Short abstract
Surveillance data indicate youth have many sexual and gender identities that should be included in clinical forms and surveys to document and improve health equity.
Abstract
OBJECTIVES
To estimate the prevalence of diverse sexual orientations and gender identities in a statewide surveillance survey of adolescents and examine how experiences of bias-based bullying and depressive symptoms vary.
METHODS
Data come from 8th, 9th, and 11th-grade students participating in the 2019 Minnesota Student Survey (N = 124 778). We examined the prevalence of sexual and gender identities and used multifactor analysis of variance models to understand experiences with sexual orientation– and gender-based bullying and depression across sexual and gender identities.
RESULTS
Among 9th and 11th graders, 9.4% identified as lesbian, gay, bisexual, queer, or pansexual (1.7% pansexual, 0.4% queer). Among 8th, 9th, and 11th graders, 1.4% were transgender, genderqueer, or genderfluid, with almost half of those identifying as nonbinary; 2.1% were unsure of their gender identity. Rates of depressive symptoms were highest among pansexual students compared to other sexual orientations and among nonbinary and transmasculine youth who identified their sex as female. Rates of depression and bias-based bullying for youth who did not identify their sexual orientation as 1 of the response options were comparable to straight youth or those who did not understand the question.
CONCLUSIONS
Findings provide strong support for the inclusion of a broader set of sexual and gender identity response options in epidemiologic surveys and patient forms. Pansexual and queer youth and transmasculine and nonbinary youth whose sex is female carry a particularly high burden of bias and discrimination, and clinicians should screen for additional services and supports these youth may need to thrive.
What’s Known on this Subject:
Youth commonly use sexual and gender identities infrequently included on surveillance surveys or clinical forms. Those with newer identities may face greater challenges than their peers, but epidemiologic data including newer identities is needed to describe variation among lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) youth.
What This Study Adds:
Identities such as pansexual and nonbinary are common among LGBTQ+ youth. Rates of emotional distress and bias-based bullying were particularly high for pansexual and queer youth as well as transmasculine and nonbinary youth indicating their sex as female.
Young people use a range of terms to describe their sexual and gender identities (eg, pansexual, demisexual, nonbinary, fluid); yet, very few public health surveillance surveys include these terms as response options.1,2 Information about specific identities is critical because preliminary evidence in convenience samples of youth and national samples of adults demonstrates that lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) people are not homogenous. Rates of health outcomes, risk, and protective factors vary significantly by sexual and gender identity.1–4 As a result, gaps in surveillance survey response options lead directly to gaps in our knowledge of health disparities and limit the ability of clinicians, providers, and communities to promote health equity, particularly among LGBTQ+ youth.5,6
A substantial subset of LGBTQ+ youth use terms for their sexual and gender identities that are beyond response options typically used in epidemiologic surveys (eg, gay, lesbian, bisexual, transgender).7–11 Examples of terms commonly used at the time of writing include pansexual, a term for those attracted to any gender.12 Queer is a word that younger generations have reclaimed and is often used as an umbrella term for individuals who are not cisgender and/or heterosexual.1 Asexual describes people who experience little to no sexual attraction or may experience sexual attraction only under specific circumstances. Nonbinary describes alternative genders other than exclusively girl and boy or woman and man. Some nonbinary youth may also identify as transgender while others may not, and nonbinary is a term that can be used to describe a person’s aesthetic and presentation among both cisgender and transgender people.12 Genderqueer describes a person who identifies as both man or boy and woman or girl, neither, or somewhere in between, or may feel restricted by gender descriptors.12 Genderfluid describes individuals whose gender identities and/or presentation fluctuate over time.12
Although past work indicated that the prevalence of these identities was relatively low,13 language and identities have rapidly changed over the last 15 years. Evidence from recent national convenience samples of LGBTQ+ adolescents illustrates the importance of assessing these identities. Watson and colleagues found 14 distinct sexual identities and 12 gender identities in their national survey of LGBTQ+ adolescents, with 24% of this sample selecting terms beyond traditional survey options.2 One-third of the youth in the sample identified as nonbinary, transmasculine, transgender boys, transfeminine, and transgender girls (in decreasing order of prevalence). Another large convenience sample of US adolescents found that in open-ended responses to sexual and gender identity questions, pansexual and asexual were the most commonly written-in sexual orientation terms.14 Genderfluid and nonbinary were the most commonly given gender identity responses.14 Convenience samples, however, especially those specifically sampling LGBTQ+ youth, do not provide generalizable estimates, and no large-scale population-based estimates among US adolescents are available, to our knowledge, that specifically include diverse identities. This further limits the ability to determine best practices for health screening and clinical practice, including clinical data collection.
In addition to accurately counting LGBTQ+ populations, the inclusion of a range of response options is necessary to track health disparities and guide prevention efforts. Some studies suggest that people using emerging labels may experience larger health disparities than peers using traditional labels.4 For example, among US college students, pansexual and queer students report more depression and anxiety symptoms than their gay and lesbian peers.15 Nonbinary youth have higher rates of nonsuicidal self-injury and emotional distress than binary transgender youth.16 Experiences of bias-based bullying, harassment, and discrimination, considered a distal minority stressor for LGBTQ+ youth that drives key health disparities, may also vary by identity, with emerging evidence indicating nonbinary and bisexual or pansexual youth carry greater burden.17,18
The aim of this study was to provide the first prevalence estimates of LGBTQ+ identities in a large, statewide survey using new response options rarely included in surveillance instruments overall, by sex,* and by race, because of cultural differences in identity label usage.2 Additionally, we explore differences in select indicators where health disparities are well established (ie, depressive symptoms and bias-based bullying), focusing on disparities across newer and more traditional identity labels. We also aim to understand how youth selecting another identity not listed compare to LGBTQ+ and cisgender straight youth on these outcomes. Findings will shed light on future survey creation and have implications for clinicians and researchers working with LGBTQ+ youth.
Methods
Data used was from the 2019 Minnesota Student Survey (MSS), a triennial, anonymous survey of the state’s public and charter school students in select grades. The University of Minnesota Instituional Review Board exempted this study from review because of the use of anonymous, existing data. All districts are invited to participate (81% participated in 2019), and passive parental consent procedures are used. Students reported their sex (“biological sex”: male or female), grade (8th, 9th, or 11th), race and ethnicity (see Table 1), and whether they received free or reduced price lunch (yes, no, or not sure). The MSS team recorded the location of the school as within the 7-county Twin Cities metropolitan area or other areas of Minnesota.
TABLE 1.
Prevalence of Sexual and Gender Identities Overall and by Sex.
| All | Male | Female | ||||
|---|---|---|---|---|---|---|
| N | % | n | % | n | % | |
| Race and ethnicitya | ||||||
| American Indian | 1509 | 1.2 | 804 | 1.3 | 699 | 1.1 |
| Asian | 8215 | 6.6 | 4107 | 6.7 | 4103 | 6.6 |
| Black | 9661 | 7.8 | 4995 | 8.1 | 4646 | 7.5 |
| Hispanic or Latino/Latina | 7601 | 6.1 | 3795 | 6.2 | 3799 | 6.1 |
| Native Hawaiian or Pacific Islander | 270 | 0.2 | 165 | 0.3 | 103 | 0.2 |
| White | 85 830 | 69.3 | 42 747 | 69.4 | 42 979 | 69.2 |
| Multiracial | 10 827 | 8.7 | 5020 | 8.1 | 5783 | 9.3 |
| Sexual orientationb | ||||||
| Heterosexual (straight) | 62 799 | 78.7 | 33 369 | 83.9 | 29 368 | 73.7 |
| Bisexual | 4515 | 5.7 | 918 | 2.3 | 3585 | 9.0 |
| Gay or lesbian | 1253 | 1.6 | 548 | 1.4 | 701 | 1.8 |
| Pansexual | 1350 | 1.7 | 208 | 0.5 | 1131 | 2.8 |
| Queer | 351 | 0.4 | 105 | 0.3 | 240 | 0.6 |
| Questioning or not sure | 1662 | 2.1 | 381 | 1.0 | 1278 | 3.2 |
| I don’t describe myself in any of these ways | 6671 | 8.4 | 3469 | 8.7 | 3179 | 8.0 |
| I am not sure what this question means | 1192 | 1.5 | 790 | 2.0 | 392 | 1.0 |
| Transgender, genderqueer, or genderfluidc | ||||||
| Yes | 1756 | 1.4 | 436 | 0.7 | 1279 | 2.0 |
| No | 115 787 | 92.8 | 57 672 | 92.9 | 58 009 | 92.8 |
| Not sure | 2105 | 1.7 | 746 | 1.2 | 1337 | 2.1 |
| I am not sure what this question means | 5130 | 4.1 | 3252 | 5.2 | 1852 | 3.0 |
| Gender identityb,c | ||||||
| Male, trans male, trans man, transmasculine | 636 | 36.7 | 302 | 48.2 | 416 | 32.8 |
| Female, trans female, trans woman, transfeminine | 203 | 11.7 | 60 | 14.3 | 139 | 11.0 |
| Nonbinary, genderqueer, or genderfluid | 744 | 43.0 | 97 | 23.0 | 631 | 49.7 |
| I prefer to describe my gender as something else | 148 | 8.5 | 61 | 14.5 | 83 | 6.5 |
We did not test for sex differences in race and ethnicity because they were not part of the research questions.
P < .05 for prevalence differences by sex.
Among those who responded “yes” to the previous question, verbatim response options.
Response options for sexual orientation were: heterosexual (straight), bisexual, gay or lesbian, questioning or not sure, pansexual, queer, I don’t describe myself in any of these ways, and I am not sure what this question means. A modified 1-step question asked if students were “transgender, genderqueer or genderfluid,” (responses: yes; no; I am not sure about my gender identity; and I am not sure what this question means).10 Students answering no were considered cisgender. For those who answered yes, a follow-up question provided specific identity terms: (1) male, transmale, transman, or transmasculine; (2) female, transfemale, transwoman, or transfeminine; (3) nonbinary, genderqueer, or genderfluid, or (4) I prefer to describe my gender as something else. Participants could only select 1 response option for each question.
Youth also completed the Patient Health Questionnaire-2 (PHQ-2), a commonly used screener for depressive symptoms in the past 2 weeks.19 Responses to the 2 questions (0 to 3 scale) were summed. Scores of 3 or more were considered a positive screen for depressive symptoms, indicating the need for additional assessment. Respondents also reported their experiences of bullying on the basis of (1) sexual orientation (“because you are gay, lesbian, bisexual or because someone thought you were”) and (2) gender (“your gender [being male, female, transgender, etc.]”) in the past 30 days (recoded to none or any).20
Analysis Plan
Analyses used data from 9th and 11th graders for sexual orientation (N = 79 793) and 8th, 9th, and 11th graders for gender identity (N = 124 778), based on question availability. Within those grades, we employed list-wise deletion by analysis. To understand the full range, we calculated the prevalence of all sexual and gender identity responses for the analytic sample and by sex, grade, and race and ethnicity. χ2 tests identified significant differences in prevalence by these key demographic characteristics. Multifactor analysis of variance (ANOVA) with the full sample examined sexual and gender identity differences in positive depression screens and bias-based bullying, adjusting for grade, sex, race and ethnicity, free or reduced-price lunch, and region. ANOVAs allow for comparison among all groups without the need to specify a reference group; estimated marginal means can be interpreted as predicted prevalences.21,22 Posthoc Bonferroni tests probed significant main effects. α was set to 0.05, and IBM SPSS v27 was used.
Results
Overall, 9.4% of high schoolers identified as lesbian, gay, bisexual, queer, or pansexual (4.5% of those reporting their sex as male and 14.2% of those reporting their sex as female), 9.1% of 9th graders and 9.8% of 11th graders. An additional 2.1% (1.0% reporting male sex, 3.2% reporting female sex) questioned their sexual orientation, 2.3% of 9th graders and 1.8% of 11th graders. Of note, 8.4% of youth indicated that they did not use any of the sexual orientation terms (8.7% of those reporting male sex, 8.0% of those reporting female sex). Table 1 documents prevalence of each specific identity separately.
For gender identity, 1.4% of 8th, 9th, and 11th graders indicated they were transgender, genderqueer, or genderfluid (0.7% of those reporting male sex, 2.0% of those reporting female sex), which was consistent across grades. Overall, 1.7% of youth were unsure of their gender identity (1.2% of those reporting male sex and 2.1% of those reporting female sex), 2.1% of 8th graders, 1.6% of 9th graders, and 1.2% of 11th graders. Among those who identified as transgender, genderqueer, or genderfluid and also reported their sex as male, almost one-half identified as male, transman, or transmasculine, almost one-quarter as nonbinary, and ∼14% each as female, transwoman, transfeminine, or another identity. For transgender, genderqueer, or genderfluid youth who identified their sex as female, one-half identified as nonbinary, one-third as male, transman, or transmasculine; and 11% as female, transwoman or transfeminine; and ∼6% as another identity. χ2 tests indicated these response patterns differed significantly by sex.
Table 2 describes preliminary exploration of the intersection of sexual orientation and gender identity. Bisexual (20.5%) and pansexual (28.8%) were common sexual orientation identities among those who identified as transgender, genderqueer, or genderfluid. Prevalence of sexual and gender identities varied by race and ethnicity as well (Table 3). Among American Indian and multiracial youth, bisexual (10.7% and 9.3%, respectively) and pansexual (4.0% and 3.6%) were common sexual identities, and rates of transgender, genderqueer, or genderfluid identity (2.7% and 2.5%) were higher relative to other race and ethnicity groups. Race and ethnicity differences emerged for not understanding the sexual orientation and gender identity questions as well, with White and multiracial youth less likely to choose this option than other groups.
TABLE 2.
Sexual Orientation by Gender Identity (N = 79 609)
| Cisgender | Transgender/Genderqueer/ Genderfluid | Unsure of My Gender Identity | Don’t Know What This Question Means | |||||
|---|---|---|---|---|---|---|---|---|
| Percent Cisgender Among This Sexual Orientation Group | Percent in Sexual Orientation Group Among Cisgender Group | Percent TGD Among This Sexual Orientation Group | Percentage in Sexual Orientation Group Among TGD Group | Percent Unsure Among This Sexual Orientation Group | Percent in Sexual Orientation Group Among Unsure Group | Percent Don’t Understand Among This Sexual Orientation Group | Percent in Sexual Orientation Group Among Don’t Understand Group | |
| Straight | 96.9 | 81.2 | 0.2 | 13.5 | 0.3 | 16.6 | 2.6 | 63.6 |
| Bisexual | 86.3 | 5.2 | 5.2 | 20.5 | 5.6 | 21.7 | 2.9 | 5.0 |
| Gay or lesbian | 75.8 | 1.3 | 13.3 | 14.6 | 8.6 | 9.2 | 2.3 | 1.1 |
| Questioning | 82.4 | 1.8 | 3.1 | 4.6 | 10.6 | 15.1 | 3.8 | 2.5 |
| Pansexual | 59.6 | 1.1 | 24.3 | 28.8 | 14.5 | 16.7 | 1.6 | 0.9 |
| Queer | 48.1 | 0.2 | 30.9 | 9.5 | 18.9 | 5.7 | 2.0 | 0.3 |
| Don’t describe myself in any of these ways | 91.1 | 8.1 | 1.2 | 7.1 | 2.2 | 12.5 | 5.5 | 14.2 |
| Not sure what this question means | 68.1 | 1.1 | 1.4 | 1.4 | 2.5 | 2.5 | 28.0 | 12.8 |
Because sexual orientation was only asked of 9th and 11th graders, 8th graders are excluded from this analysis. For each gender identity, there are 2 columns. The first column indicates the percent of the sexual orientation group (eg, straight) that identifies as that particular gender identity (eg, 96.9% of straight youth identify as cisgender). The second column indicates the percent of the gender group (eg, cisgender) who identify as a particular sexual orientation (eg, 81.2% of cisgender youth identify as straight). TGD, transgender and gender diverse.
TABLE 3.
Percent of Students Selecting Each Sexual and Gender Identity by Race
| American Indian or Alaska Native, % | Asian, % | Black, % | Hispanic or Latino, % | Native Hawaiian or Pacific Islander, % | White, % | Multiracial, % | |
|---|---|---|---|---|---|---|---|
| Sexual orientationa | |||||||
| Straight | 67.3 | 74.8 | 76.5 | 73.2 | 68.2 | 80.8 | 73.4 |
| Bisexual | 10.7 | 5.3 | 4.5 | 6.4 | 5.7 | 5.2 | 9.3 |
| Gay or lesbian | 3.0 | 1.5 | 1.1 | 1.5 | 1.3 | 1.5 | 2.0 |
| Questioning | 1.6 | 2.4 | 1.3 | 1.9 | 2.5 | 2.0 | 3.3 |
| Pansexual | 4.0 | 1.2 | 1.0 | 1.4 | 1.3 | 1.6 | 3.6 |
| Queer | 0.8 | 0.5 | 0.4 | 0.3 | 0.6 | 0.4 | 0.6 |
| Don’t describe myself in any of these ways | 10.8 | 12.0 | 12.8 | 12.7 | 15.9 | 7.2 | 6.7 |
| Not sure what this question means | 1.8 | 2.4 | 2.3 | 2.6 | 4.5 | 1.2 | 1.2 |
| Transgender, genderqueer, or genderfluida | |||||||
| Yes | 2.8 | 1.2 | 1.1 | 1.1 | 2.2 | 1.3 | 2.5 |
| No | 87.7 | 90.8 | 91.4 | 91.1 | 82.2 | 93.8 | 90.8 |
| Not sure | 2.2 | 2.2 | 1.5 | 1.8 | 5.9 | 1.5 | 2.4 |
| I am not sure what this question means | 7.3 | 5.9 | 6.1 | 6.0 | 9.6 | 3.4 | 4.3 |
P< .05 for prevalence differences by race.
Results from multifactor ANOVAs indicated significant differences in depressive symptoms and bias-based bullying experiences by sexual orientation (Table 4) and gender identity (Table 5). Pansexual and queer youth had similar rates of depression and bias-based bullying, and their rates of gender-based bullying were higher than any other group. Students who identified as gay or lesbian had the highest predicted prevalence of sexual orientation-based bullying. Youth selecting “I don’t describe myself in any of these ways” for their sexual orientation did not differ from youth who did not understand the question on both forms of bias-based bullying and were the same as straight youth on depression.
TABLE 4.
Estimated Marginal Means From ANOVAs Predicting Depression and Bias-Based Bullying by Sexual Orientation With Sociodemographic Controls
| Heterosexual (Straight) | Bisexual | Gay or Lesbian | Questioning or Not Sure | Pansexual | Queer | I Don’t Describe Myself in Any of These Ways | I am Not Sure What This Question Means | |
|---|---|---|---|---|---|---|---|---|
| PHQ-2 | 22.8a | 51.9b | 51.2b | 44.1c | 59.9d | 54.4b,d | 22.2a | 24.8a |
| Sexual orientation-based bullying | 4.0a | 30.3b | 50.0c | 18.2d | 43.2e | 41.8e | 5.5f | 7.1f |
| Gender-based bullying | 5.6a | 16.3b,c | 19.2b | 14.8c | 28.1d | 31.3d | 7.3e | 9.5e |
Multifactor ANOVAs control for grade, sex, race and ethnicity, free or reduced price lunch, and region. Estimated marginal means can be interpreted as predicted prevalences when the dependent variable is dichotomous. Estimates that share a superscript are not significantly different from one another (P > .05).
TABLE 5.
Estimated Marginal Means From ANOVAs Predicting Depression and Bias-Based Bullying by Gender Identity With Sociodemographic Controls.
| Male, Transmale, Transman, or Transmasculine | Female, Transfemale, Transwoman, or Transfeminine | Nonbinary, Genderqueer, or Genderfluid | I Prefer to Describe My Gender as Something Else | I Am Not Sure About My Gender Identity | Cisgender | I Don’t Know What This Question Means | |
|---|---|---|---|---|---|---|---|
| Male sex | |||||||
| PHQ-2 | 37.2a | 52.0a,b | 57.7b,c | 45.0a,c | 41.4a | 19.7d | 23.3e |
| Sexual orientation-based bullying | 32.9a | 36.6a | 54.4b | 41.9a,b | 30.3a | 7.1c | 9.6d |
| Gender-based bullying | 33.4a | 46.5b | 48.4b | 42.0a,b | 24.8c | 5.1d | 8.6e |
| Female sex | |||||||
| Depression | 73.8a | 43.6b | 71.6a | 47.6b,c | 59.5c | 30.8d | 32.2b,d |
| Sexual orientation-based bullying | 51.6a | 16.0b | 54.7a | 43.3a,c | 36.9c | 6.5d | 9.7b |
| Gender-based bullying | 71.9a | 26.0b | 56.5c | 38.6b | 31.6b | 9.2d | 10.9e |
Multifactor ANOVAs control for grade, sex, race and ethnicity, free/reduced price lunch, and region. Estimated marginal means can be interpreted as predicted prevalences when the dependent variable is dichotomous. Estimates that share a superscript are not significantly different from one another (P > .05).
Among youth who identified their sex as male, those identifying as nonbinary had higher rates of depression and bias-based bullying than those identifying as male, transman, transmasculine, and unsure about their gender identity. Over 70% of youth reporting their sex as female and identifying as nonbinary or male, transman, or transmasculine screened positive for depression, higher than all other groups. Gender-based bullying was also particularly high among nonbinary and male, transman, or transmasculine youth reporting their sex as female. Youth who identified with a gender identity not listed on the survey had rates of depression and bias-based bullying in line with youth identifying as transmasculine, transfeminine, nonbinary, or unsure of their gender identity and higher than cisgender respondents.
Discussion
This study is the first to report on statewide youth surveillance data that includes more contemporary response options for sexual and gender identity. Results indicate these identities are relatively common and important to capture among LGBTQ+ youth. Similar proportions of students indicated they were pansexual (1.7%) as gay or lesbian (1.6%). Nonbinary youth comprised about one-half of transgender or gender diverse youth who reported their sex as female and about one-quarter of youth reporting male sex. Critically, rates of depression and bias-based bullying differed by identity, sometimes dramatically, demonstrating the importance of examining specific sexual and gender identities in clinical practice and research. These findings underscore the need to include updated response options, such as pansexual and nonbinary, in epidemiologic surveys and in clinical encounters.
Some unexpected findings emerged regarding gender identity. One-half of transgender and gender diverse youth indicating male sex also listed their gender identity as male, transman, or transmasculine, which may be related to a number of factors. The wording of the sex question (ie, “What is your biological sex?”) is problematic for transgender youth, who may have answered this question differently than intended by survey developers. For example, transgender and gender diverse youth may report the option closest to their gender identity as their biological sex, rather than responding with their sex assigned at birth. The inclusion of the term male in the gender identity response option may be problematic for transgender and gender diverse youth, who have likely spent time differentiating sex (eg, male) and gender (eg, cisgender man, transgender man, or transmasculine) terms.23 It is also possible that youth might have answered yes to being transgender, genderqueer, or genderfluid thinking more about gender presentation than gender identity (eg, a youth assigned male at birth who identifies as a boy or man and has a fluid gender presentation).24 Developmental considerations, including where youth are in their gender identity exploration, may come into play, especially for youth who are still determining the best-fitting descriptors. Cognitive testing with young people is needed, updated from previous foundational work given rapid change in conceptions of sexual and gender identity,10,11 to understand the ways in which gender diverse youth approach these questions.
Results from this analysis give rise to several question regarding the best way to capture participants who use an identity term that is not among the response options provided. Unexpectedly, 8.4% of youth selected “I don’t describe myself in any of these ways” for sexual orientation, and results demonstrated that youth selecting this option were much more similar in terms of depression and bias-based bullying to straight youth and youth who did not understand the sexual orientation question than they were to any other group of LGBQ+ youth. Current recommendations suggest including this option in surveys of adolescents as a response option for LGBTQ+ youth who use identity descriptors not provided on the survey (eg, asexual or omnisexual for the MSS).10,16,25 However, the fact that more youth endorsed this response than any other nonheterosexual option in this survey suggests further study is warranted to determine how these youth identify and why they selected this option. These may be youth who are navigating specific cultural identities alongside their sexual and gender identities, who reject sexual and gender identity labels altogether, or who select this option for other reasons.26 They may also be youth who identify as straight but did not select the heterosexual option. Given the percent of the sample that selected this option, it is likely that most or all of these reasons are represented. As such, interpretation of this response category is ambiguous, because of significant heterogeneity in this group.
For gender identity, the option to indicate an identity beyond those listed was only offered to youth who first indicated they identified as transgender, genderqueer, or genderfluid. As a result, youth selecting this option were more similar to transgender or gender diverse youth than they were to cisgender youth on depression and bias-based bullying. A key takeaway from these results is that umbrella response options for youth to indicate that they use a different term than those listed, particularly when the inclusion of an open-ended text field or write-in is not feasible, should be approached with caution. On the basis of this study, we suggest these options only be presented to youth who have indicated some LGBTQ+ identity; however, additional pilot and cognitive testing will ensure robust and accurate data collection.
Finally, rates of depression and bias-based bullying varied by sexual and gender identity with important implications for prevention. For example, positive PHQ-2 depression screens were particularly high among nonbinary and transmasculine youth who indicated their sex as female, which suggests the need for bolstering screening, services, and targeted support for this group of youth. From a prevention perspective, these findings are consistent with established disparities in rates of bias and emotional distress among transgender and gender diverse youth compared to cisgender youth,27,28 supporting known needs for school- and community-wide interventions to create supportive and inclusive climates.29 In addition, findings point to nuanced prevention needs, such as addressing gender-based bullying of transmasculine and nonbinary youth assigned female at birth. These efforts should tackle conceptions of masculinity and gender in more complex ways than acceptance for transgender and gender diverse youth in general.
The current study has several limitations. The MSS is a school-based survey; given that LGBTQ+ youth are more likely than their straight, cisgender peers to drop out or miss school (eg, because of bullying victimization),30 the results may be an underestimate of true population prevalence. Although this survey included some newer response options, others were not included (eg, asexual), and youth were not able to provide open-ended responses. Further, the one-step gender identity question may be difficult for youth who do not identify as transgender or cisgender. The phrasing of the sex question as biological sex is a limitation because this term is considered offensive or is not preferred by transgender and gender diverse youth.12 It is also not clear that all youth interpreted this question similarly. These results should be interpreted with caution and replicated with survey questions specifically asking about sex assigned at birth, as recommended.9–11 This preliminary exploration of sexual and gender identities did not allow for an in-depth examination of multiple, intersecting socially marginalized identities. Preliminary, descriptive analyses presented here support the need for in-depth future studies of the ways these identities shape lived experiences. Finally, the PHQ-2 is only a screener for depressive symptoms; a more comprehensive assessment was not possible in this large sample.
Evidence from this statewide survey of adolescents indicates the importance of including identities not commonly used in surveys and patient demographic forms. LGBTQ+ youth are a diverse group, and more screening and targeted interventions are needed to adequately address emotional distress and experiences of bias, particularly given emerging evidence that intervention needs may vary by sexual and gender identity.31 Clinicians should familiarize themselves with the range of sexual and gender identities used by youth and attend to bias or bullying experiences and emotional distress among all LGBTQ+ youth, but particularly pansexual and queer youth and transmasculine and nonbinary youth who indicate their sex as female. Accurate measurement of sexual orientation and gender identity including diverse response options among adolescents is critical to documenting prevalence, identifying and monitoring health disparities, and ultimately developing interventions to promote health among LGBTQ+ youth.
Glossary
- ANOVA
analysis of variance
- LGBTQ+
lesbian, gay, bisexual, transgender, queer, and questioning
- MSS
Minnesota Student Survey
- PHQ-2
Patient Health Questionnaire 2
- TGD
transgender and gender diverse
Footnotes
Dr Gower conceptualized the paper, analyzed the data, and drafted and revised the manuscript; Drs Rider, Brown, and Eisenberg contributed to the analysis plan, interpreted findings, and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under award R01MD015722. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Minnesota Student Survey data were provided by public school students in Minnesota via local public school districts and are managed by the Minnesota Student Survey Interagency Team. Funded by the National Institutes of Health (NIH).
We use the term sex in this paper, rather than sex assigned at birth, because the survey item available asked about biological sex, a term which many transgender and gender diverse youth find insensitive.12
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