, 2019. Available at: https://1xfsu31b52d33idlp13twtos-wpengine.netdna-ssl.com/wp-content/uploads/2019/02/Race-and-Ethnicity-in-Higher-Education.pdf Accessed July 22, 2021.
- 9. Gonzales G, Loret de Mola E, Gavulic KA, et al. : Mental health needs among lesbian, gay, bisexual, and transgender college students during the COVID-19 pandemic. J Adolesc 2020;67:645–648. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Salerno JP, Pease M, Devadas J, et al. : COVID-19-Related Stress Among LGBTQ+ University Students: Results of a U.S. National Survey. University of Maryland Prevention Research Center, 2020. Available at: https://drum.lib.umd.edu/bitstream/handle/1903/26375/LGBTQ_COVID_Report_09032020.pdf?sequence=3&isAllowed=y Accessed July 22, 2021.
- 11. Hunt C, Gibson GC, Vander Horst A, et al. : Gender diverse college students exhibit higher psychological distress than male and female peers during the novel coronavirus (COVID-19) pandemic. Psychol Sex Orientat Gend Divers 2021;8:238–244. [Google Scholar]
- 12. Salerno JP, Shrader CH, Algarin AB, et al. : Changes in alcohol use since the onset of COVID-19 are associated with psychological distress among sexual and gender minority university students in the U.S. Drug Alcohol Depend 2021;221:108594. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. The Trevor Project: 2021 National Survey on LGBTQ Youth Mental Health. West Hollywood, California: The Trevor Project, 2021. Available at: https://www.thetrevorproject.org/survey-2021/?section=Covid19 Accessed July 22, 2021.
- 14. Fish JN, McInroy LB, Paceley M, et al. : “I'm kinda stuck at home with unsupportive parents right now”: LGBTQ youths' experiences with COVID-19 and the importance of online support. J Adolesc 2020;67:450–452. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Woodford MR, Kulick A, Garvey JC, et al. : LGBTQ policies and resources on campus and the experiences and psychological well-being of sexual minority college students: Advancing research on structural inclusion. Psychol Sex Orientat Gend Divers 2018;5:445–446. [Google Scholar]
- 16. Pitcher EN, Camacho TP, Renn KA, Woodford MR: Affirming policies, programs, and supportive services: Using an organizational perspective to understand LGBTQ+ college student success. J Divers High Educ 2018;11:117–132. [Google Scholar]
- 17. Woodford MR, Weber G, Nicolazzo Z, et al. : Depression and attempted suicide among LGBTQ college students: Fostering resilience to the effects of heterosexism and cisgenderism on campus. J Coll Stud Dev 2018;59:421–438. [Google Scholar]
- 18. Russell ST, Fish JN: Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth. Annu Rev Clin Psychol 2016;12:465–487. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Hill RL, Nguyen DJ, Kilgo CA, et al. : How LGBTQ+ students thrive in college. J Stud Aff Res Pract 2020;58:1–15. [Google Scholar]
- 20. Salerno JP, Williams ND, Gattamorta KA: LGBTQ populations: Psychologically vulnerable communities in the COVID-19 pandemic. Psychol Trauma 2020;12:S239–S242. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Conron KJ, O'Neill K, Sears B: COVID-19 and Students in Higher Education: A 2021 Study of the Impact of the COVID-19 Pandemic on the Educational Experiences of LGBTQ and Non-LGBTQ U.S. Adults Aged 18–40. Los Angeles, CA: The Williams Institute, UCLA, 2021. Available at: https://escholarship.org/content/qt6zz9v5w7/qt6zz9v5w7_noSplash_2d08c94b6126220f0e7f144ec1bd3642.pdf?t=qtgpta Accessed July 22, 2021.
- 22. Salerno JP, Devadas J, Pease M, et al. : Sexual and gender minority stress amid the COVID-19 pandemic: Implications for LGBTQ young persons' mental health and wellbeing. Public Health Rep 2020;135:721–727. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Iacono G, Craig SL, Pascoe R: Critical reflections and reflexivity on responding to the needs of LGBTQ+ youth in a global pandemic. Qual Soc Work 2021;20:479–486. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Fish JN, Schulenberg JE, Russell ST: Sexual minority youth report high-intensity binge drinking: The critical role of school victimization. J Adolesc 2019;64:186–193. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Seelman K, Woodford M, Nicolazzo Z: Victimization and microaggressions targeting LGBTQ college students: Gender identity as a moderator of psychological distress. J Ethn Cult Divers Soc Work 2017;26:112–125. [Google Scholar]
- 26. Hatchel T, Valido A, De Pedro KT, et al. : Minority stress among transgender adolescents: The role of peer victimization, school belonging, and ethnicity. J Child Fam Stud 2019;28:2467–2476. [Google Scholar]
- 27. Meyer IH: Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull 2003;129:674–697. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Brooks VR: Minority Stress and Lesbian Women. Lexington, MA: Free Press, 1981. [Google Scholar]
- 29. Dürrbaum T, Sattler FA: Minority stress and mental health in lesbian, gay male, and bisexual youths: A meta-analysis. J LGBT Youth 2020;17:298–314. [Google Scholar]
- 30. Kulick A, Wernick LJ, Woodford MR, Renn K: Heterosexism, depression, and campus engagement among LGBTQ college students: Intersectional differences and opportunities for healing. J Homosex 2017;64:1125–1141. [DOI] [PubMed] [Google Scholar]
- 31. Balsam KF, Beadnell B, Molina Y: The daily heterosexist experiences questionnaire. Meas Eval Couns Dev 2013;46:3–25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. Outland PL: Developing the LGBT Minority Stress Measure. Colorado State University, 2016. Available at: https://mountainscholar.org/handle/10217/176760 Accessed July 22, 2021.
- 33. Kessler RC, Andrews G, Colpe LJ, et al. : Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 2002;32:959–976. [DOI] [PubMed] [Google Scholar]
- 34. Andrews G, Slade T: Interpreting scores on the Kessler Psychological Distress Scale (K10). Aust N Z J Public Health 2001;25:494–497. [DOI] [PubMed] [Google Scholar]
- 35. Hughes ME, Waite LJ, Hawkley LC, Cacioppo JT: A short scale for measuring loneliness in large surveys: Results from two population-based studies. Res Aging 2004;26:655–672. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Fish JN, Baams L, McGuire JK: Sexual and gender minority mental health among children and youth. In: The Oxford Handbook of Sexual and Gender Minority Mental Health. New York, NY: Oxford University Press, 2020, pp 229–244. [Google Scholar]
- 37. Busby DR, Horwitz AG, Zheng K, et al. : Suicide risk among gender and sexual minority college students: The roles of victimization, discrimination, connectedness, and identity affirmation. J Psychiatr Res 2020;121:182–188. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38. DeMulder J, Kraus-Perrotta C, Zaidi H: Sexual and gender minority adolescents must be prioritised during the global COVID-19 public health response. Sex Reprod Health Matters 2020;28:1804717. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39. Rostosky SS, Richardson MT, McCurry SK, Riggle EDB: LGBTQ individuals' lived experiences of hypervigilance. Psychol Sex Orientat Gend Divers 2021. [Epub ahead of print]; DOI: 10.1037/sgd0000474. [DOI] [Google Scholar]
- 40. Dunbar MS, Sontag-Padilla L, Ramchand R, et al. : Mental health service utilization among lesbian, gay, bisexual, and questioning or queer college students. J Adolesc 2017;61:294–301. [DOI] [PubMed] [Google Scholar]
- 41. Phillips II G, Felt D, Ruprecht MM, et al. : Addressing the disproportionate impacts of the COVID-19 pandemic on sexual and gender minority populations in the United States: Actions toward equity. LGBT Health 2020;7:179–282. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42. Chaudoir SR, Wang K, Pachankis JE: What reduces sexual minority stress? A review of the intervention “toolkit.” J Soc Issues 2017;73:586–617. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43. Pachankis JE: A transdiagnostic minority stress treatment approach for gay and bisexual men's syndemic health conditions. Arch Sex Behav 2015;44:1843–1860. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44. Pachankis JE, Hatzenbuehler ML, Rendina HJ, et al. : LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: A randomized controlled trial of a transdiagnostic minority stress approach. J Consult Clin Psychol 2015;83:875–889. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45. Diamond GM, Shpigel MS: Attachment-based family therapy for lesbian and gay young adults and their persistently nonaccepting parents. Prof Psychol Res Pr 2014;45:258–268. [Google Scholar]
- 46. Cohen J, Mannarino A, Wilson K, Zinny A: Trauma-Focused Cognitive Behavioral Therapy LGBTQ Implementation Manual. Pittsburgh, PA: Allegheny Health Network, 2018. Available at: https://tfcbt.org/wp-content/uploads/2019/10/TF-CBT-LGBTQ-Implementation-Manual-FINAL.pdf Accessed July 22, 2021.
- 47. SAMHSA: A Practitioner's Resource Guide: Helping Families to Support Their LGBT Children. HHS Publication No. PEP14-LGBTKIDS. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. Available at: https://store.samhsa.gov/sites/default/files/d7/priv/pep14-lgbtkids.pdf Accessed July 22, 2021.
- 48. Austin A, Craig SL, D'Souza SA: An AFFIRMative cognitive behavioral intervention for transgender youth: Preliminary effectiveness. Prof Psychol Res Pr 2018;49:1–8. [Google Scholar]
- 49. Poquiz JL, Shrodes A, Garofalo R, et al. : Supporting pride, activism, resiliency, and community: A telemedicine-based group for youth with intersecting gender and racial minority identities. Transgend Health 2021. [Epub ahead of print]; DOI: 10.1089/trgh.2020.0152. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50. Burton CL, Wang K, Pachankis JE: Psychotherapy for the spectrum of sexual minority stress: Application and technique of the ESTEEM treatment model. Cogn Behav Pract 2019;26:285–299. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51. Williams ND, Fish JN: The availability of LGBT-specific mental health and substance abuse treatment in the United States. Health Serv Res 2020;55:932–943. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52. Feinstein BA, Dyar C: Bisexuality, minority stress, and health. Curr Sex Health Rep 2017;9:42–49. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53. Mefford TE, Chen EC: Minority stress, stigma, and violence: Affirmative counseling for bisexual individuals. In: Violence Against LGBTQ+ Persons. Switzerland AG: Springer, 2021, pp 163–177. [Google Scholar]
- 54. Bostwick WB, Harrison EA: Bisexual Mental Health. New York, NY: Oxford University Press, 2020, pp 269–282. [Google Scholar]
- 55. Tankersley AP, Grafsky EL, Dike J, Jones RT: Risk and resilience factors for mental health among transgender and gender nonconforming (TGNC) youth: A systematic review. Clin Child Fam Psychol Rev 2021;24:183–206. [DOI] [PubMed] [Google Scholar]
- 56. Valentine SE, Shipherd JC: A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States. Clin Psychol Rev 2018;66:24–38. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 57. Coyne CA, Poquiz JL, Janssen A, Chen D: Evidence-based psychological practice for transgender and non-binary youth: Defining the need, framework for treatment adaptation, and future directions. Evid Based Pract Child Adolesc Ment Health 2020;5:340–353. [Google Scholar]
- 58. Cahill S, Grasso C, Keuroghlian A, et al. : Sexual and gender minority health in the COVID-19 pandemic: Why data collection and combatting discrimination matter now more than ever. Am J Public Health 2020;110:1360–1361. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 59. Cahill S, Makadon H: Sexual orientation and gender identity data collection in clinical settings and in electronic health records: A key to ending LGBT health disparities. LGBT Health 2014;1:34–41. [DOI] [PubMed] [Google Scholar]
- 60. National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Committee on Population; Committee on Understanding the Well-Being of Sexual and Gender Diverse Populations: Public policy and structural stigma. In: Understanding the Well-being of LGBTQI+ Populations. Washington, DC: National Academies Press (US), 2020. [Google Scholar]
- 61. Salerno JP, Gattamorta KA, Williams ND: Impact of family rejection and racism on sexual and gender stress among LGBTQ young people of color. Psychol Trauma 2022. [Epub ahead of print]; DOI: 10.1037/tra0001254. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 62. Velez BL, Polihronakis CJ, Watson LB, Cox R: Heterosexism, racism, and the mental health of sexual minority people of color. Couns Psychol 2019;47:129–159. [Google Scholar]
- 63. Sutter M, Perrin PB: Discrimination, mental health, and suicidal ideation among LGBTQ people of color. J Couns Psychol 2016;63:98–105. [DOI] [PubMed] [Google Scholar]
- 64. English D, Rendina HJ, Parsons JT: The effects of intersecting stigma: A longitudinal examination of minority stress, mental health, and substance use among Black, Latino, and multiracial gay and bisexual men. Psychol Violence 2018;8:669–679. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 65. Bowleg L: The problem with the phrase women and minorities: Intersectionality—An important theoretical framework for public health. Am J Public Health 2012;102:1267–1273. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 66. Collins PH: Intersectionality as Critical Social Theory. Durham: Duke University Press, 2019. [Google Scholar]
- 67. Ford CL, Griffith DM, Bruce MA, Gilbert KL: Racism: Science & Tools for the Public Health Professional. Washington DC: American Public Health Association Press, 2019. [Google Scholar]
- 68. Ford CL, Airhihenbuwa CO: The public health critical race methodology: Praxis for antiracism research. Soc Sci Med 2010;71:1390–1398. [DOI] [PubMed] [Google Scholar]
- 69. Bowleg L: We're not all in this together: On COVID-19, intersectionality, and structural inequality. Am J Public Health 2020;110:917. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 70. Ford CL: Commentary: Addressing inequities in the era of COVID-19: The pandemic and the urgent need for critical race theory. Fam Community Health 2020;43:184–186. [DOI] [PubMed] [Google Scholar]
- 71. Testa RJ, Habarth J, Peta J, et al. : Development of the gender minority stress and resilience measure. Psychol Sex Orientat Gend Divers 2015;2:65–77. [Google Scholar]