Sexual and gender minority youth (SGMY) face multiple challenges to their mental and physical well-being, including higher rates of suicide, substance use, and victimization when compared with heterosexual and cisgender youth.1 This is not due to their being lesbian, gay, bisexual, transgender, or queer and/or questioning (LGBTQ), but rather is a result of shame and stigma imposed by others because of their identity. In this issue of Pediatrics, Coulter et al2 review interventions that attempt to address these health inequities for SGMY in their article titled “Mental Health, Drug, and Violence Interventions for Sexual/Gender Minorities: A Systematic Review.” Among their most important findings are that only 9 interventions met criteria for inclusion.
Clearly, these findings signal an urgent need for more research. We agree with the authors’ call for inclusion of SGMY in large, population-based studies and more studies specific to SGMY with appropriate comparison groups whenever possible. This should be combined with improvements in strategies to systematically measure sexual orientation and gender identity that are both inclusive and specific, recognize that youth identification may shift developmentally, measure the spectrum of sexual orientations and gender identities, and acknowledge that SGMY-related terminology is rapidly changing. Efforts to build on the work of The Williams Institute, which proposes a 2-step method for assessing gender identity to standardize data collection in any study or program involving youth, are encouraging.3
There is an urgent need for more research to guide SGMY clinical care. Multiple interventions showed improved mental health outcomes for gender-minority youth receiving medical interventions, including puberty blockers and gender-affirming hormones.4–6 We agree it would be unethical to include a control group in studies when the intervention is the standard of care recommended by organizations like the World Professional Association for Transgender Health and the Endocrine Society.7,8 Nonetheless, more studies are needed to address fundamental questions such as optimal timing of interventions, longitudinal metabolic effects of treatment, appropriate guidance related to preservation of biological fertility, and how clinicians can best support SGMY and their families. For some SGMY at extraordinarily high risk for health problems, tailored policies and programs will be necessary. For example, the medical and research communities have recently recognized that young transgender women of color have among the highest rates of HIV infection in the United States, with nearly 1 in 4 becoming infected by their twenties.9 Yet only 1 evidence-based intervention for HIV prevention exists for this group, and no interventions exist to specifically address daily threats of violence and victimization.10
We agree that more research to inform interventions at organizational, community, and policy levels is needed. This is amplified by policy interventions showing that legalizing same-sex marriage reduced suicide attempts, and antibullying legislation reduced victimization among sexual-minority youth.11,12 Section 1557 of the Patient Protection and Affordable Care Act, which protects transgender individuals from discrimination by insurers and health care providers, needs the support of health professionals.13
The 2011 Institute of Medicine (now the National Academy of Medicine) report on LGBTQ health and the new National Institutes of Health Sexual and Gender Minority Research Office have led to an increase in funded studies.1 However, these studies will not be sufficient to meet the research needs highlighted by this review by Coulter et al.2 Strategies to achieve health equity among SGMY need to be informed by a larger research agenda and require increased funding across federal agencies, private entities, and health care institutions. Future research should include strengths-based and resiliency approaches rather than an isolated focus on risk, include the voices of SGMY and their parents, and be grounded in a developmental framework.
What are implications for practicing pediatricians? The vast majority of SGMY are under the care of primary care clinicians. Clinicians who routinely ask all adolescents about gender identity, preferred pronouns, and sexual orientation in a nonjudgmental and developmentally sensitive way during annual visits are more likely to identify SGMY and better meet their health needs; they will also be conveying acceptance of SGMY to all youth. Research is now clear that parental support for LGBTQ youth leads to better adult mental health outcomes.14 Allowing transgender or gender-diverse children to socially transition results in lower rates of anxiety and depression when compared with youth who are not allowed to socially transition and yields similar rates to those of their cisgender peers.15 Pediatricians are well positioned to support SGMY and their families through the process of acceptance; support and advocate for gender-minority youth who are socially and medically transitioning in their homes, school, and communities; and refer SGMY and their families to appropriate professionals when needed. These activities translate research into practice and fulfill professional responsibilities to combat shame and stigma directed toward SGMY and their families. It is also important to highlight that many SGMY are marginalized and not connected to traditional clinic settings, and we need to develop interventions and policies that help us meet these youth where they are, whether in schools, community centers, or online, by using new social media and technologies.1
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: Supported by the National Institutes of Health (grant K23MH102128-01A1 to Dr Dowshen, principal investigator). Funded by the National Institutes of Health (NIH).
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-3367.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.