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Delaware Journal of Public Health logoLink to Delaware Journal of Public Health
. 2025 Jul 31;11(2):26–34. doi: 10.32481/djph.2025.07.08

Mental Health and Substance Use Disparities by Sexual Orientation and Gender Identity Among Delaware Youth

Eric K Layland 1,✉, August X Wei 2, Natalie M Maurer 3, Rochelle Brittingham 4, Ronet Bachman 5
PMCID: PMC12333826  PMID: 40786711

Abstract

Objective

To investigate mental health and substance use disparities by sexual orientation and gender identity among Delaware youth.

Methods

Data were from the Delaware School Surveys (DSS) administered to 8th and 11th graders (n=17,361; ages 12-17 years old) in 2022, 2023, and 2024. Frequency statistics were used to summarize sexual orientation and gender identity composition, including frequency of youth who were lesbian, gay, bisexual, transgender, and other minoritized sexual and gender identities (LGBT+). Using logistic regression, we tested associations between LGBT+ status and odds of reporting psychological distress, anxiety, underage drinking, cigarette smoking, vaping, marijuana use, and prescription drug misuse.

Results

Around one in four (25-26%) Delaware youth identified as LGBT+, including 6-7% of youth who were transgender or nonbinary. Rates of lifetime mental health symptoms and underage substance use were elevated among LGBT+ youth for every health outcome. For 8th grade LGBT+ youth relative to cisgender heterosexual youth, odds were elevated by 269% for psychological distress, 276% for anxiety, 91% for drinking, 141% for cigarette smoking, 121% for vaping, 98% for marijuana use, and 86% for prescription drug misuse. In 11th grade LGBT+ youth relative to cisgender heterosexual youth, odds were elevated by 228% for psychological distress, 240% for anxiety, 33% for drinking, 71% for cigarette smoking, 51% for vaping, 57% for marijuana use, and 70% for prescription drug misuse.

Conclusions

Mental health and substance use disparities between LGBT+ youth and cisgender heterosexual youth highlight an alarming public health crisis in Delaware. With growing numbers of youth identifying as LGBT+ and persistent health disparities, state policy and clinical practice must be attuned to the needs and lived experiences of LGBT+ youth to identify and eliminate drivers of these disparities. Schools, healthcare, and policy provide important avenues for intervention.

Background

Mental health and substance use disparities between cisgender (individuals whose sex assigned at birth is congruent with their gender identity, e.g., a person whose sex assigned at birth was male and whose current gender identity is man) heterosexual youth and lesbian, gay, bisexual, transgender and other sexual and gender minoritized (LGBT+) youth are well-established in national data.1 National and state level research shows higher rates of anxiety,2 depression,3 drinking,4,5 smoking,4,6 vaping,7,8 marijuana use,4,9 and prescription drug use9 among LGBT+ youth relative to cisgender heterosexual youth. As mental health and substance use disparities have been widening,10 the proportion of youth who identify as sexual and gender minority youth has also been increasing nationally,11 pointing to even greater relevance and need for identifying mental and behavioral health challenges prevalent in this population. Increasing evidence of these disparities over the last decade and a growing LGBT+ youth population warrants Delaware-specific empirical examination of youth mental health and substance use disparities by sexual and gender identity. A focus on Delaware youth not only expands the existing evidence of LGBT+ health disparities established in other states, but more formally provides evidence of Delaware-specific LGBT+ youth disparities and invites alignment of state and local resources to address and eliminate these disparities.

Mental Health and Substance Use Disparities between LGBT+ and Cisgender Heterosexual Youth

Over the last two decades, increasing national and state-level studies provide evidence of consistent mental health disparities between LGBT+ and cisgender heterosexual individuals. While the majority of this research has focused on adults, landmark national studies demonstrated higher levels of depression among lesbian, gay, and bisexual youth compared to heterosexual youth.3,12 A systematic review of adolescent and adult mental health disparities by sexual identity revealed consistently elevated levels of depression and anxiety across national, state, and local research studies.2 More recent studies provide evidence that these disparities have persisted into more contemporary cohorts of LGBT+ youth.13 In addition, transgender and non-binary youth exhibit higher rates of depression and anxiety symptoms relative to cisgender heterosexual youth but also higher than cisgender sexual minority youth.14 This within group differences suggest that while LGBT+ youth generally are at risk of worse mental health, there are some subgroups for whom mental health disparities are particularly alarming. These mental health disparities are often attributed to experiences of minority stress wherein dominant norms of cisgender heterosexuality are used to justify mistreatment of LGBT+ youth, resulting in an extra burden of identity-specific stress that is known to erode mental health.15,16 Together, theoretical explanation and empirical evidence have consistently pointed to the stark mental health disparities between LGBT+ and cisgender heterosexual youth, yet little of this research has been conducted in Delaware.

Rates of underage substance use are also higher for LGBT+ youth compared to their cisgender heterosexual peers. Like with mental health, substance use disparities are more robustly established among adults, but growing research among adolescents extends this epidemiological research to find similar disparities among youth.17 For example, in a California-based study of underage substance use, sexual minority youth had higher rates of drinking, cigarette smoking, and marijuana use relative to their heterosexual peers.4 This research was later extended to examine differences by gender identity and found transgender youth had higher binge drinking rates than cisgender youth.18 Regional research in the southeastern United States (US) demonstrated disparities in lifetime use of cigarettes, marijuana, prescription drugs, and both vaped tobacco and marijuana.9 More recent studies also demonstrate these disparities persist into emerging types of substance use including vaping.19 Emerging research including nonbinary and transgender youth provides new evidence of elevated substance use among these youth. For example, in a California-based study transgender youth were more likely to have used substances (e.g., alcohol, tobacco, marijuana, other drugs) than their cisgender peers.20,21 Further still in a national study, nonbinary and genderqueer youth demonstrate greater odds of lifetime marijuana and cigarette use compared to their cisgender sexual minority peers.22

To date, there are few studies examining youth mental health and substance use disparities by sexual orientation and gender identity in Delaware. One notable exception used data from 2003 to 2007 to demonstrate prevalence of drinking and marijuana use was higher among sexual minority youth relevant to heterosexual youth.23 Although this study provides important early evidence of these disparities, expansion of this research is necessary to (1) include transgender and nonbinary youth, (2) extend research to contemporary youth, (3) examine a broader array of substances and mental health.

The Expanding LGBT+ Population

Comparison of historical and contemporary surveys of youth reveals a seemingly expanding population of LGBT+ youth in the US and abroad. For example, in a Delaware study of sexual minority health using data from 2003-2007, around 5% of high school students identified as homosexual, bisexual, or questioning their sexual orientation.23 In contrast, more recent national studies in the US found 12% of adolescents identified with a sexual identity other than heterosexual in 201913 and 20% of adolescents in 2021.24 Scholars and community members point to an explanation in increased visibility, representation, and shifts in cultural acceptance facilitating more identity exploration, flexibility, and disclosure than permitted in prior generations, thereby contributing the appearance of an expanding LGBT+ population.25 Transgender and nonbinary youth are estimated to comprise 1.4% of the US adolescent population,26 however, prevalence of these identities may also be increasing and diversifying. Inclusion of diverse gender identity options in more recent state and national data allows researchers to more precisely estimate prevalence of transgender and non-binary identities in contemporary data sets. When paired with health disparities data, population estimates allow us to estimate both the magnitude of the disparities and how many young people may be affected. According to 2023 census data, an estimated 7.3% (n=75,538) of Delawareans (total population 1.3 million) are between the ages of 12 to 17 years old.27,28 Yet it remains unclear how many of these youth are LGBT+ and to what degree they are experiencing elevated rates of mental health and underage substance use disparities.

Current Study

The purpose of the current study was to investigate differences in mental health and substance use between LGBT+ youth and cisgender heterosexual youth in Delaware. To accomplish this objective, we first described how many youth identified as LGBT+. Then, mental health and substance use prevalence rates were compared among LGBT+ and cisgender heterosexual youth, separately in 8th grade and in 11th grade. Finally, we examined associations between LGBT+ status and mental health and substance use outcomes while accounting for racial and ethnic differences and potential change in prevalence across years. Based on prior research, we anticipated higher rates of mental health challenges and substance use among LGBT+ youth compared to cisgender heterosexual youth.

Methods

Data were from the Delaware School Survey (DSS) that was administered annually to 8th and 11th grade students in the 2022-2024 period.29,30 Surveys from 5th grade students were not included because gender identity was not collected in 5th grade. The DSS is funded by the Delaware Division of Substance Abuse and Mental Health and has been regularly administered for 26 years. We included 2022 to 2024 data for two reasons. First, the 2022 survey was the first year that responses to the question, “What is your gender?” were expanded to include non-binary. Second, 2022 was also the first year the question “Are you transgender?” was also included.

The DSS included students from all public, charter, and alternative schools that volunteered to be included. As such, it was not a probability sample but included schools from all three Delaware counties. The DSS aimed to provide prevalence estimates of students’ substance use, other risk-taking behaviors, and mental health data. Following the COVID-19 pandemic, the DSS was converted to an online format, with an alternative option of completing the DSS using paper and pencil in a classroom setting. Surveys were conducted in both English and Spanish. Passive parental/guardian consent via letter or email was used to obtain permission for students to participate in the survey. Parents/guardians who did not want their child(ren) to participate were allowed to submit an opt out form either electronically, by mail, or by calling the school. Students were allowed to refuse to participate in the survey at any time. Relatively few parents declined to have their child respond to the survey.

Because the current study analyzed 8th and 11th grade surveys across a three year period, it is unlikely that any data points were repeated from the same participants in more than one year or grade. Survey data from 2022, 2023, and 2024 were pooled, in 8th grade and 11th grade separately, to increase power for detecting differences in health outcomes with low prevalence and to maintain confidentiality of youth in demographic groups with lower prevalence (e.g., nonbinary youth).

Measures

All survey measures were identical in 8th grade and 11th grade.

Mental health. To measure psychological distress, participants answered the following question, “Do you ever feel sad, empty, hopeless, angry, or anxious,” with response options of yes, no, or don’t know. Don’t know responses were coded missing, no responses were coded 0, and yes responses were coded 1. Participants who responded yes to the psychological distress question were then asked, “Over the past two weeks, how often have you felt very nervous or anxious?” Responses options were not at all, several days, over half the days, or nearly every day. To contrast students who experienced no anxiety versus those who experienced any anxiety, ‘not at all’ responses were coded 0 and all other responses were coded 1.

Substance use. Participants reported their lifetime frequency of alcohol drinking, e-cigarette vaping, and marijuana use on 7-point scales (6-point for vaping) with ordinal response options ranging from 0 times through 40 times or more (31 times or more for vaping). Specifically, participants reported how many times in their life they “had a drink (not just a few sips) of alcohol, beer, wine, liquor, or missed drinks,” “used nicotine in an e-cigarette or other vaping device (tobacco or nicotine products only),” and “smoked marijuana (weed, pot, hash, blunts, dabs, wax).” Additionally, participants reported how many cigarettes they have smoked in their lifetime on a 7-point scale with ordinal response options ranging from none to 31 or more cigarettes. Due to skewness and to create variables reflecting any lifetime underage use of each substance, participants who reported never using a substance were coded 0 and participants who reported they had used a substance at least once were coded 1, on each respective substance. Participants also reported whether, in the prior year, they had taken each of 13 different prescription drugs (e.g., OxyContin/Oxycodone, Ritalin/Adderall, Xanax) without a doctor’s prescription or differently than prescribed. Responses were recoded to reflect any past year prescription misuse coded as 0 and no misuse of any prescription drugs coded 1.

Sexual orientation and gender identity. Three questions were used to operationalize students’ gender identity and sexual orientation. First, participants reported their sexual orientation by selecting the option that best described them from the options: heterosexual (straight), gay or lesbian, bisexual, other, or not sure. Students who responded heterosexual were coded as 0 and all other participants were coded as 1, indicating a sexual minority identity. Second, participants reported their gender by selecting from the following options: boy, girl, non-binary, and prefer to self-describe with write-in option. Write-in responses were coded as missing as they could not be validly reported as any one separate category. Third, participants responded to the question, “Are you transgender?” with the response options, “No, I am not transgender,” “Yes, I am transgender,” “I am not sure if I am transgender,” and “I don’t know what this question is asking.” Participants who responded no were coded 0 and students who responded yes or that they were not sure were coded 1. Coding “not sure if transgender” participants as 1 reflected common practice applied to sexual orientation clustering wherein youth not sure of their sexual identity are grouped with sexual minority rather than heterosexual youth. Those who were not sure what the question was asking were coded missing. We created a new variable to contrast LGBT+ participants with cisgender heterosexual participants. Participants who (1) were identified as a sexual minority identity, (2) reported a non-binary gender, or (3) were identified as transgender were coded 1 for LGBT+ (all sexual and gender minorities) and participants who were heterosexual, boys or girls, and not transgender were coded 0 (cisgender heterosexual).

Covariates. To measure race and ethnicity, participants first selected the race group that best described them from the options: American Indian or Alaskan Native, Native Hawaiian or Pacific Islander, Asian, Black or African American, White, or Other (describe). Then participants reported whether they were Hispanic or Latino by selecting the option no or one of five Hispanic or Latino ethnic groups (e.g., Mexican/Mexican American/Chicano, Cuban/Cuban American). Race and Latino ethnicity responses were combined to create categories similar to typical census reporting groups: White/non-Latinx, Black/non-Latinx, Latinx/Any Race, and Other/non-Latinx (aggregated due to low subsample sizes). The reference category was White/non-Latinx. In addition, year of survey was also controlled in multivariate models, with 2022 used as the reference category.

Analysis Plan

To investigate mental health and substance use disparities by sexual orientation and gender identity among Delaware youth, analyses proceeded first through a descriptive stage and then through a series of between group comparisons. All analyses were completed with pooled samples across three years (2022, 2023, 2024) within 8th grade and 11th grade. Frequency statistics were used to describe the sexual and gender and identity composition of all 8th and 11th grade students who completed the DSS from 2022–2024. We described the total number of LGBT+ youth in 8th grade and 11th grade and then summarized disaggregated sexual orientations and gender identities.

Bivariate chi-squared tests were used to investigate whether prevalence of each mental health and substance use outcome differed significantly between LGBT+ and cisgender heterosexual youth in 8th grade and then again in 11th grade. Following bivariate tests, we used multivariable logistic regression to test associations between LGBT+ status and odds of each mental health and substance use outcome, adjusting for race and ethnicity and year of data collection. All analyses were run in SPSS (Version 29).

Results

The total DSS sample pooled from 2022 to 2024 included 17,361 youth (8th grade n=9,181; 11th grade n=8,180). Sample demographic characteristics are summarized in Table 1. Approximately one in four youth identified as LGBT+ (8th grade: 24.5%; 11th grade: 26.1%). For sexual orientation, the majority of participants identified as straight/heterosexual with a marginally lower proportion in 11th grade compared to 8th grade (8th grade: 76.4%; 11th grade: 70.4%). The most common sexual minority identity was bisexual (8th grade: 9.2%; 11th grade: 11.9%) followed by other and not sure, and then gay or lesbian. The majority of participants were cisgender with 6-7% of participants identifying as transgender or nonbinary (8th grade: 6.6%; 11th grade: 6.0%). Regarding gender identity, boys composed 46.6-50.6% of the sample, with the majority being cisgender boys. Girls composed 47.4-51.1% of the samples, with the majority being cisgender girls. White/non-Latinx was the largest race and ethnicity subgroup (37.3%) followed by Latinx/Any race in 8th grade (24.5%) and Black/non-Latinx in 11th grade (26.2%), however, no single race and ethnicity group comprised a majority in either grade. Participant ages ranged from 12 to 19 years old. For 8th grade, the majority (55.6%) were 14 years old followed by 13 (41.2%). For 11th grade, the majority (56.2%) were 17 years old followed by 16 (38.4%).

Table 1. Demographic Sample Summary in 8th and 11th Grades.

8th Grade
(n=9,181)		 11th Grade
(n=8,180)
Demographic category n Valid % n Valid %
LGBT+ Status
  LGBT+ 2,103 24.5 2,139 26.1
  Cisgender Heterosexual 6,493 75.5 5,657 69.2
  Missing 585 384
Gender Modality
  Transgender and Nonbinary 568 6.6 492 6.0
  Cisgender 8,081 93.4 7,344 89.8
  Missing 532 344
Gender Identity a
  Cisgender boy 4,091 49.0 3,453 45.5
  Transgender boy 136 1.6 82 1.1
  Cisgender girl 3,869 46.4 3,812 50.2
  Transgender girl 87 1.0 63 0.8
  Non-binary 163 2.0 177 2.3
  Missing 835 593
Sexual Orientation
  Straight/Heterosexual 6,712 76.4 5,761 73.6
  Bisexual 809 9.2 977 12.5
  Gay/Lesbian 287 3.3 327 4.2
  Other 458 5.2 414 5.3
  Not sure 523 6.0 347 4.4
  Missing 392 354
Race
  While/non-Latinx 3,274 37.3 3,053 37.3
  Black/non-Latinx 2,135 24.4 2,143 26.2
  Other/non-Latinx 1,205 13.7 903 11.0
  Latinx (Any Race) 2,152 24.5 1,739 21.3
  Missing 415 342
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Note. All frequency percentages based on valid, non-missing data. aThese percentages were obtained from a crosstabulation of transgender identity with gender identity; missingness gender identity reflects missingness from transgender status AND gender identity.

Approximately two-thirds of youth in both 8th grade (61.2%) and 11th grade (64.7%) reported experiencing any lifetime psychological distress. Over 59.0% of 8th graders and 56.0% of 11th graders reported experiencing any anxiety in the past 2 weeks. Generally, rates of lifetime underage substance use were lower among 8th grade compared to 11th grade youth: drinking (19.9% vs. 38.1%), cigarette smoking (3.9% vs. 7.9%), vaping (12.3% vs. 20.7%), and marijuana use (9.9% vs. 25.7%). Prior year prescription misuse was reported by 8.8% of 8th grade participants and 7.3% of 11th grade participants.

Are there disparities in mental health and substance use between LGBT+ and cisgender heterosexual youth?

Table 2 shows bivariate comparisons of mental health and substance use prevalence between LGBT+ and cisgender heterosexual youth in 8th and 11th grade. In both 8th and 11th grade, LGBT+ youth had significantly higher prevalence of every mental health and substance use outcome, relative to cisgender heterosexual youth. For example in 8th grade, 80.7% of LGBT+ youth reported feeling anxious compared to 50.7% of cisgender heterosexual youth. This pattern was replicated in 11th grade. As an example of substance disparities in 11th grade, 32.2% of LGBT+ youth reported ever using marijuana compared to 23.3% of cisgender heterosexual youth. This disparity was also apparent in 8th grade. In every case, the overall sample prevalence was pulled higher by higher prevalence of every outcome among LGBT+ youth.

Table 2. Comparison of the Prevalence of Mental Health and Substance Use Outcomes between LGBT+ and Cisgender Heterosexual Youth.

8th Grade 11th Grade
LGBT+ Cisgender Heterosexual LGBT+ Cisgender Heterosexual
Psychological Distress 82.1 55.1*** 81.8 58.2***
Anxiety 80.7 50.7*** 75.0 48.8***
Alcohol Drinking 28.4 16.9*** 43.3 36.3***
Cigarette Smoking 6.6 3.0*** 11.0 6.8***
Vaping 13.4 6.6*** 26.0 18.8***
Marijuana Use 14.9 8.2*** 32.3 23.3***
Prescription Drug Misuse 13.0 7.5*** 10.4 6.4***
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Note. ***p<.001.

Is LGBT+ status associated with mental health and underage substance use?

Tables 3 and 4 show the results of logistic models testing the association of LGBT+ status with odds of mental health and substance use outcomes, adjusting for effects of race and ethnicity and data year. Results indicate that even after accounting differences by race and ethnicity and data year, LGBT+ youth were significantly more likely to report all mental health and substance use outcomes compared to cisgender heterosexual youth in both 8th and 11th grades.

Table 3. Adjusted Logistic Regression Testing Associations between LGBT+ status and Mental Health and Substance Use in 8th Grade.

Psychological Distress Anxiety Alcohol Drinking Cigarette Smoking Vaping Marijuana Use Prescription Misuse
n=7,468 n=7,001 n=7,850 n=7,968 n=7,979 n=6,821 n=8,385
OR SE OR SE OR SE OR SE OR SE OR SE OR SE
LGBT+ 3.69*** .07 3.76*** .07 1.91*** .06 2.41*** .12 2.21*** .07 1.98*** .08 1.86*** .08
Race and Ethnicity
Black/ non-Latinx 0.79*** .06 0.69*** .07 0.83* .08 0.84 .17 1.28 .09 1.33** .10 1.22 .10
Latinx/Any Race 0.83* .06 0.82** .07 1.30*** .07 1.31 .14 1.71*** .09 1.54*** .10 1.12 .10
Other Race/non-Latinx 1.11 .10 0.84* .08 0.91 .09 0.91 .19 0.80 .12 1.04 .13 1.14 .12
Data Year
2023 0.95 .06 0.69*** .06 0.93 .07 1.23 .15 1.25 .08 1.21 .09 0.94 .09
2024 0.79*** .06 0.63*** .07 0.84* .08 2.78*** .14 1.27 .09 1.02 .10 1.43*** .10
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Note. Reference group for LGBT+ status was cisgender heterosexual youth. Reference group for race and ethnicity was White/non-Latinx and for data collection year was 2022. OR = odds ratio. SE = standard error. *p.<.05, **p.<.01, ***p.<.001. aPrescription misuse recall period is past year, in contrast to lifetime for all other substances.

Table 4. Adjusted Logistic Regression Testing Associations between LGBT+ status and Mental Health and Substance Use in 11th Grade.

Psychological Distress Anxiety Alcohol Drinking Cigarette Smoking Vaping Marijuana Use Prescription Misuse
n=6,523 n=6,505 n=6,838 n=6,953 n=6,967 n=6,821 n=7,379
OR SE OR SE OR SE OR SE OR SE OR SE OR SE
LGBT+ 3.28*** .07 3.40*** .06 1.33*** .06 1.71*** .09 1.51*** .09 1.57*** .06 1.70*** .09
Race and Ethnicity
Black/ non-Latinx 0.89 .07 0.77*** .07 0.51*** .06 0.34*** .13 0.66*** .13 0.96 .07 1.27* .11
Latinx/Any Race 0.81* .07 0.88 .07 0.70*** .07 0.58*** .12 0.85* .12 0.82 .08 1.19 .12
Other Race/non-Latinx 0.99 .09 0.89 .09 0.59*** .09 0.49*** .17 0.65*** .17 0.66*** .10 1.13 .15
Data Year
2023 0.95 .07 0.93 .07 1.00 .06 1.04 .14 1.07 .14 1.17* .07 0.81 .11
2024 0.58*** .06 0.33*** .06 0.86* .06 2.99*** .11 1.07 .11 0.83 .07 1.15 .10
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Note. Reference group for LGBT+ status was cisgender heterosexual youth. Reference group for race and ethnicity was White/non-Latinx and for data collection year was 2022. OR = odds ratio. SE = standard error. *p.<.05, **p.<.01, ***p.<.001. aPrescription misuse recall period is past year, in contrast to lifetime for all other substances. 9 11 12 15 11 10

Findings for mental health showed that LGBT+ youth in both 8th and 11th grades had significantly higher odds of experiencing psychological distress and past 2-week anxiety compared to cisgender heterosexual youth. Like the bivariate results, the relationships were not only highly significant, but the magnitude of the differences were very high. For example, the odds of experiencing anxiety or depression increased by over 220% for both 8th and 11th grade LGBT+ youth compared to cisgender heterosexual youth (to obtain the percentage change in the odds, the formula (((Exp(Β)-1) X 100)) is used31). Similarly, the odds of experiencing anxiety in the past two weeks increased by over 240% for both 8th and 11th grade LGBT+ youth compared to cisgender heterosexual youth.

Although LGBT+ youth had higher odds of using every substance compared to cisgender heterosexual youth, the associations between LGBT+ status and odds of substance use were stronger in 8th grade than in 11th grade. In 8th grade, for LGBT+ youth odds of drinking were 91% higher, odds of cigarette smoking were 141% higher, odds of vaping were 121% higher, odds of marijuana use were 98% higher, and odds of prescription misuse (prior year) were 86% higher, relative to cisgender heterosexual youth. Associations were similar though smaller in magnitude in 11th grade. In 11th grade, for LGBT+ youth odds of drinking were 33% higher, odds of cigarette smoking were 71% higher, odds of vaping were 51% higher, odds of marijuana use were 57% higher, and odds of prescription misuse (prior year) were 70% higher, relative to cisgender heterosexual youth.

Discussion

Increasing numbers of youth identifying as LGBT+ and persistent evidence of mental health and substance use disparities nationally together warranted investigation of these disparities among LGBT+ youth in Delaware. The current study makes several major contributions to our understanding of sexual orientation and gender identity health disparities in Delaware. First, results demonstrate a higher proportion of youth identifying as LGBT+ than in prior national and Delaware-based studies. Second, we provided evidence consistent with that found in other state and national studies showing LGBT+ youth in Delaware exhibit higher rates of mental health burdens and substance use than cisgender heterosexual youth. Third, when contrasting disparities in 8th and 11th grade, we uncovered greater disparities in 8th grade highlighting the early emergence of these disparities and need for early intervention. Together, results point to the urgent need for increased research investigation and expanded resource allocation to address alarming mental health and substance use disparities among LGBT+ youth in Delaware.

With one in four Delaware youth identifying as LGBT+, the health behaviors and needs of this population warrants increased health surveillance and attention in Delaware public health initiatives. Furthermore, more than one in twenty surveyed youth identified as transgender or nonbinary. Finding 25% of youth are LGBT+ in the current study contrasts with Button and colleagues’ estimate that 5.3% of youth were identified as LGB in Delaware school-based surveys from 2003-2007.23 Extrapolating results of the current study onto the most recent Delaware census estimates suggests that there may be between 18,000 to 20,000 LGBT+ youth living in Delaware (24.5%-26.1% × 75,538 youth ages 12-17 in Delaware).27,28 Similarly, results of the current study suggest there may be as many as 4,500-5,000 transgender and nonbinary youth in Delaware (including youth who are still unsure whether they are transgender; 6.0%-6.6% × 75,538). Documenting the potential size of the Delaware LGBT+ youth population emphasizes the importance of ensuring adequate public health and school-based resources across the state for supporting the unique needs of LGBT+ youth. In particular, this highlights the growing need for transgender and nonbinary affirming healthcare and school policies. The seemingly high prevalence of LGBT+ youth mirrors and marginally exceeds national and international trends documenting the higher proportion of Generation Z youth identifying as part of the LGBT+ community,24,32,33 often attributed to increased cultural acceptance and visibility of diverse sexual and gender identities.34 Taken together, identifying the size of the LGBT+ youth population draws attention to the magnitude of disparities and urgency for public health response in Delaware.

This is one of the first studies of sexual orientation and gender identity youth disparities to use state-level data collected entirely after the most restrictive COVID19 pandemic lockdowns when mental health challenges among youth were acutely severe.35 The results of the current study show sustained prevalence of psychological distress and anxiety 2-4 years after the beginning of the pandemic, with rates of mental health challenges for LGBT+ alarmingly higher than cisgender heterosexual youth. For cisgender heterosexual youth, half of youth reported feelings of anxiety in the prior two weeks. Although this rate alone is concerning, rates of psychological distress and current anxiety were even higher among LGBT+ youth with 75-80% of LGBT+ youth currently experiencing anxiety. These rates exceed national levels of psychological distress for LGBT+ youth. National data from the 2023 Youth Risk Behavior Survey found around 60% of LGBT+ youth reported persistent feelings of sadness or hopelessness in the past year and around 50% reporting poor mental health in the past month.36 LGBT+ youth in Delaware appear to be faring worse in their mental health compared to cisgender heterosexual youth in Delaware and compared to LGBT+ youth nationally. Additionally, mental health disparities that emerged in the 8th grade data appear to generally be sustained through 11th grade; thereby suggesting that disparities between LGBT+ youth and cisgender heterosexual youth are well established by early adolescence and do not appear to improve by late adolescence. These results support the need for LGBT+ tailored mental health resources in both middle and high schools across the state. Expanded health surveillance into earlier adolescence and childhood will be necessary to identify when these disparities emerge and escalate.

Across all substances, LGBT+ youth in Delaware demonstrated elevated rates of lifetime use compared to cisgender heterosexual youth in both 8th and 11th grade. This means that, on average, by ages 13-14 years old, more LGBT+ youth are using substances relative to their heterosexual cisgender peers. Though differences in recall period prevents direct comparison, results of the current study did reiterate evidence of drinking and marijuana use sexual orientation disparities previously uncovered from 2003-2007.23 When contrasted with national prevalence rates, Delaware youth substance use reported in the DSS appears to be lower than national averages.37 However, when disaggregating by LGBT+ status in Delaware, LGBT+ substance use is more similar and, at times, exceeds national averages. The 2023 national rate for lifetime drinking in 8th grade was 20.1% of youth which is virtually equivalent to the 19.9% of all DSS youth in the current study. Among LGBT+ youth in Delaware, the percentage of 8th graders who ever drank was 28.4%, well above the national average. Of note, Delaware 8th grade LGBT+ youth drinking, cigarette smoking, and prescription misuse rates were above the national general youth averages and 11th grade LGBT+ drinking, cigarette smoking, marijuana use, prescription misuse were similar to national general youth averages.

When contrasting LGBT+ substance use disparities between 8th and 11th grade, it is apparent that disparities are generally larger in 8th grade than 11th grade. This suggests that disparities emerge earlier in adolescence and may narrow as youth age towards adulthood. Indeed, the magnitude of the disparity for every substance diminished, but remained significant in 11th grade. This is likely due to the overall increase in substance use across adolescence typically of this developmental period.38 Thus, more cisgender heterosexual youth initiate substance use by 11th grade, but rates of lifetime use remain higher for LGBT+ youth. Disparities in 8th grade are especially pronounced for tobacco/nicotine smoking, including both cigarette and nicotine vaping. These Delaware results mirror studies of LGBT+ smoking in other states39 and highlight the on-going need for culturally tailored smoking prevention and cessation education among LGBT+ youth40 including during childhood and early adolescence. A particularly alarming finding is that rates of lifetime drinking, cigarette smoking, vaping, and prior year prescription misuse for LGBT+ 8th grade youth are more similar to 11th grade cisgender heterosexual youth than to 8th grade heterosexual youth. This means that the lifetime substance use patterns of LGBT+ youth in early and middle adolescence more closely resemble the substance use patterns of older adolescence. Given that early onset of substance use is a predictor of faster escalation to substance use disorder,41 the elevated substance use for LGBT+ youth in 8th grade is particularly concerning.

Limitations and Future Directions

The strengths of the current study must be interpreted within the limitations of the data and analyses. First, although the DSS includes a racially and ethnically diverse sample from all across the state, this is a non-probability sample. As such, prevalence of LGBT+ identities and magnitude of disparities cannot confirm the actual LGBT+ youth population size in the state and may not represent youth from schools who did not participate. Future research should attend to the specific health behaviors and needs of LGBT+ youth who are outside the school system as called for by scholars and community members previously.42 Second, the DSS offers only a small number of options for gender and sexual identities which may limit some youth with other identities from selecting an appropriate box to reflect their LGBT+ identity. Adolescents today are more likely to identify with newer identity labels such as pansexual and queer25 which are not in the DSS. Future iterations of the DSS and other youth health surveillance in Delaware and elsewhere should consider expanded, more inclusive sexual orientation and gender identity options. Third, because the DSS only assessed past year rather than lifetime misuse of prescription drugs, frequency of this outcome may be artificially deflated in contrast to all other substances measured at the lifetime level. Because rates of prescription drug use for LGBT+ youth in the current sample exceeded lifetime levels in national data, it is pertinent that we expand measurement and response to prescription drug misuse in Delaware. Fourth, it is difficult to contextualize the current results for transgender and nonbinary participants because prior research has often not collected gender identity, including in prior DSS and national youth surveys. Therefore, it is pertinent that state and national youth surveys continue to collect gender identity data among youth to continue accurate surveillance of transgender youth health and health disparities.

Public Health Implications

Alarming mental health and substance use disparities together with evidence that one in four Delaware youth may identify as LGBT+ emphasize the urgent need for public health response. Although an extensive state-level needs assessment is warranted, we make the following recommendations for public health response. Without change to resource allocation and increased access to prevention and treatment services, LGBT+ youth will likely continue to exhibit higher levels of mental health burdens and early and higher rates of substance use. There are several potential avenues for promoting LGBT+ well-being and reducing negative health outcomes. Evidence from multiple intervention studies suggest schools can be effective sites for reducing LGBT+ mental health burdens when schools take “whole school” approaches wherein the dominant cisgender, heterosexual norms of the school environment are challenged and discrimination and marginalization of LGBT+ youth is addressed.43 This requires response at the environmental, staff, curriculum, and policy levels. In addition to schools, clinical mental health and substance use interventions can play a key role in addressing stigma against LGBT+ youth and reduction of mental health and substance use burdens.44,45 Targeted training for LGBT+ mental health providers can be implemented to improve competency and skills for serving LGBT+ individuals through culturally tailored LGBT+ clinical interventions.46 Because disparities between LGBT+ and cisgender heterosexual youth are well-established by 8th grade, it is likely necessary to extend LGBT+ tailored school and clinical response beyond high schools to include middle and elementary schools. Relatedly, LGBT+ youth today are often coming out in late elementary school and middle school, pointing to the need for intervention and resources available to these youth and their families in Delaware.25,33 In addition to school and clinical response, state level policy provides an opportunity for far reaching intervention impact. States with more policies that protect LGBT+ youth rights and fewer policies that restrict LGBT+ youth rights tend to exhibit better youth mental health outcomes, on average.47 Although Delaware has some policies in place to protect the well-being of LGBT+ youth, additional laws and protection could help address the vast mental health and substance use disparities uncovered in the current study. For example, Delaware does not have state-level policy naming sexual orientation and gender identity in anti-bullying laws and does not require state school curriculum to be LGBT+ inclusive.48

Conclusion

Significant disparities in mental health and substance use exist between LGBT+ youth and cisgender heterosexual youth in Delaware, underscoring an urgent public health crisis. Stark disparities in mental health and substance use emerge as early as 8th grade and persist into 11th grade. These disparities reflect and extend evidence of LGBT+ mental health and substance use disparities from two decades prior. Prevalence rates of LGBT+ youth are similar to and above national averages, even in 8th grade, signaling the need for early intervention. State-level policies, school strategies, and mental healthcare practice must be tailored to the unique needs and lived experiences of LGBT+ youth to eliminate disparities and prevent continuance of these disparities into future generations of Delaware youth.

Footnotes

Financial Disclosure

Funding for the Delaware School Surveys has been provided by the Delaware Department for Health and Social Services, Division of Substance Abuse and Mental Health through the Substance Abuse and Mental Health Services Administration (SAMHSA).

References

  • 1.Marshal, M. P., Friedman, M. S., Stall, R., King, K. M., Miles, J., Gold, M. A., et al. Morse, J. Q. (2008, April). Sexual orientation and adolescent substance use: A meta-analysis and methodological review. Addiction (Abingdon, England), 103(4), 546–556. 10.1111/j.1360-0443.2008.02149.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Plöderl, M., & Tremblay, P. (2015). Mental health of sexual minorities. A systematic review. International Review of Psychiatry (Abingdon, England), 27(5), 367–385. 10.3109/09540261.2015.1083949 [DOI] [PubMed] [Google Scholar]
  • 3.Hatzenbuehler, M. L., McLaughlin, K. A., & Xuan, Z. (2012, October). Social networks and risk for depressive symptoms in a national sample of sexual minority youth. Social Science & Medicine, 75(7), 1184–1191. 10.1016/j.socscimed.2012.05.030 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Fish, J. N., Bishop, M. D., & Russell, S. T. (2021, June). Developmental differences in sexual orientation and gender identity-related substance use disparities: Findings from population-based data. The Journal of Adolescent Health, 68(6), 1162–1169. 10.1016/j.jadohealth.2020.10.023 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Ziyadeh, N. J., Prokop, L. A., Fisher, L. B., Rosario, M., Field, A. E., Camargo, C. A., Jr., & Austin, S. B. (2007, March 16). Sexual orientation, gender, and alcohol use in a cohort study of U.S. adolescent girls and boys. Drug and Alcohol Dependence, 87(2-3), 119–130. 10.1016/j.drugalcdep.2006.08.004 [DOI] [PubMed] [Google Scholar]
  • 6.Corliss, H. L., Rosario, M., Birkett, M. A., Newcomb, M. E., Buchting, F. O., & Matthews, A. K. (2014, June). Sexual orientation disparities in adolescent cigarette smoking: Intersections with race/ethnicity, gender, and age. American Journal of Public Health, 104(6), 1137–1147. 10.2105/AJPH.2013.301819 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Azagba, S., Ebling, T., & de Silva, G. S. R. (2025, February). E-cigarette, tobacco, and cannabis vaping among diverse sexual and gender identities in U.S. high school students. Public Health, 239, 55–61. 10.1016/j.puhe.2024.12.034 [DOI] [PubMed] [Google Scholar]
  • 8.Felner, J. K., Andrzejewski, J., Strong, D., Kieu, T., Ravindran, M., & Corliss, H. L. (2022, February 14). Vaping disparities at the intersection of gender identity and race/ethnicity in a population-based sample of adolescents. Nicotine & Tobacco Research: Official Journal of the Society for Research on Nicotine and Tobacco, 24(3), 349–357. 10.1093/ntr/ntab152 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Goldbach, J. T., Mereish, E. H., & Burgess, C. (2017, January 28). Sexual orientation disparities in the use of emerging drugs. Substance Use & Misuse, 52(2), 265–271. 10.1080/10826084.2016.1223691 [DOI] [PubMed] [Google Scholar]
  • 10.Fish, J. N., & Baams, L. (2018, August/September). Trends in alcohol-related disparities between heterosexual and sexual minority youth from 2007 to 2015: Findings from the Youth Risk Behavior Survey. LGBT Health, 5(6), 359–367. 10.1089/lgbt.2017.0212 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Phillips, G. L., II, Curtis, M. G., Kelsey, S. W., Floresca, Y. B., Davoudpour, S., Quiballo, K., & Beach, L. B. (2024, May 1). Changes to sexual identity response options in the Youth Risk Behavior Survey. JAMA Pediatrics, 178(5), 506–508. 10.1001/jamapediatrics.2024.0024 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Rosario, M., Reisner, S. L., Corliss, H. L., Wypij, D., Frazier, A. L., & Austin, S. B. (2014, July). Disparities in depressive distress by sexual orientation in emerging adults: The roles of attachment and stress paradigms. Archives of Sexual Behavior, 43(5), 901–916. 10.1007/s10508-013-0129-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Depa, N., Desai, S., Patel, S., Silvi, S., Hanif, S., Rizvi, S., et al. Mansuri, Z. (2022, August). Mental health disparities amongst sexual-minority adolescents of the US - A national survey study of YRBSS-CDC. Psychiatry Research, 314, 114635. 10.1016/j.psychres.2022.114635 [DOI] [PubMed] [Google Scholar]
  • 14.Lefevor, G. T., Boyd-Rogers, C. C., Sprague, B. M., & Janis, R. A. (2019, July). Health disparities between genderqueer, transgender, and cisgender individuals: An extension of minority stress theory. Journal of Counseling Psychology, 66(4), 385–395. 10.1037/cou0000339 [DOI] [PubMed] [Google Scholar]
  • 15.Brooks, W. K. (1981). Minority stress and lesbian women. Lexington Books. [Google Scholar]
  • 16.Goldbach, J. T., Schrager, S. M., Dunlap, S. L., & Holloway, I. W. (2015, February). The application of minority stress theory to marijuana use among sexual minority adolescents. Substance Use & Misuse, 50(3), 366–375. 10.3109/10826084.2014.980958 [DOI] [PubMed] [Google Scholar]
  • 17.Marshal, M. P., Friedman, M. S., Stall, R., & Thompson, A. L. (2009, June). Individual trajectories of substance use in lesbian, gay and bisexual youth and heterosexual youth. Addiction (Abingdon, England), 104(6), 974–981. 10.1111/j.1360-0443.2009.02531.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Bishop, M. D., Moran, S. A., Turpin, R. E., Aparicio, E. M., Mereish, E. H., Russell, S. T., & Fish, J. N. (2024, September 1). Binge drinking disparities by grade, race and ethnicity, sexual orientation, and gender identity. Pediatrics, 154(3), e2023063978. Retrieved from https://publications.aap.org/pediatrics/article-abstract/154/3/e2023063978/198927 10.1542/peds.2023-063978 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Steeger, C. M., Gust, C. J., Harlow, A. F., Cambron, C., Barrington-Trimis, J., Combs, K. M., et al. Hill, K. G. (2025). Nicotine and cannabis vaping among early high school adolescents: Disparities of use across sociodemographic characteristics and associations with psychosocial factors. Addictive Behaviors Reports, 21, 100577. 10.1016/j.abrep.2024.100577 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Day, J. K., Fish, J. N., Perez-Brumer, A., Hatzenbuehler, M. L., & Russell, S. T. (2017). Transgender youth substance use disparities: Results from a population-based sample. The Journal of Adolescent Health, 61(6), 729–735. 10.1016/j.jadohealth.2017.06.024 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Reisner, S. L., Greytak, E. A., Parsons, J. T., & Ybarra, M. L. (2015). Gender minority social stress in adolescence: Disparities in adolescent bullying and substance use by gender identity. Journal of Sex Research, 52(3), 243–256. 10.1080/00224499.2014.886321 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Watson, R. J., Fish, J. N., McKay, T., Allen, S. H., Eaton, L., & Puhl, R. M. (2020, January). Substance use among a national sample of sexual and gender minority adolescents: Intersections of sex assigned at birth and gender identity. LGBT Health, 7(1), 37–46. 10.1089/lgbt.2019.0066 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Button, D. M., O’Connell, D. J., & Gealt, R. (2012). Sexual minority youth victimization and social support: The intersection of sexuality, gender, race, and victimization. Journal of Homosexuality, 59(1), 18–43. 10.1080/00918369.2011.614903 [DOI] [PubMed] [Google Scholar]
  • 24.Manges, M. E., Jaeger, J. A., & Doxbeck, C. R. (2025). Examining substance use and suicide risk among sexual minority and heterosexual youth. Substance Use & Misuse, 60(8), 1099–1108. 10.1080/10826084.2025.2481324 [DOI] [PubMed] [Google Scholar]
  • 25.Bishop, M. D., Fish, J. N., Hammack, P. L., & Russell, S. T. (2020, November). Sexual identity development milestones in three generations of sexual minority people: A national probability sample. Developmental Psychology, 56(11), 2177–2193. 10.1037/dev0001105 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Williams Institute. (2022). How many adults and youth identify as transgender in the United States? https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/
  • 27.Kids Count Data Center. (2025). Child population by age group in Delaware. The Annie E. Casey Foundation. https://datacenter.aecf.org/data/tables/101-child-population-by-age-group#detailed/2/9/false/2545/64,6,4693/419,420
  • 28.United States Census Bureau. (2024). Delaware QuickFacts. https://www.census.gov/quickfacts/fact/table/DE/PST045224
  • 29.Center for Drug & Health Studies. (2025). Delaware school survey: Secondary [annual survey]. University of Delaware. https://cdhs.udel.edu/resources/data-resources/school-data-resources/
  • 30.Highberger, J., Wang, W., & Brittingham, R. (2022). Differences in perception of safety before and after school shootings: A multi-event analysis. Journal of School Violence, 21(3), 312–326. 10.1080/15388220.2022.2098500 [DOI] [Google Scholar]
  • 31.Bachman, R. D., Paternoster, R., & Wilson, T. H. (2021). Statistics for criminology and criminal justice. SAGE Publications. [Google Scholar]
  • 32.Gallup Inc. G. (2022). LGBT identification in U.S. ticks up to 7.1%. Gallup. https://news.gallup.com/poll/389792/lgbt-identificationticks- up.aspx
  • 33.Layland, E. K., Bränström, R., Murchison, G. R., & Pachankis, J. E. (2023, October). Kept in the closet: Structural stigma and the timing of sexual minority developmental milestones across 28 European countries. Journal of Youth and Adolescence, 52(10), 2012–2030. 10.1007/s10964-023-01818-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Bishop, M. D., Fish, J. N., & Russell, S. T. (2024). The timing of sexual identity development milestones: Disentangling age from cohort influences. Psychology of Sexual Orientation and Gender Diversity. 10.1037/sgd0000745 [DOI]
  • 35.Meade, J. (2021, October). Mental health effects of the COVID-19 pandemic on children and adolescents: A review of the current research. Pediatric Clinics of North America, 68(5), 945–959. 10.1016/j.pcl.2021.05.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Centers for Disease Control and Prevention. (2024). Youth risk behavior survey data summary & trends report: 2013-2023. US Department of Health and Human Services [Google Scholar]
  • 37.Miech, R. A., Johnston, L. D., Patrick, M. E., & O’Malley, P. M. (2024). Monitoring the future. National survey results on drug use, 1975-2023: Overview and detailed results for secondary school students. University of Michigan Institute for Social Research. [Google Scholar]
  • 38.Schulenberg, J., Maslowsky, J., Patrick, M. E., & Martz, M. (2016). Substance use in the context of adolescent development. Oxford University Press New York, NY. [Google Scholar]
  • 39.Harlow, A. F., Liu, F., Young, L. E., Coreas, S. I., Rahman, T., Unger, J. B., et al. Krueger, E. A. (2024, January 22). Sexual and gender identity disparities in nicotine and tobacco use susceptibility and prevalence: Disaggregating emerging identities among adolescents from California, USA. Nicotine & Tobacco Research: Official Journal of the Society for Research on Nicotine and Tobacco, 26(2), 203–211. 10.1093/ntr/ntad131 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Baskerville, N. B., Dash, D., Shuh, A., Wong, K., Abramowicz, A., Yessis, J., & Kennedy, R. D. (2017, February 16). Tobacco use cessation interventions for lesbian, gay, bisexual, transgender and queer youth and young adults: A scoping review. Preventive Medicine Reports, 6, 53–62. 10.1016/j.pmedr.2017.02.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Behrendt, S., Wittchen, H.-U., Höfler, M., Lieb, R., & Beesdo, K. (2009, January 1). Transitions from first substance use to substance use disorders in adolescence: Is early onset associated with a rapid escalation? Drug and Alcohol Dependence, 99(1-3), 68–78. 10.1016/j.drugalcdep.2008.06.014 [DOI] [PubMed] [Google Scholar]
  • 42.Mitsdarffer, M. L., McColl, R., Nescott, E., Bianchetta, J., Layland, E. K., & Tóth, T. (2023, June 12). LGBTQ+ youth homelessness in Delaware: Building a case for targeted surveillance and assessment of LGBTQ+ youth needs and experiences. Delaware Journal of Public Health, 9(2), 80–86. 10.32481/djph.2023.06.014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.McDermott, E., Kaley, A., Kaner, E., Limmer, M., McGovern, R., McNulty, F., et al. Spencer, L. (2024, December). Reducing LGBTQ+ adolescent mental health inequalities: A realist review of school-based interventions. Journal of Mental Health (Abingdon, England), 33(6), 768–778. 10.1080/09638237.2023.2245894 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Bochicchio, L., Carmichael, A. J., Veldhuis, C., & Stefancic, A. (2023). What we lose when we “don’t say gay”: Generational shifts in sexual identity and gender. Social Work, 68(2), 159-165, swad006. 10.1093/sw/swad006 [DOI] [PMC free article] [PubMed]
  • 45.Layland, E. K., Carter, J. A., Perry, N. S., Cienfuegos-Szalay, J., Nelson, K. M., Bonner, C. P., & Rendina, H. J. (2020, October 12). A systematic review of stigma in sexual and gender minority health interventions. Translational Behavioral Medicine, 10(5), 1200–1210. 10.1093/tbm/ibz200 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Pachankis, J. E., Soulliard, Z. A., Seager van Dyk, I., Layland, E. K., Clark, K. A., Levine, D. S., & Jackson, S. D. (2022, July). Training in LGBTQ-affirmative cognitive behavioral therapy: A randomized controlled trial across LGBTQ community centers. Journal of Consulting and Clinical Psychology, 90(7), 582–599. 10.1037/ccp0000745 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Burson, E., Renley, B. M., Layland, E. K., Rathus, T., Caba, A. E., Simon, K. A., . . . Watson, R. J. (2025). Associations between state-level structural stigma and sexual and gender minority youth mental health. Sexuality Research & Social Policy. 10.1007/s13178-024-01073-5 [DOI]
  • 48.Movement Advancement Project. (2025). Movement Advancement Project: Delaware’s Equality Profile. https://www.lgbtmap.org/equality-maps/profile_state/DE

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