Sexual and Gender Minority Stress Amid the COVID-19 Pandemic: Implications for LGBTQ Young Persons’ Mental Health and Well-Being

Population-level increases in psychopathology and other negative mental health outcomes, including posttraumatic stress, depression, anxiety, and elevated substance use, are directly linked to large-scale disasters in the United States. ¹ Thus, it is unsurprising that the current coronavirus disease 2019 (COVID-19) pandemic is seriously impacting population-level mental health in the United States, especially among socially disadvantanged, young, and racial and ethnic minority persons. ² The indirect psychological harms of the COVID-19 pandemic for those who belong to minoritized communities are complicated, exacerbated, and compounded by experiences and stressors specific to their marginalized social identities. In this regard, lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) adolescents and young adults have received limited public health attention. ^{3 -6} This commentary aims to provide a nuanced perspective on the potential indirect mental health effects of the COVID-19 pandemic crisis on LGBTQ young persons.

International research suggests that heteronormativity and cisnormativity in practice and policy-level response to large-scale disasters systematically ignores the needs of LGBTQ populations. ⁷ Globally, issues relevant to LGBTQ communities in disaster contexts (eg, discrimination in accessing emergency government services because of LGBTQ status) are largely unreported, and government agencies historically fail to support LGBTQ-affirming interventions during recovery efforts. ⁷ International guidelines and policy frameworks on disaster response and recovery have further failed to consider the needs of LGBTQ populations. ⁷ The dearth of existing research on LGBTQ communities and disaster response in the United States speaks to the invisibility of LGBTQ young persons in the current public health response to the COVID-19 pandemic crisis.

Despite limited attention to the mental health needs of LGBTQ young persons during the COVID-19 pandemic, LGBTQ young persons may face unique mental health challenges ^6,8 driven by the overlapping experience of pandemic-related ^{9 -11} and sexual and gender minority–related ^3,11,12 stressors.

Sexual and Gender Minority Stress Among LGBTQ Young Persons in the Context of COVID-19

Compared with heterosexual and/or cisgender young persons, their LGBTQ peers are more likely to experience social inequalities, such as food insecurity, homelessness, foster care, other unstable housing, and poverty, ^{13 -15} which could exacerbate their mental health and well-being during the current pandemic. LGBTQ young persons are also disproportionately burdened by existing mental health concerns, ^{16 -18} which could further increase their medical and psychological vulnerabilities during the current pandemic crisis. Given the well-established link between sexual and gender minority stress and mental health among LGBTQ young persons, ^19,20 much may be gained from investigating how minority stress operates in the context of the COVID-19 pandemic. LGBTQ minority stressors include objective distal stressors, which are external and often enacted through discriminatory events perpetrated against LGBTQ young persons as a direct result of their LGBTQ identities, and subjective proximal stressors, which are negative internalized self-experiences among LGBTQ young persons as a direct result of their LGBTQ identities (eg, internalized homophobia or transphobia). ^21,22

Perhaps one of the most salient potential occurrences of enacted distal minority stress for LGBTQ young persons is family rejection, which has the potential to threaten LGBTQ young persons’ psychological and physical well-being. ²³ Young persons who report high levels of LGBTQ-related family rejection are 6 times more likely to experience depression and 8 times more likely to attempt suicide than LGBTQ young persons who report low levels of family rejection. ²⁴ Family rejection of LGBTQ identities is also the top cited reason for homelessness among LGBTQ young persons. ²⁵ Social and physical distancing measures to limit the spread of COVID-19 in the United States have forced many LGBTQ young persons into homes that are unsupportive and potentially unsafe (eg, LGBTQ young persons confined to staying at home with unsupportive parents because of kindergarten through 12th grade [K-12] school closings or virtual operations, or forced to move home with unsupportive parents because of university closings or virtual operations), ^3,6,11,12 thereby increasing their risk of family rejection, harassment, and victimization, and the associated negative mental ¹³ and physical health consequences. The concealment of LGBTQ identities also negatively affects mental health ^26,27 ; LGBTQ young persons who are not out to their families at home may struggle with the inability to live authentically in their day-to-day lives and may fear being outed and the potential consequences (eg, homelessness, physical abuse). ^11,12 Although these experiences likely vary for LGBTQ young persons of various ages, experiencing enacted forms of distal minority stress, such as family rejection and victimization, may increase proximal minority stress experiences, such as internalized homophobia and transphobia and LGBTQ identity rejection hypervigilance, which are linked to risks for substance use, psychiatric symptoms (eg, depression, anxiety, posttraumatic stress), suicidal ideation, and cumulative psychological distress among LGBTQ young persons. ^{17,28 -30}

Adolescence and young adulthood are critical developmental periods for LGBTQ young persons. ^31,32 Universities are often the first opportunity for LGBTQ young persons to live independently and authentically as their true selves; this freedom from their families and communities of origin allows LGBTQ young persons to explore and express their gender identities and sexual orientations, engage in LGBTQ community and romantic relationships, and develop a strong sense of identity and self-acceptance. ^31,32 K-12 school contexts can similarly be a primary source of affirming social and community support outside the home for LGBTQ young persons. ^17,33,34 K-12 school and university resources (eg, gender and sexuality alliances, affirming teachers, student organizations, LGBTQ student community centers) are related to the development of internal and external sources of resiliency (eg, identity pride, outness, self-esteem, community connectedness, social support) among LGBTQ young persons, ^{17,33 -37} which can reduce their risks for depression, anxiety, posttraumatic stress, and suicidality related to minority stress. ^{17,37 -39} LGBTQ young persons further rely on K-12 schools and universities for substantial professional mental health services and support. ^40,41 However, because of the physical closing of K-12 schools and universities (beginning March 2020), LGBTQ young persons may be lacking access to affirming social support and coping resources to deal with increased psychological distress and LGBTQ-related minority stressors (eg, family rejection), ^3,11,12 increasing threats against their psychological well-being.

Thus, COVID-19 may serve not only as an indirect mechanism through which LGBTQ young persons could experience distal and proximal minority stress, but also as one that could sever their ties to supportive and affirming people and resources. ^3,12 Even with the lifting of state-based physical isolation mandates, many K-12 schools and universities remained closed during summer 2020, and many will operate virtually in the fall 2020 semester and potentially beyond, extending the disconnect between LGBTQ young persons and social and coping resources available in their K-12 schools and universities. These stressful circumstances could result in lasting mental health and developmental ramifications among LGBTQ young persons.

Public Health Implications

Protecting the mental health and well-being of LGBTQ young persons is especially important given the potential for psychological and physical harms caused by both sexual and gender minority stress and pandemic stress. To mitigate the negative effects of sexual and gender minority stress, particularly among young persons who are forced into unsupportive homes or homes where they are not out, positive and affirming social interactions normally obtained in K-12 school and university environments need to be maintained via online mechanisms ⁶ ; this can be achieved while still adhering to social distancing guidelines through various mediums, including video conferencing (eg, Zoom, Skype, Facebook Messenger) and social media (eg, Twitter, Instagram, Facebook). Public health stakeholders (ie, public health policy makers, researchers, and practitioners) need to continue supporting K-12 school systems and universities in their delivery of online education, with strong emphasis on providing online opportunities for social interactions. Given the potential for family rejection and conflict around LGBTQ identities ^3,12 and the associated mental health and physical safety ramifications ^24,25 in the current pandemic context, we urge public health stakeholders to widely disseminate provider and parental education resources for promoting family acceptance and affirmation of LGBTQ young persons’ identities. ^{42 -45} Family acceptance programs could improve the protection of LGBTQ young persons’ mental and physical health and well-being. ^23,29,46

Considerations for Online, Text, and Chat Mental Health and Crisis Intervention Resources

In light of the susceptibility of LGBTQ young persons to mental health burden and minority stress, mental health service organizations and providers must be supported by public health stakeholders in the continuity of and increased access to affirming mental health care in order to mitigate mental health crises associated with the COVID-19 pandemic ⁴⁷ ; this is particularly important for LGBTQ young persons who were displaced during the pandemic and whose access to mental health care has been severed. Fortunately, many school and community-based centers that serve LGBTQ young persons have transitioned their services (eg, support groups, mental health care services, social activities) to online platforms. Online mental health supports, such as teletherapy and digital support groups, can help maintain external support in the absence of in-person access and may mitigate psychological burden. ^6,47 However, LGBTQ-relevant guidelines for providing safe teletherapy services for young LGBTQ clients are needed, especially for young persons who have not come out in their current homes or who are currently in unaffirming living circumstances. Such young persons may benefit from online chat and text-based mental health and crisis support services that protect their privacy, safety, and confidentiality. ^3,12 The Trevor Project, LGBT National Help Center, and Q Chat Space provide private, confidential, and safe online chat and text-based mental health, and social and crisis support services for LGBTQ young persons. However, these resources are likely overwhelmed as a result of COVID-19, ³ and few comparable community LGBTQ-relevant digital resources are available for LGBTQ young persons. ⁴⁸ The reach of other mental health, and social and crisis support chat and text resources, such as the National Suicide Prevention Lifeline Chat, Crisis Text Line, and QuarantineChat, can be strengthened if public health stakeholders provide support for organizations to increase their visibility toward and allyship with LGBTQ young persons, as well as their competency in serving these populations. Public health stakeholders can further support mental health organizations and therapists who serve LGBTQ young persons by providing them with more resources if they continue to face challenges in migrating their services successfully to online modes.

Intersectional, Structural, and Social Considerations for LGBTQ Young Persons During COVID-19

Considering that LGBTQ young persons are at risk for abuse generally ^49,50 and likely during the pandemic as well, ⁵¹ it is crucial for public health practitioners to implement strategies that strengthen the reporting and identification of abuse and domestic violence during the COVID-19 pandemic crisis. Such strategies should include the collection of information on LGBTQ victims’ identities necessary to recognize instances of abuse directly related to LGBTQ identities, which many social service agencies fail to do. ^52,53 Not having such strategies in place hinders the ability of researchers and practitioners to assess the incidence and prevalence of abuse burden among LGBTQ young persons and as a result of stigma and prejudice against LGBTQ identities. Public health stakeholders must advocate for the collection of data on sexual orientation and gender identity among social service agencies; without systematic data collection, mental health and social service providers are limited in their ability to intervene in meaningful ways to address LGBTQ-specific mental and physical health inequities. ^4,5 School-, community-, and government-based organizations serving young LGBTQ victims of abuse and domestic violence should further be supported in conducting in-person check-ins with young persons identified as at risk for abuse during the pandemic. ⁵¹ Social service and community-based organizations serving young LGBTQ victims of abuse urgently require support from public health stakeholders to facilitate and increase access to social service and mental health resources in the current pandemic context, including LGBTQ-affirming mental health treatment, safe housing, and shelters.

Amid COVID-19, LGBTQ young persons with intersectionally marginalized identities (eg, LGBTQ young persons of color or undocumented immigrants) face disproportionate risks for complex experiences of oppression and trauma as a result of various forms of social and structural inequality. ^{12,54 -56} For example, they may not have access to digital technologies, health insurance, or the financial means necessary to receive teletherapy or participate in digital support groups. ^12,54,55 Text and online chat-based mental health, and social and crisis intervention resources can address some of these challenges by providing LGBTQ-affirming support to young persons with access to smartphones with sufficient data capacity to use these services. However, intersectionally vulnerable LGBTQ young persons, such as those living in unstable housing or in poverty, undocumented immigrants, and those with language barriers, living in rural locations, or with physical and/or mental disabilities, may be unable to benefit from these recommended services. Public health stakeholders are urged to consider the complex structural challenges faced by intersectional LGBTQ young persons in COVID-19 crisis intervention efforts. For example, undocumented immigrant LGBTQ young persons are unable to benefit from Coronavirus Aid, Relief, and Economic Security Act emergency relief services and programs, ⁵⁷ many lack access to health insurance, ⁵⁸ and many face various other forms of social inequality, ^57,59 such as poverty and language barriers. Undocumented immigrant LGBTQ young persons further face prejudice and discrimination from service providers because of their intersectional identities. ⁵⁷ Such intersectional challenges hinder the ability of undocumented immigrant LGBTQ young persons to access and use medical, mental health, social support, and crisis intervention services. Government, school, academic, and community-based agencies responding to pandemic mental health needs urgently require support from public health stakeholders in providing equitable access to their resources among young intersectional LGBTQ populations; otherwise, these highly marginalized groups will likely not benefit from potentially life-saving mental health and crisis intervention services.

Many transgender young persons often rely on gender identity–affirming therapy (eg, puberty blockers, hormone therapy, surgery, mental health treatment) to medically transition their sex assigned at birth to correspond with their gender identity. ⁶⁰ Transgender young persons—especially those who were displaced during the COVID-19 pandemic—likely face unique obstacles to continuing and accessing gender-affirming medical and mental health care. ^{61 -63} As a result, transgender young persons may experience gender dysphoria and elevated levels of anxiety, depression, and suicidal behavior during the current pandemic. ^{60,61 -65,66} Given that many medical and mental health providers lack adequate training in transgender-affirming care, ⁶⁷ it is critical for public health stakeholders to support and advocate for provider capacity building in gender-affirming therapy and conducting high-quality referrals to address transgender mental health needs amid the current pandemic. ^61,63

Conclusion

Public health stakeholders must increase the visibility of the mental health threats faced by LGBTQ young persons during COVID-19 and increase access to LGBTQ-affirming resources. These resources, however, must be sensitive to intersectional needs within populations of LGBTQ young persons (eg, persons of color, persons with disabilities, and immigrants and undocumented persons). Elevating stakeholder allyship and competency at provider and organizational levels is essential for reducing the threat of minority stress faced by LGBTQ young persons during the pandemic. Public health stakeholders must advocate for allocation of pandemic crisis funds to community-based organizations involved in supporting crisis and mental health interventions among LGBTQ young persons. It is imperative for national, state, and local departments of health to make explicit statements and increase public awareness about the mental health vulnerabilities of LGBTQ young persons (and other marginalized groups) amid the COVID-19 pandemic, and to commit to eliminating mental health inequities. ⁵ Public health researchers, academics, and scholars must elevate discourse on LGBTQ young persons’ mental health and well-being during the pandemic, ⁵ with intentional centering of intersectional LGBTQ young persons, who are often pushed to the margins of public health research and intervention. ^4,5,56 Knowledge to action is also critical; researchers must commit to rapid and effective dissemination strategies reaching beyond academic journals, ⁵ including engaging public health policy stakeholders; leveraging existing community–academic partnerships, social media, and the internet; and establishing new collaborations to maximize impact across communities of LGBTQ young persons. We implore public health policy makers to consider the unique needs of LGBTQ young persons (including intersectional LGBTQ young persons) in their efforts to provide COVID-19 mental health relief and support. The mental health needs of LGBTQ young persons are long-standing, but the current COVID-19 pandemic requires swift, decisive, and intentional public health action to support LGBTQ young persons.