Sexual- and gender-diverse youth (SGDY) are at the forefront of a growing mental health crisis, navigating their formative adolescent years in a sociopolitical climate marked by both increased visibility and heightened vulnerability. Despite growing acceptance in some arenas, rampant anti-LGBTQ legislation and societal discrimination pose daily challenges,^1,2 exacerbating systemic and interpersonal stressors that significantly impact their mental health and well-being.³ At the same time, the prevalence of sexual and gender diversity is growing rapidly; according to a recent Gallup poll, 1 in 5 individuals in Generation Z (born 1997-2012) identifies as SGDY,⁴ underscoring the importance of acknowledging and addressing the mental health needs of SGDY.

Research has demonstrated that SGDY—those who identify as LGBTQ or another nonheterosexual/cisgender identity—exhibit significantly elevated incidence of mental health diagnoses and conditions compared with their counterparts, including higher rates of suicidality, depressive and anxiety disorders, and substance misuse.^5-7 The 2023 US National Survey on the Mental Health of LGBTQ Young People, which had responses from more than 28,000 SGDY aged 13 to 24 years, indicated that 41% of participants seriously considered attempting suicide in the past year, and nearly 20% of transgender/nonbinary youth attempted suicide.8 Transgender individuals, nonbinary individuals, and youth of color had higher rates of considered and attempted suicidality than their peers.⁸

These disparities in mental health are attributable to the experience of minority stressors, such as bullying and victimization, discriminatory practices, and internalized homosexual/transgender negativity.⁹ Minority stress theory posits that one’s experience of stigmatization within society is associated with an increased risk of negative health outcomes.^7,10,11 The health disparities between SGDY and their cisheterosexual counterparts are attributed to the additional stress and burden associated with their minority status—in this case, related to sexual orientation, gender identity, and expression (SOGIE). Such stressors include both distal and proximal factors, resulting from political climates limiting affirming care for LGBTQ individuals and direct victimization and internalized stigma.^7,12,13 Health disparities contribute to health inequities: the unjust, preventable, and systematic variations in health outcomes that result as a consequence of systematic social, economic, and cultural exclusion due to factors such as race, gender, sexuality, socioeconomic status, and geographic location.^14-16

Health disparities and health inequities are compounded for SGDY who exist within multiple marginalized identities. Intersectionality is a theoretic framework that suggests that multiple marginalized identities—eg, race, ethnicity, gender, and sexual orientation—intersect at the individual level of experience and reflect larger social-structural inequities experienced on the societal level.17,18 For Black and Latinx SGDY, the intersection of racial and LGBTQ identities intensifies their experience of stress and discrimination, further exacerbating mental health disparities and hindering their access to mental health services.¹⁹ One study demonstrated that Black adolescent and young adult women who identified as SGDY, faced an 80% greater likelihood of their mental health needs going unrecognized compared with their White counterparts,²⁰ highlighting how intersectional factors contribute to disparities in needed mental health care among Black SGDY.

Adolescence represents a crucial developmental period of vulnerability influenced by individual experiences of rejection and victimization, interpersonal dynamics with peers and family, and systemic societal factors. The initial disclosure of sexual orientation and gender identity by SGDY frequently occurs during adolescence.²¹ The reactions elicited by such disclosure can engender stress and exacerbate mental health. Notably, SGDY who encounter adverse reactions following the disclosure are more likely to suffer from mental health issues.²² Such youth frequently experience high rates of victimization, including family rejection, system involvement, precarious housing, unemployment, and arrest.^10,11,23,24

In fact, suicidality has been correlated with living in nonaffirming environments,²⁵ and parental and family rejection increases one’s risk of suicidality and depression during young adolescence and adulthood.²⁶ More than 60% of SGDY surveyed in the 2023 US National Survey on the Mental Health of LGBTQ Young People reported that their home was not accepting of their sexual orientation or gender identity/expression (SOGIE).⁸ Studies have demonstrated the potency of parental relationships on the well-being of SGDY.^27,28 Family acceptance promotes self-esteem and protects against suicidality, depression, and substance use.²⁸ Youth with higher levels of family rejection are 5.9 times more likely to report moderate/severe levels of depression, 3.4 times more likely to use substances, and 8.4 times more likely to attempt suicide.²⁶

Beyond family of origin, relationships with nonparental adults and peers have a significant impact, both as barriers and facilitators to mental health. For instance, The Trevor Project found a lower percentage of students reported having considered suicide if they felt their school was gender affirming,⁸ highlighting the protective power of inclusive environments. In contrast, in results from a study of 800,000 California students, less than 50% of SGDY felt safe at school and were more than twice as likely to report experiencing bullying, harassment, and threats of physical violence.²⁹ Another study found that more than 95% of SGDY have heard homophobic/transphobic slurs used in school, with 56% of homophobic remarks and 71% of transphobic remarks coming from school staff; 57% of SGD students were sexually harassed in the past year at school, and although 55% did not report incidents at all, 60% of the students who did said that school staff did nothing in response or told the student to ignore it.³⁰

Other studies’ results suggest that the mental health of SGDY is influenced by broader societal attitudes toward SOGIE. Most of the transgender and nonbinary youth surveyed in the 2022 National Survey on LGBTQ Youth Mental Health said that they have worried about transgender individuals being denied access to gender-affirming medical care (93%), access to bathrooms (91%), and sports participation (83%) due to state or local laws.³¹ Neighborhood-level LGBTQ hate crimes, for example, have been associated with higher rates of suicide, bullying, and marijuana use.^32-34 In contrast, residing in counties with a more supportive environment for sexual and gender diversity (evidenced by a higher proportion of same-sex couples, more schools implementing antibullying policies, and the presence of gender and sexuality alliances) has been associated with lower instances of victimization, suicidality, and depressive symptoms.³⁵ The impact of anti-LGBTQ policies is heightened for Black SGDY due to the additive impact of structural racism on anxiety and depression.³⁶

The COVID-19 pandemic further exacerbated anxiety, depression, and poor mental health.³⁷ More than half (56%) of SGDY surveyed in the
2022 National Survey on LGBTQ Youth Mental Health reported that their mental health was poor most of the time or always due to the COVID-19 pandemic.³¹ Approximately 3 of 5 transgender and 2 of 5 cisgender youth surveyed reported wanting mental health care in the past year but were unable to get it.³¹ Contextual factors that contributed to higher rates included social isolation, lack of family support, and limited access to services.^38-40 Shelter-in-place orders during COVID-19 curtailed community connectedness and confined youth to environments that were potentially harmful. Youth with intersectional identities, such as Black individuals, indigenous individuals, and youth of color who experience other social determinants of health including low socioeconomic status, unstable housing, and unemployment, were particularly vulnerable to higher rates of anxiety and depression during the pandemic due to diminished access to services.⁴¹

Despite facing significant challenges during the pandemic, SGDY exhibit remarkable resilience and resourcefulness in navigating their mental health. A key source of strength lies in positive supports, fostering environments that affirm their identities and offer avenues for growth. These include chosen families, self-made networks of peers, mentors, and allies who offer acceptance, belonging, and emotional validation.⁴² These chosen families, often formed online or within supportive school communities, provide safe spaces for authentic self-expression and combat feelings of isolation or rejection, especially when biological families are unsupportive. Supportive school communities can also play a vital role, offering safe spaces for self-expression and combating feelings of isolation or rejection. Robust literature demonstrates the benefits of mentorship, with concomitant positive socio-emotional, cognitive, and
identity development

SGDY also demonstrate positive coping skills, employing strategies such as mindfulness, creative expression, and connection with nature to manage stress and anxiety.⁴³ Recent scholarship has demonstrated the potency of positive storytelling of gender euphoria, rather than merely focusing on pathology; celebrating and nurturing joy can be a vital form of resistance for marginalized communities.⁴⁴ Importantly, seeking professional help from LGBTQ-affirmative mental health services is encouraged whenever needed. By harnessing their inner strength, fostering supportive communities, and utilizing positive coping mechanisms, SGDY actively navigated the challenges of the pandemic and built a brighter future for themselves.

Pediatricians are uniquely positioned to intercede and mitigate the negative impacts of minority stress.⁴⁵ Health care providers also run the risk of exacerbating the detrimental effects of homosesxual/transgender phobia and heterosexism. According to a survey conducted by the Human Rights Campaign of more than 10,000 SGDY aged 13 to 17 years, 67% of lesbian, gay, and bisexual youth and 61% of transgender youth opted not to disclose their sexual orientation or gender identity to their health care providers. Furthermore, 80% of the SGDY who identified as racial/ethnic minorities reported experiences of racial discrimination within health care settings.⁴⁶ SGDY who have postponed the disclosure of their sexual orientation or gender identity have reported instances of discrimination, denial, and inferior quality of care as direct consequences of their sexual orientation or gender identity.⁴⁷ Such experiences can culminate in delayed medical attention and inadequate access to treatment,^48,49 and can potentially exacerbate, rather than alleviate, the disproportionate risk of depression, suicidal ideation, poor sexual and reproductive health outcomes, and substance use that SGDY face relative to their heterosexual and cisgender counterparts.²³

The mental health crisis among SGDY necessitates a comprehensive, inclusive approach to address the deep-rooted societal and structural barriers that perpetuate disparities in care. Pediatricians play a crucial role in educating and supporting families, fostering environments of acceptance and affirmation, and ensuring every young person has access to the care they need to thrive. To accomplish this, providers will need enhanced training around the unique challenges faced by SGDY, emphasizing the critical importance of intersectionality and the tools needed to systematically collect information on sexual orientation and gender identity and incorporate mental health screening into electronic health records.⁵⁰ Pairing physical symbols that indicate affirming environments and easily accessible community resources can enable a more streamlined approach to linking patients with mental health providers who have LGBTQ+ expertise.⁵¹ The development of community and school-based resources that promote acceptance and support, alongside programs that educate and support families, can significantly reduce rates of depression and suicidality among SGDY. More legislation and funding are needed to remove structural barriers and ensure equitable access to mental health services.