Abstract
Unhealthy preteen behaviors are associated with adolescent depression. However, little is known about preteen factors among sexual minority young people, a group at increased risk for teen depression and suicide. We completed weighted multivariate logistic regression analyses on data from the national 2015 and 2017 Youth Risk Behavior Survey of 30 389 high school students in the United States. Preteen sex, cigarette smoking, and alcohol and marijuana use were significantly more prevalent among lesbian, gay, or bisexual (LGB) and questioning students who reported depressive symptoms than among their heterosexual peers (adjusted prevalence ratio [APR] range, 1.33-2.34; all significant at P < .05). The only exception was that marijuana use among questioning students was not significantly different from use among heterosexual peers (APR = 1.34; P = .11). Assessment of preteen sex and substance use—especially among LGB and questioning young people, who are more prone to depressive symptoms and more likely to initiate risky preteen behaviors than their heterosexual counterparts—will facilitate a life course approach to sexual minority mental health that should begin by early adolescence.
Adolescent depression is a major risk factor for teen suicide, a growing public health concern given that suicide is now the second leading cause of death among adolescents and young adults aged 15-19 in the United States. 1 Adolescents who identify as lesbian, gay, or bisexual (LGB) are more likely to experience depression and suicidality than their heterosexual peers. 2,3 Depression and suicidality have been attributed to environmental sources such as societal stigma, bullying, family rejection, and victimization rather than to inherent factors of sexuality. 2,3 Although preteen sex and use of tobacco, alcohol, and substances have been linked to adolescent depression, future suicide risk, and other health problems, 4 -7 little is known about the prevalence of these preteen factors among depressed adolescents of different sexual orientations. An examination of unhealthy preteen behaviors and their prevalence among heterosexual, LGB, and questioning adolescents who report depressive symptoms may uncover information on childhood factors associated with depression and clues to the disparities in depression between sexual minority and heterosexual populations during adolescence.
Methods
We completed a secondary analysis of data from the 2015 and 2017 Youth Risk Behavior Survey (YRBS), 8,9 a biennial survey developed by the Centers for Disease Control and Prevention of a nationally representative sample of high school students (2 years combined: N = 30 389; overall response rate = 60%). The national YRBS included questions about sexual orientation for the first time beginning in 2015 and for the second time in 2017. The national YRBS is approved by the Centers for Disease Control and Prevention Institutional Review Board. National YRBS data are weighted for grade, sex, and race/ethnicity. These data are representative of all public and private high school students in grades 9-12 in the United States and the District of Columbia. YRBS methodology is described elsewhere. 10
Measures
The national YRBS asks about sexual orientation with the following question: “Which of the following best describes you?” We grouped the 4 responses, “Heterosexual (straight), gay or lesbian, bisexual, not sure” into 3 categories: heterosexual; lesbian, gay, or bisexual (LGB); and not sure (ie, questioning). We assessed depressive symptoms by a yes response to the following question: “During the past 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing some usual activities?” Our measurement of variables for the first occurrence of preteen behaviors was a response of ≤8, 9 or 10, or 11 or 12 for the following 4 questions: “How old were you when you smoked a whole cigarette for the first time?” “How old were you when you had your first drink of alcohol other than a few sips?” “How old were you when you tried marijuana for the first time?” and “How old were you when you had sexual intercourse for the first time?”
Analysis
We calculated weighted proportions of depressive symptoms and preteen behaviors by sexual orientation and stratified by depressive symptoms. We used multivariate logistic regression to estimate the relative odds of preteen behaviors comparing LGB and questioning respondents with heterosexual respondents, controlling for sex, race/ethnicity, and school grade. We used marginal standardization to obtain adjusted prevalence ratios (APRs). We used the Pearson χ2 test of significance, with P < .05 considered significant. We conducted all analyses using SAS-callable SUDAAN version 11 (RTI International).
Results
Most respondents reported their sexual orientation as heterosexual (87.1%; 95% CI, 86.0%-88.2%), followed by LGB (9.2%; 95% CI, 8.3%-10.1%), and questioning (3.7%; 95% CI, 3.3%-4.1%). About one-quarter (27.0%; 95% CI, 25.7%-28.2%) of heterosexual respondents, 61.9% (95% CI, 58.8%-64.9%) of LGB respondents, and 46.4% (95% CI, 41.8%-51.0%) of questioning respondents reported depressive symptoms. Among respondents who reported depressive symptoms, the prevalence of all 4 preteen behaviors was significantly higher among LGB respondents than among heterosexual respondents (APR range, 1.33-2.34, P < .001) and highest among questioning respondents. The APRs for smoking cigarettes (APR = 1.68, P = .01), consuming alcohol (APR = 1.37, P = .01), and first sex (APR = 2.13, P = .01) were all significantly higher among questioning respondents than among heterosexual respondents, but the APR for smoking marijuana was not significant (APR = 1.34, P = .11; Table).
Prevalence of preteen behaviors among high school students with depressive symptoms, by sexual orientation, United States, 2015-2017a
Abbreviations: APR, adjusted prevalence ratio; LGB, lesbian, gay, or bisexual.
bAdjusted for race/Hispanic ethnicity, sex, and school grade.
c P values were determined using the Pearson χ2 test, with P < .05 considered significant.
Discussion
Compared with their heterosexual peers with depressive symptoms, LGB and questioning students with depressive symptoms were significantly more likely to have had sex, smoked cigarettes, and used alcohol and marijuana before age 13 (except marijuana use in the questioning group, which was higher but not significantly so). The early onset of these behaviors, before age 13, suggests that many middle school students—especially those with depressive symptoms by high school age and who identify as LGB or questioning—have already engaged in unhealthy behaviors. The reason for the increased prevalence of risky preteen behaviors among sexual minority young people during early adolescence is complex and unclear. 11 As with older teens and adults, children forming their sexual identities may not be in a supportive environment to do so. This lack of a supportive environment may be especially true among younger adolescents who are more vulnerable to the effects of bullying and victimization when their sexual identities differ from their peers. 12,13 A 2016 Dutch study of sexual minority adolescents reported associations between sexual orientation and depressive symptoms starting as early as age 11, and these associations were mediated by parental rejection and peer victimization. 14 The challenges of adolescence are numerous, and, as Meyer’s minority stress theory posits, LGB and questioning adolescents must confront the challenges of normal adolescence in addition to the challenges related to their stigmatized identities. 15 Countering the adverse effects of bullying and victimization, helpful factors such as support from parents, family, friends, school staff members, and community organizations can improve the psychological well-being of LGB and questioning adolescents. 16
Although many studies of sexual minority young people either exclude the questioning group or include it together with the LGB group, we found that the questioning group merited separate study. Our data revealed that high school students with depressive symptoms who self-identified as questioning reported higher rates of risky preteen behaviors than LGB and heterosexual students who reported depressive symptoms. Birkett et al 12 reported more bullying and victimization among questioning adolescents than among LGB adolescents and advocated including the questioning group separately in studies because their behavior may be unique. Questioning young people, who are unsure of their sexual identity, may not seek or receive support from LGB and heterosexual peers. The national YRBS does not ask about transgender status.
With the inclusion of sexual identity measures on the core national YRBS starting in 2015, further study of LGB young people as separate subsets and by gender and race could elucidate important features of these groups with regard to their high rates of depressive symptoms and suicidality. In addition, the number of studies by the National Institutes of Health on sexual minority populations, especially children and adolescents aged <18, has been deemed inadequate. 17,18 Filling this research gap will be a necessary step in improving the health outcomes for these populations.
Early screening for depression starting at age 12, recently recommended by the US Preventive Services Task Force 19 and endorsed by the American Academy of Pediatrics, 20 will help identify younger adolescents with depressive disorders. In addition, knowledge about preteen sex and substance use may help clinicians to assess depression, especially among sexual minority young people, many of whom have engaged in unhealthy preteen behaviors. Both teens and clinicians often feel uncomfortable with the discussion of sex, sexual orientation, mental health, and substance use. 21,22 A clear explanation of confidentiality by clinicians and the provision of a comfortable, nonjudgmental environment will help teens feel safe discussing these personal topics.
Limitations
This study had several limitations. First, the national YRBS does not include questions about the age of onset of other preteen behaviors commonly associated with depression, such as bullying, victimization, and lack of parental support, among sexual minority young people. These factors may be linked to the higher prevalence of unhealthy preteen behaviors and depressive symptoms among sexual minority young people than among their heterosexual peers. Second, the “not sure” group may have included respondents who were unsure of what the question was asking and respondents who were unsure of their sexual identity. Those respondents who were unsure of the question may actually have been heterosexual or LGB and not questioning their identity. Third, depressive symptoms on the YRBS were self-reported and may not represent a diagnosis of depression; a comprehensive evaluation is needed to establish this clinical diagnosis. However, the YRBS question about depressive symptoms is similar to the questions asked in the Patient Health Questionnaire’s 2-question tool, a validated screen for adolescent depression. 23,24 Fourth, self-reported data on unhealthy behaviors and sexual identity are inherently subject to social desirability bias, inaccurate responses, nonresponse, and responder bias, which often result in lower reported rates of the factors studied than in non–self-reported data. Finally, sexuality is a dynamic concept that evolves over time. It encompasses more than self-identification, involving sexual attraction and sexual behaviors. The YRBS questions used in this study asked about identification only.
Conclusion
In our study, the onset of sex, cigarette smoking, and alcohol and marijuana use before age 13 was significantly more prevalent among LGB and questioning high school students with depressive symptoms than their heterosexual peers with depressive symptoms. Conversations with health care providers and family about these issues should be encouraged during the preteen and teen years and may facilitate a better understanding of the mental health disparities in depression and suicide among sexual minority young people. In addition to screening for depression starting at age 12, as recommended by the US Preventive Services Task Force, an additional assessment of unhealthy preteen behaviors may contribute to a life course approach for optimization of sexual minority mental and behavioral health, which ideally begins in childhood and early adolescence. Future research will enrich our understanding of differences between sexual minority and heterosexual mental health and may lead to optimal methods for the prevention of these differences.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
