Exploring How U.S. High School Staff Support,Protect,and Affirm Sexual and Gender Minority Youth: Methods and Lessons Learned from a Qualitative Interview Study

Abstract

Background. Sexual and gender minority youth (SGMY) experience health inequities compared with cisgender heterosexuals, and these inequities are heightened in areas with high structural stigma. Quantitative research shows school assets (e.g., adult support) are associated with better health for SGMY. Though some qualitative studies elucidated how school staff support SGMY, none have triangulated such strategies in a geographically and sociodemographically diverse sample of school staff and SGMY. This paper describes a multi-perspective qualitative study design and offers lessons learned from conducting such a study. Methods. Using a novel stratified sampling frame, we interviewed 60 SGMY and 29 school staff who attended/worked at high schools in U.S. states with low, medium, and high structural stigma. To ensure sociodemographic diversity, we constructed sampling quotas, and recruited SGMY using social media and staff using a multi-pronged approach. Results. The stratified sampling strategy met our goal of enrolling diverse SGMY and staff participants. SGMY participants attended schools in low (n = 20), medium (n = 22), and high (n = 18) structural stigma states. We enrolled 18 cisgender girls, 18 cisgender boys, and 24 gender minority youth. Fifty-three percent of SGMY were youth of color, and 45% attended schools in rural areas. School staff participants worked at schools in low (n = 11), medium (n = 11), and high (n = 7) structural stigma states. School staff participants were 55% heterosexual, 91% cisgender, and had diverse roles (e.g., teacher, principal, librarian, and nurse). Conclusions. This paper describes new methods for collecting qualitative data from diverse SGMY and school staff. Some lessons learned from this study include the importance of using trauma-informed interviewing methods, having a suicidality safety protocol, establishing a priori sampling quotas, and creating tailored social media advertisements. With these data we will explore the heterogeneity of SGMY and school staff experiences across varying structural stigma levels, yielding foundational information for future school-based interventions.

Keywords

qualitative research sexual minority youth gender minority youth school environment

Background

Sexual minority (e.g., lesbian, gay, bisexual, and queer) and gender minority (e.g., transgender, nonbinary, and genderqueer) youth in the United States (U.S.) experience health inequities compared with their heterosexual cisgender (non-transgender) peers. For example, sexual and gender minority youth (SGMY) have up to 4.5 times higher odds of violence victimization, 7.2 times higher odds of lifetime substance use, and 12.3 times higher odds of mental health problems (Marshal et al., 2008; Marshal et al., 2011; Friedman et al., 2011; Reisner et al., 2015; Coulter et al., 2018; Clark et al., 2014; Veale et al., 2017). Many of these health inequities have been documented in population-based samples for 25 years (Garofalo et al., 1998); and emerging research suggests that some of these inequities are widening in recent years (Watson et al., 2018, 2018b). Furthermore, these disparities are more pronounced in regions of the U.S. with high structural stigma (i.e., areas with policies, practices, and norms less inclusive of sexual and gender minority populations) (Hatzenbuehler, 2014). Nevertheless, these disparities still exist in regions with medium and low structural stigma (Coulter et al., 2017; Schneider et al., 2012; Reisner et al., 2014; Coulter et al., 2016; Hatzenbuehler et al., 2013; Hatzenbuehler et al., 2012; Hatzenbuehler et al., 2014a, 2014b), suggesting that SGMY health disparities are widespread. In addition to state-level structural stigma, microenvironments for SGMY also need careful attention—including school policies and practices—because they impact the wellbeing of SGMY.

Quantitative epidemiologic research has identified many risk and protective factors for SGMY, and much of this research has focused on factors in the school environment. For example, research on minority stress theory shows that sexual and gender minority youth face specific stressors (e.g., discrimination and bullying in schools) because on their minority sexual orientation, gender identity, and/or gender expression, and, in turn, these SGMY-specific stressors contribute to myriad health problems and inequities for SGMY (Coulter et al., 2018; Meyer, 1995; Institute of Medicine, 2011; Tan et al., 2020). Regarding protective factors, SGMY who report having support from adults at school and greater school connectedness have reduced health problems, such as violence, substance use, and mental health problems (Coulter et al., 2017; Darwich et al., 2012; Day et al., 2020; De Pedro et al., 2017; Fallin-Bennett & Goodin, 2019; Seil et al., 2014; Stone et al., 2015; Watson et al., 2018, 2018b; Whitaker et al., 2016; Wilson et al., 2018). However, compared with their peers, SGMY are generally more likely to lack supportive adults at school and have lower school connectedness (Coulter et al., 2017; Day et al., 2018; La Salle et al., 2019; Stone et al., 2015; Watson et al., 2018, 2018b). Altogether, these findings are important because they suggest that SGMY’s surplus of risk factors and deficit of protective factors at school may be contributing to health inequities for SGMY.

Qualitative studies also offered important insights into the school experiences of SGMY and how high school staff (e.g., teachers, principals, counselors, and nurses) support, protect, and affirm SGMY. From the perspectives of SGMY, qualitative research has most commonly documented experience of school-based victimization of SGMY (Grossman et al., 2009; Wilson & Cariola, 2019; Newman et al., 2017) and SGMY’s subsequent coping techniques (Grossman et al., 2009; Marshall et al., 2015). Some qualitative research has explored SGMY’s interactions with specific types of high school staff, such as teachers, nurses, and counselors, mainly resulting in the documentation of unsatisfactory experiences, such as feeling marginalized and judged (Ken, 2017; Laiti et al., 2021; Roe, 2013; Rutter & Leech, 2006). Additional research has examined SGMY’s experiences with and attitudes towards gender-sexuality alliances (GSAs; also known as gay-straight alliances), bathroom policies, and physical features of the school environment (Eisenberg et al., 2017; Porta et al., 2017; Mayo, 2013; Wolowic et al., 2016). From the perspectives of high school staff, qualitative research has examined how specific types of school staff—such as teachers (Shelton, 2019; Smith, 2015), librarians (Oltmann, 2016), social workers (de Jong, 2015), counselors (Simons & Cuadrado, 2018), coaches (Halbrook et al., 2019), sex educators (Preston, 2016), and GSA advisors (Mayberry et al., 2013; Valenti & Campbell, 2009)—aim to support SGMY. Previous qualitative research has also examined what influences staff’s responses to bullying or the development of inclusive policies and staff coalitions (Steck & Perry, 2017; Young et al., 2017; Reisner et al., 2020).

Despite the important insights gleaned from prior qualitative research on SGMY and school staff, existing studies have several methodological limitations. These limitations include: (1) enrolling only SGMY or only school staff, but not both (de Jong, 2015; Eisenberg et al., 2017; Grossman et al., 2009; Halbrook et al., 2019; Higa et al., 2014; Ken, 2017; Laiti et al., 2021; Marshall et al., 2015; McCormick & Krieger, 2020; Newman et al., 2017; Porta et al., 2017; Preston, 2016; Steck & Perry, 2017; Valenti et al., 2017; Young et al., 2017), thereby constraining the ability to triangulate SGMY and staff perspectives; (2) recruiting and sampling participants from small geographical locations (Grossman et al., 2009; Newman et al., 2017; Marshall et al., 2015; Ken, 2017; Mayo, 2013; Valenti & Campbell, 2009; Steck & Perry, 2017; Reisner et al., 2020; McCormick & Krieger, 2020; Higa et al., 2014); (3) researching sexual minority youth but not gender minority youth (Marshall et al., 2015; Rutter & Leech, 2006); (4) primarily enrolling white SGMY (Marshall et al., 2015; Ken, 2017; Porta et al., 2017; Mayo, 2013; Reisner et al., 2020); (5) recruiting SGMY or school staff solely from GSAs (Mayo, 2013; Valenti & Campbell, 2009); and (6) restricting school staff samples to specific roles (e.g., only counselors) (de Jong, 2015; Halbrook et al., 2019; Preston, 2016; Valenti & Campbell, 2009; Steck & Perry, 2017). As a result, these limitations hamper our ability to identify qualitative themes across sociodemographically diverse groups of SGMY and school staff. Prior methodological designs also hinder our ability to compare qualitative experiences by group (i.e., SGMY vs. school staff), structural stigma level, sexual orientation, gender, and race/ethnicity. Such limitations can be addressed by using innovative methods for recruiting, sampling, and interviewing SGMY and school staff.

To improve the existing qualitative literature in this area, studies can: (1) enroll and interview both SGMY and school staff; (2) use online recruitment and interviewing methods as well as novel sampling frames to recruit SGMY and school staff from broader geographical catchment areas with varying levels of structural stigma; (3) explicitly aim to enroll a substantial proportion of gender minority youth, including transgender girls, transgender boys, and nonbinary youth, through the use of a priori sampling quotas; (4) create sampling quotas to oversample racial/ethnic minority SGMY; (5) recruit using social media to reach SGMY who may not participate in gender-sexuality alliances; and (6) include staff participants who hold diverse roles in schools. While such a study design can help enhance the field, it may also lead to new problems. By explicitly acknowledging these problems and the lessons learned, recommendations can be disseminated to researchers who may consider adopting these new methods in future studies.

Aims of the Overall Study

To address the gaps noted above, we conducted a qualitative study to describe the detailed strategies used by high school staff to support, protect, and affirm SGMY. Importantly, we systematically collected information from multiple types of stakeholders (e.g., SGMY, teachers, school administrators, school clinicians, librarians, and cafeteria workers), thereby gathering data from multiple points of view. The primary aims of our study were two-fold: (1) to investigate ways in which SGMY have been and would like to be supported, protected, and affirmed by high school staff; and (2) to investigate ways in which high school staff members have and would like to support, protect, and affirm SGMY. The secondary aims of this study were: to explore whether our qualitative findings differ by level of structural stigma—high, medium, and low levels of structural stigma; to explore the extent to which perspectives and experiences among SGMY differ by race/ethnicity and gender; and to explore whether strategies and perspectives among school staff differ by race/ethnicity and sexual and gender minority status.

Purposes of the Current Paper

The current paper has three purposes. First, we describe, in detail, our novel study design used to methods for recruiting, sampling, and interviewing SGMY and high school staff across the U.S. Second, we describe the sociodemographic characteristics of our study samples, which can provide evidence of the success of our study’s design and methods. Third, we highlight the lessons we learned from implementing our methods. By making transparent the successes and challenges of our methods in conducting inclusive research with SGMY and school staff, this paper transparentizes our rigorous methods, thereby increasing its reproducibility (such that if others wished to replicate our study, they would have the necessary details to do so). As a result, we inform the field about how future studies can also obtain rich qualitative on the heterogenous experiences of vulnerable youth and school staff in ways that specifically include sociodemographically diverse populations and consider differences caused by structural factors, such as structural stigma.

Methods and Materials

We followed the Standards for Reporting Qualitative Research (O’Brien et al., 2014) in crafting our study and presenting our methods.

Overall Study Design and Population

This study collected qualitative data using cross-sectional, one-on-one, in-depth, semi-structured interviews with SGMY (aged 14–18 years) and high school staff members. Interviews enabled us to gather detailed information about the experiences of both SGMY and high school staff. We used a phenomenological approach (Giorgi, 1997) to understand the school experiences and desires of SGMY and school staff’s experiences of supporting SGMY, and entered the research using an interpretivist paradigm (Patton, 2014), aiming to understand the school experiences of SGMY from multiple perspectives, including from themselves as well as school staff.

As described in detail below, we used a stratified sampling frame to enroll SGMY and school staff from high schools in U.S. states with low, medium, and high structural stigma using a validated scale (Hatzenbuehler et al., 2014). For SGMY, we oversampled youth of color and gender minorities to ensure diversity in our data and recruited participants via advertisements on Facebook and Instagram. For school staff, we aimed to ensure diversity in our school staff sample with regards to gender, race/ethnicity, urbanicity, sexual and gender minority status, and role in school. We recruited school staff using a multi-pronged strategy, including advertisements on social media, at professional organizations, and via our social networks. The University of Pittsburgh Institutional Review Board reviewed and approved the SGMY study protocol and designated the school staff study protocol as exempt under section 45 CFR 46.101(b)(2).

Sampling Strategy

Overall, we used a stratified sampling frame to guide enrollment of SGMY and staff in high schools in U.S. states with low, medium, and high structural stigma. The level of sexual minority-related structural stigma was assessed using a validated scale developed by ; Hatzenbuehler et al. (2014a, 2014b), which considered: the proportion of schools with gay-straight alliances; concentration of same-sex couples as reported in the 2010 Census; public opinion towards sexual minorities; and policies related to sexual orientation. For gender minority-related structural stigma, this scale substituted in public opinion towards gender minorities and policies related to gender identity. Based on these scores, we created tertiles of high, medium, and low structural stigma strata, with approximately equal number of states in each stratum (range: 16-18 states in each stratum). In the SGMY sample, we used sexual minority-related structural stigma strata for cisgender youth, and sexual minority-related or gender minority-related strata, whichever was highest, for gender minority youth; this was because all gender minority youth were also sexual minorities and therefore faced multiple structural stigmatizations. For the high school staff sample, we used sexual minority-related structural stigma strata. We aimed to enroll an equal number of participants in the high, medium, and low structural stigma strata for both SGMY and school staff.

Sexual and Gender Minority Youth Sampling Frame

For SGMY participants, we aimed to recruit a total of 60 participants, with approximately 20 participants in each of the three structural stigma strata. We carefully constructed additional sampling quotas to ensure diversity in our SGMY sample with regards to gender and race/ethnicity. Within each stratum, we planned to enroll 18 participants who were cisgender girls, 18 who were cisgender boys, and 24 gender minorities, including 6 transgender girls, 6 transgender boys, and 12 nonbinary youth (with half of the nonbinary youth assigned female at birth, and half of them assigned male at birth). Within each of these gender groups, we aimed to have at least half of the participants be youth of color. We also desired a wide range of sexual orientations and ages but did not establish formal guidelines for these characteristics.

School Staff Sampling Frame

For high school staff participants, we aimed to recruit 30 participants, with approximately 10 participants in each of the three structural stigma strata. We constructed additional sampling quotas to ensure diversity in our school staff sample with regards to gender, race/ethnicity, urbanicity, sexual and gender minority status, and role in school. With regards to gender, only 23% of U.S. school teachers are male (National Center for Education Statistics, 1987); therefore, in an effort to oversample cisgender men (because they were the minority), we aimed to enroll at least 3 cisgender men per stratum. With regards to race/ethnicity, 80% of U.S. school teachers are non-Hispanic White (National Center for Education Statistics, 1987); therefore, to oversample racial/ethnic minorities, we aimed to enroll at least three people of color per stratum. With regards to urbanicity, 80% of the U.S. population lives in urban areas (United States Census Bureau) (defined by a population density of at least 1000 people per square mile); therefore, we aimed to enroll at least two staff from rural areas (ZIP codes with <1000 people per square mile) per stratum. With regards to sexual and gender minority status, we strongly desired to have cisgender heterosexuals in our sample but anticipated that sexual and gender minority school staff may be more likely to participate; therefore, we aimed to enroll at least six cisgender heterosexuals per stratum. Finally, with regards to role in school, we aimed to achieve diversity, with at least two administrators (e.g., principal) per stratum, at least one clinical provider (e.g., nurse, therapist) per stratum, at least one librarian in total, at least one food service worker in total, and the remaining participants could be any role (e.g., teachers).

Sample Size Justifications

The goals of this study were to generate formative knowledge about SGMY’s experiences of and desires for being supported by high school staff as well as school staff’s experiences with supporting SGMY. Thematic saturation (i.e., the point at which additional data yield no new information (Morse, 2000)) was not the goal of this study; instead, we aimed to acquire insights from key stakeholders about youth and staff’s experiences in schools. Given the scope of our study, the nature of the topic, and the study design (Morse, 2000), we expected to acquire ample qualitative data from samples of 60 SGMY and 30 high school staff and from our purposive sampling matrix.

Recruitment

Sexual and Gender Minority Youth recruitment

We recruited SGMY from June 2018 to February 2019 on Facebook and Instagram. Facebook and Instagram are appropriate recruitment platforms since they are highly utilized by adolescents (Anderson & Teens, 2018) and have been used to recruit SGMY in prior studies (Coulter et al., 2019). One benefit of using Facebook and Instagram for recruitment was the ability to disseminate advertisements to certain geographic locations, helping us target certain structural stigma strata. Also, to successfully recruit our diverse SGMY sample, we created a variety of advertisements. The advertisements consisted of a main header that specifically stated different identities, including: “LGBTQ girls wanted for research study” (where LGBTQ stands for lesbian, gay, bisexual, transgender, and queer); “GBTQ boys wanted for research study”; “Transgirls wanted for a research study”; “Genderqueer AMAB students wanted for a research study” (where AMAB stands for assigned male at birth); “Study for Genderqueer Male-Assigned Teens”; “Study for Nonbinary Male-Assigned teens”; and “Nonbinary AMAB Students Wanted for a Study.” We did not need any advertisements tailored to nonbinary AFAB (assigned female at birth) youth because these participants responded to the other advertisements, aligning with prior research (Coulter et al., 2019). Advertisement subheadings stated: “Help us learn about your relationships with adults at school! And earn a gift card!” The advertisements instructed potential participants to click a link to see if they are eligible. Each advertisement rotated between several different pictures that included images of youth who were racially/ethnically diverse, were in same-gender couples, and had diverse gender presentations. We also used images containing various pride flags (e.g., transgender and nonbinary pride flags).

School Staff Recruitment

We recruited high school staff from August 2018 to August 2019 using advertisements in multiple venues: Facebook, Instagram, Twitter, Reddit, professional organizations, and our own social networks. Our initial effort included recruiting school staff from Facebook and Instagram. The advertisements consisted of education-related stock photos with a header which read “High school staff wanted for research study!” and a subheading which read “Help us learn about your relationships with LGBTQ+ students! And earn a gift card!” The advertisement instructed potential participants to click a link to see if they were eligible. To increase reach to racial/ethnic minority staff, we distributed advertisements to areas with high racial/ethnic minority composition according to the U.S. Census (United States Census Bureau). We also created tailored advertisements that read, “Are you a high school staff POC?” These advertisements contained stock photos of education-related settings with staff of color.

Unlike our success in recruiting SGMY through Facebook and Instagram, recruiting high school staff in this manner was less successful and more expensive, so we therefore adopted alternative recruitment strategies. We contacted administrators of education-related Facebook groups and Facebook pages (e.g., Badass Teachers Association, Black Teacher Project, Coalition to Increase Teachers of Color, High School ELA [English and Language Arts] Teachers Support Group) and asked them to share our recruitment flyers and posts with their members.

We also recruited high school staff on Twitter and Reddit. We created a Twitter account dedicated to school staff recruitment and followed education- and LGBTQ-related accounts and groups. Our tweets contained a brief message explaining the purpose of the study, a photo of the recruitment flyer, and a link to the survey screener. The tweets included popular hashtags such as #Education, #TeachersChangeLives, and #LGBTQ to increase the tweet’s reach to our targeted audience. We also requested that users retweet and share our flyer with their organizations and potential participants. Similar to Twitter, we also created a study-specific Reddit account and advertised our study on education- and LGBTQ-related subreddits. With the exception of the hashtags, Reddit posts were similar to our tweets.

We also contacted national and state-level education professional associations. At each of these organizations, we asked the organization to advertise our study to their memberships. Nationally, we contacted the National Association of Secondary School Principals. At the state-level, we contacted teacher and principal associations. Associations in Kansas, Maine, Nebraska, and Oklahoma agreed to distribute our study information and flyer.

Screening

Individuals who were interested in participating clicked on the website link provided in the advertisement. SGMY and high school staff advertisements directed potential participants to different screening questionnaires, which were collected via REDCap, a secure, HIPAA-approved, web-based software platform designed to support data capture for research studies (Harris et al., 2009; Harris et al., 2019). These screeners described the study, provided a short consent script, and, if the individual agreed, instructed them to answer the screening questions to determine eligibility.

Sexual and Gender Minority Youth screening questionnaire

Potential SGMY participants were asked their age, current gender identity, sex assigned at birth, sexual identity, sexual attraction, sexual behavior, race, ethnicity, grade, school name, school state, school city, and school ZIP code. The potential participant then provided their contact information, either phone or email address. We did not tell individuals whether they were eligible or not, but, instead, at the conclusion of the screener, we told potential participants that if they were eligible, we would reach out to them; otherwise, we would not contact them. The end of the screener then provided all youth with a thorough list of national SGMY resources.

School Staff Screening Questionnaire

Potential staff participants were asked whether they worked in a U.S. school, their school state, school city, school ZIP code, role in school, age, race, ethnicity, gender identity, sex assigned at birth, sexual identity, whether they had ever participated in eLearning or online training courses, and how many years they worked in kindergarten through grade 12. The potential participant then provided their contact information, either phone or email address. We did not tell individuals whether or not they were eligible, but, instead, at the conclusion of the screener, we told potential participants that if they are eligible, we would reach out to them; otherwise, we would not contact them.

Inclusion and exclusion criteria

Sexual and Gender Minority Youth eligibility

Youth were eligible to participate in our study if they: attended a U.S. high school (grades 9–12); aged 14–18 years; were a sexual or gender minority; spoke English; and were able to complete an interview via Skype (for which we gave them instructions on how to download, if necessary). We defined sexual minority as those who were non-heterosexual based on sexual identity, behavior, or attraction, and gender minorities as those who had a gender identity that did not match their sex assigned at birth. Individuals were excluded if they did not meet all the above criteria. Each eligible individual was invited to participate in an interview if space remained available in their respective stratum and quota.

School Staff Eligibility

High school staff were eligible to participate if they were: currently employed in a U.S. high school; and were available to complete an interview via telephone or Skype. We anticipated that school staff would be less comfortable with Skype than the adolescents and therefore provided them with an additional interview mode. Individuals were excluded if they did not meet all the above criteria. Each eligible individual was invited to participate in an interview if space remained available in their respective stratum and quota.

Interview Data Collection

We conducted cross-sectional, one-on-one, semi-structured interviews with SGMY from July 2018 through December 2018 and with high school staff from September 2018 through April 2019. We selected semi-structured interviews because they provide a comprehensive and systematic approach to addressing gaps in existing literature and generating knowledge (Galletta & Cross, 2013). Additionally, ideas and themes that emerge during one interview can be made richer through further inquiry in subsequent interviews through small but meaningful interview guide modifications, such as including probing questions.

For SGMY, interviews were conducted via Skype, and for staff, interviews were conducted via Skype or telephone. We primarily conducted interviews via Skype because video interviews allow for rapport building that may not be attainable over the telephone. For example, in all SGMY interviews, our interviewer wore a rainbow pin that included black and brown stripes signifying inclusion of people of color, in an effort to make participants more comfortable and at ease. Skype also allowed the interviewers to assess and respond appropriately to body language and other nonverbal communication, which can help bolster rapport and facilitate the gathering more in-depth information. Furthermore, Skype uses Advanced Encryption Standard (also known as Rijndael), which is used by the U.S. Government to protect sensitive information and has strong 256-bit encryption.

On average, interviews lasted 63 minutes (range: 21–97) for SGMY and 60 minutes (range: 40–74) for high school staff. All interviews were only audio-recorded (no video-recording was done). At the conclusion of each interview, the interviewer immediately typed and saved post-interview notes (without identifying information) summarizing the interview and detailing any key nonverbal information that would be missed in the audio recording.

Consent Processes

Interviewers obtained verbal consent from participants prior to conducting interviews with SGMY and school staff. During the consent process, the interviewer provided the following information to each potential participant: the purpose of the study; study procedures; potential risks; actions to minimize potential risks; a statement about the voluntary nature of their participation; that the interview would be audio-recorded; who would have access to this interview; and the contact information of the Principal Investigator. After this, the interviewer asked the participant whether they wished to participate in the interview.

For SGMY, we had additional modifications to the consent process. First, we had an IRB-approved waiver of parental consent. By requiring parental consent, we could have “outed” SGMY as LGBTQ to their parent(s), potentially placing them at risk for violence from their family. By obtaining a waiver of parental consent, our study also lessened selection bias because we were more likely to interview SGMY participants who may not have supportive and accepting parents or may not be out to their parents, thereby including unique perspectives from the most vulnerable youth. In lieu of obtaining parental consent, we instructed SGMY in the verbal consent process to be aware of their surroundings during the interview and to complete the interview in a quiet and safe place.

Second, we explained to all SGMY that we were required to break confidentiality and contact appropriate agencies if we learned that they were in danger of serious harm. This was particularly important for SGMY because they are known to be at greater risk for suicidality (Marshal et al., 2011; Clark et al., 2014; Veale et al., 2017). Although our interview guide (described below) did not contain any questions about the participant’s own mental health, many SGMY brought up their own mental health issues on their own volition. In response, we established a suicidality protocol. (Hawk et al., 2021) During the consent process, we wrote down the participant’s physical location at the time of the interview and told the participant we needed their address in case of emergency but would destroy and trash their location at the conclusion of the interview. During the interview, if a participated stated that they have thought about or attempted suicide in the recent past, we would automatically assess them for suicidality through an assessment developed by the study team. The assessment was designed to first determine whether the participant is currently having suicidal thoughts. It is important to note that asking youth about their suicidality does not make them suicidal (Blades et al., 2018). If the participant reported being currently suicidal, the interview would then ask whether they had a suicide plan and their intention to carry out the plan. If the participant did not have a plan, they were given referral information to the Trevor Project, a well-respected hotline that can be accessed either online or by phone that specializes in the support of suicidal SGMY. If the participant currently had a plan, the interviewer would call the Trevor Project Hotline or National Suicide Hotline and have participant speak with hotline to establish a safety plan prior to ending the interview. If a safety plan could not be established, the interviewer would call 911 to have the participant transported to a hospital for evaluation. Finally, at the conclusion of the interview, all participants, regardless of whether they were in danger of serious harm, were provided with a list of national resources for SGMY. SGMY and staff participants received a gift card worth $25 USD as a thank you for their time.

Interview Guides

SGMY Interview Guide

The SGMY interview guide was initially developed by the Principal Investigator and revised by the second author. Subsequently, the guide was reviewed by the UPMC Children’s Hospital of Pittsburgh’s Youth Research Advisory Board (YRAB), composed of 9 youth. The YRAB recommended that we ask about clubs at school from which LGBTQ students may feel excluded and that we ask whether the participant is out to other students in addition to staff. Additionally, the YRAB suggested that we place our advertisements on Instagram as well as Facebook, in order to reach a wider audience. Based on their input, the first and second authors revised and finalized the SGMY recruitment strategy and interview guide.

The final SGMY semi-structured interview guide covered the following topics: LGBTQ issues at schools; school experiences surrounding participant’s sexual orientation, gender identity, and gender expression; school experiences of bullying and other violence; school education on substance use and mental health; and ideal school experiences for SGMY. Each interview started with rapport building questions and ended with questions concerning participants’ reactions to the interview. Table 1 displays example interview questions within all domains.

Table 1.

Semi-Structured Interview Guide for Sexual and Gender Minority Youth.

Domain and Interview Questions
Rapport building
Tell me some things you like about school
Tell me about one of your favorite adults as school
LGBTQ issues at school
In general, what have adults at your school said about sexual orientation? What about gender?
What have you been taught about sexual orientation at school? What about gender?
What positive or good things did adults at school say about LGBTQ people?
What negative or bad things did adults at school say about LGBTQ people?
What sexual orientation issues have been brought up in your classes? What about gender issues?
What kind of group for LGBTQ students exist at your school, like a gay-straight alliance?
School experiences surrounding participant’s sexual orientation
How do you identify your sexual orientation?
Which adults at school know about your sexual orientation?
Do other kids know at your school?
Now I want to go through a list of people that you may have told at school. Please tell me about your experiences telling them about your sexual orientation. Teachers? Nurses? Guidance Counselors? Librarians? Administration? Other adults?
Do you know any adults at school that are lesbian, gay, bisexual, or queer?
What kinds of positive experiences have you had with adults at school about you being [insert participant’s sexual orientation]?
What kinds of negative experiences have you had with adults at school about you being [insert participant’s sexual orientation]?
What other school resources have helped you with anything related to your sexual orientation?
What other resources, like another organization outside school or other online websites, have helped you with your sexual orientation?
School experiences surrounding participant’s gender identitya
How do you identify your gender identity?
Which adults at school know about your gender identity?
Do other kids know at your school?
Now I want to go through a list of people that you may have told at school. Please tell me about your experiences telling them about your sexual orientation. Teachers? Nurses? Guidance Counselors? Librarians? Administration? Other adults?
Do you know any adults at school that are transgender or nonbinary?
What kinds of positive experiences have you had with adults at school about you being [insert participant’s gender identity]?
What kinds of negative experiences have you had with adults at school about you being [insert participant’s gender identity]?
What other school resources have helped you with anything related to your gender identity?
What other resources, like another organization outside school or other online websites, have helped you with your gender identity?
School experiences surrounding participant’s gender expression
How do you describe your own gender expression?
How do you think adults at school would describe your gender expression?
What comments have adults at school made about your gender expression?
How do you think the way adults perceive your gender expression affects your relationships with them?
What kinds of positive experiences have you had with adults at school about your gender expression?
What kinds of negative experiences have you had with adults at school about your gender expression?
School experiences of bullying and other violence
Have you ever seen someone bullied because they were perceived to be LGBTQ?
Why do you think bullies targeted those certain kids?
Have you been bullied at school about your sexual orientation? Would you be okay telling me more about this experience?
Have you been bullied at school about your gender expression, like the way you look or act? Would you be okay telling me more about this experience?
What programs does your school have about bullying or violence at your school? What kinds of policies?
School education on substance use and mental health
What have you heard teachers say about drug and alcohol use?
What have you heard teachers say about mental health issues, like anxiety or depression?
Ideal school experiences for LGBTQ adolescents
I’d like to finish by asking you to imagine attending school in your perfect world. How would adults at school address your sexual orientation or gender identity?
What is one of the easiest ways you think adults at school could be better for LGBTQ students?
What is one thing you wish all LGBTQ kids knew?

LGBTQ = lesbian, gay, bisexual, transgender, and queer. aAsked primarily of gender minority identified students.

School staff interview guide

The high school staff interview guide was initially developed by the Principal Investigator and revised by the second author. We sought input from a School Advisory Board composed of a school principal, expert trainer on LGBTQ students, a sexual and gender minority young adult, and four LGBTQ health researchers. Subsequently, three postdoctoral scholars trained in qualitative methods provided feedback on the interview guide. Based on input from all these sources, the first and second authors revised and finalized the school staff interview guide.

The final high school staff semi-structured interview guide addressed the following topics: working with LGBTQ students; school support and resources for LGBTQ students; school bullying and other violence; substance use and mental health; online and other training experiences and preferences. Each interview starts with rapport building questions and ends with questions concerning participants’ reactions to the interview. Table 2 displays example interview questions within all domains.

Table 2.

Semi-Structured Interview Guide for School Staff.

Domain and Interview Questions
Rapport building
Tell me about your job
Tell me what you like about your job
Working with LGBTQ students
When you are at school, how comfortable do you feel talking about LGBTQ issues?
How have you supported LGBTQ students in your classroom/school?
How could your classroom/school be more inclusive?
If a student came out to you as LGBTQ, how would you respond?
Tell me about a time you wished you knew more about LGBTQ issues
What are some of the most pressing issues for LGBTQ students in your school?
School support and resources for LGBTQ students
What kind of resources exist in your school for LGBTQ students?
What policies does your school have to support LGBTQ students?
How would your school support a student with an anti-LGBTQ parent?
Tell me about how administrators at your school support LGBTQ students
School bullying and other violence
How do you define bullying?
Does your school have a policy on bullying?
What does bullying towards LGBTQ students look like in your school?
Have you ever seen this type of bullying?
How have you tried to prevent bullying of LGBTQ students in the past?
What would you do if you heard students use anti-LGBTQ language in your classroom/school?
Substance use and mental health
How would you respond if a student told you they were depressed or suicidal?
To what extent is it a part of your job to talk about alcohol or drug use with students?
Online and other training experiences and preferences
Have you ever participated in an online training program?
Tell me about some online trainings you have participated in before
Tell me about your experience with the online training program
What is your interest in LGBTQ online training designed to help school staff support, protect, and affirm LGBTQ students?
How could we encourage school staff to participate in this kind of program?
What other ways you think we could help you support and protect LGBTQ youth?

LGBTQ = lesbian, gay, bisexual, transgender, and queer.

Researcher Characteristics and Reflexivity

We represent a wide range of sexual identities (i.e., gay/lesbian, queer, bisexual, and heterosexual), gender identities (i.e., nonbinary, transgender man, cisgender woman, and cisgender man), and race/ethnicities (i.e., Latinx, Asian, and White). We also comprise a multidisciplinary multitiered team, representing the fields of public health, school counseling, counseling, psychology, creative writing, medicine, medical anthropology, and nearly all levels of academe, including undergraduate, masters, and doctoral students; postdoctoral researchers; research assistants; and assistant and full professors. The diverse representation of sexual and gender identities and race/ethnicities complements our range of multidisciplinary expertise and professional backgrounds in informing data collection and analysis through lived experience.

We acknowledge that there are several ways our backgrounds may have influenced our research. Primarily, our interviewers for both SGMY and school staff are sexual and/or gender minorities. This could have helped put our SGMY participants at ease, especially in cases where the interviewer disclosed their sexual or gender minority identities to participants. Our school staff interviewer disclosed her sexual minority status to school staff during three interviews, which may have either facilitated openness or led to social desirability bias. All of her disclosures occurred towards the end of the interviews, so we do not believe this influenced the quality of data collected among those school staff. Secondly, the initiation of this research by and inclusion of sexual and gender minority researchers enriches our ability to identify nuanced forms of SGMY discrimination during data collection and analysis. Furthermore, the diversity and range of disciplines represented by our research team provides us with the ability to consider a myriad of potential influential factors on our research processes and outcomes.

Data Analyses

To evaluate the success of our novel methods in achieving the goal of enrolling both SGMY and school staff from sociodemographically diverse backgrounds and structurally different environments, we used descriptive statistics to describe the sociodemographics of SGMY and school high staff participants. Because our study team identified several challenges while implementing our study’s methods, in the Discussion section we present a summary of lessons learned from recruiting, sampling, enrolling, and interviewing study participants, which can support others in replicating our methods. These lessons learned were derived through reviewing study implementation documentation and via discussion with our study team.

Results

Sexual and Gender Minority Youth Sociodemographics

Sixty SGMY participated in our study (Table 3). Overall, 18 participants were cisgender girls, 18 were cisgender boys, 6 were transgender girls, 6 were transgender boys, and 12 were nonbinary. More than half (53%) of the sample was youth of color—with the largest racial/ethnic minority groups being Hispanic/Latinx youth (17%), youth with multiple races (15%), and Black (12%). The majority (70%) of participants were 16 or 17 years old. Three-fourths (73%) of the sample attended traditional public schools, with the remaining participants having attended magnet, charter, or public boarding schools. Nearly half (45%) of the SGMY participants attended schools in rural areas.

Table 3.

Sociodemographic Characteristics of Sexual and Gender Minority Youth Participants, Overall and by Structural Stigma Stratum.

	Overall	Structural Stigma
	Overall	Low	Medium	High
—	(n = 60)	(n = 20)	(n = 22)	(n = 18)
Sociodemographic characteristic	n (%)	n (%)	n (%)	n (%)
Gender	—
Cisgender girl	18 (30)	6 (30)	9 (41)	3 (17)
Cisgender boy	18 (30)	6 (30)	7 (32)	5 (28)
Transgender girl	6 (10)	2 (10)	2 (9)	2 (11)
Transgender boy	6 (10)	2 (10)	1 (5)	3 (17)
Nonbinary	12 (20)	4 (20)	3 (14)	5 (28)
Sexual identity	—
Gay or lesbian	24 (40)	8 (40)	8 (36)	8 (44)
Bisexual	13 (22)	4 (20)	6 (27)	3 (17)
Queer	7 (12)	3 (15)	2 (9)	2 (11)
Pansexual or panromantic	4 (7)	0 (0)	2 (9)	2 (11)
Demisexual	1 (2)	0 (0)	1 (5)	0 (0)
Unsure	3 (5)	1 (5)	1 (5)	1 (6)
Multiple identities	8 (13)	4 (20)	2 (9)	2 (11)
Race/ethnicity	—
White	28 (47)	10 (50)	11 (50)	7 (39)
Hispanic or Latinx	10 (17)	4 (20)	4 (18)	2 (11)
Black	7 (12)	0 (0)	3 (14)	4 (22)
Asian	3 (5)	2 (10)	1 (5)	0 (0)
American Indian or Alaska Native	3 (5)	0 (0)	0 (0)	3 (17)
Multiple races	9 (15)	4 (20)	3 (14)	2 (11)
Age (years)	—
14	6 (10)	3 (15)	2 (9)	1 (6)
15	9 (15)	3 (15)	5 (23)	1 (6)
16	23 (38)	8 (40)	6 (27)	9 (50)
17	19 (32)	5 (25)	7 (32)	7 (39)
18	3 (5)	1 (5)	2 (9)	0 (0)
Grade	—
9^th	3 (5)	2 (10)	1 (5)	0 (0)
10^th	12 (20)	4 (20)	5 (23)	3 (17)
11^th	21 (35)	7 (35)	6 (27)	8 (44)
12^th	23 (38)	6 (30)	10 (45)	7 (39)
Recently dropped out of 12^th grade	1 (2)	1 (5)	0 (0)	0 (0)
School type	—
Public	43 (73)	12 (63)	18 (82)	13 (72)
Other^a	16 (27)	7 (37)	4 (18)	5 (28)
School urbanicity	—
Rural	27 (45)	9 (45)	10 (45)	8 (44)
Urban	33 (55)	11 (55)	12 (55)	10 (56)

^aOther school types include magnet, charter, and public boarding school.

Regarding the distribution of participants by structural stigma stratum, 20 SGMY participants attended schools in states with low structural stigma, 22 attended schools in states with medium structural stigma, and 18 attended schools in states with high structural stigma. Within each of these structural stigma strata, there was wide diversity of participants across all sociodemographic characteristics.

School Staff Sociodemographics

Twenty-nine high school staff completed interviews (Table 4). Overall, 52% of the sample were cisgender women, 38% were cisgender men, and 9% were gender minorities. The sample was majority heterosexual, White, and aged 30–49 years. The sample was composed of 16 teachers, four school administrators (i.e., two Principals, one Director of Pupil Personnel Services, one Community School Director), three therapists, two guidance counselors, one nurse, one librarian, one food service staff member, and one student aide with the majority having 5–19 years of work experience in schools. The staff participants predominantly worked in public schools and urban areas.

Table 4.

Sociodemographic Characteristics of School Staff Participants, Overall and by Structural Stigma Stratum.

		Structural Stigma
	Overall	Low	Medium	High
	(n = 29)	(n = 11)	(n = 11)	(n = 7)
Sociodemographic characteristic	n (%)	n (%)	n (%)	n (%)
Gender identity	—
Cisgender woman	15 (52)	5 (46)	6 (55)	4 (57)
Cisgender man	11 (38)	5 (46)	4 (36)	2 (29)
Transgender woman	1 (3)	0 (0)	0 (0)	1 (14)
Genderqueer	1 (3)	1 (9)	0 (0)	0 (0)
Gender nonconforming woman	1 (3)	0 (0)	1 (9)	0 (0)
Sexual identity	—
Heterosexual	16 (55)	7 (64)	6 (55)	3 (43)
Gay or lesbian	9 (31)	3 (27)	4 (36)	2 (29)
Bisexual	2 (7)	0 (0)	1 (9)	1 (14)
Queer	1 (3)	1 (9)	0 (0)	0 (0)
Not sure	1 (3)	0 (0)	0 (0)	1 (14)
Race/ethnicity	—
White	21 (72)	8 (73)	7 (64)	6 (86)
Black	4 (15)	0 (0)	3 (27)	1 (14)
Hispanic or Latinx	2 (7)	2 (18)	0 (0)	0 (0)
Asian	1 (3)	1 (9)	0 (0)	0 (0)
Multiple races	1 (3)	0 (0)	1 (9)	0 (0)
Age	—
23–29 years	3 (10)	1 (9)	2 (18)	0 (0)
30–39 years	12 (41)	5 (45)	4 (36)	3 (43)
40–49 years	10 (34)	3 (27)	4 (36)	3 (43)
50–55 years	4 (14)	2 (18)	1 (9)	1 (14)
Role in school	—
Administration (e.g., principal)	4 (14)	2 (18)	2 (18)	0 (0)
Teacher	16 (55)	6 (55)	5 (46)	5 (71)
Nurse, Therapist, or Social Worker	4 (14)	1 (9)	1 (9)	2 (29)
Guidance Counselor	2 (7)	1 (9)	1 (9)	0 (0)
Librarian	1 (3)	1 (9)	0 (0)	0 (0)
Food Service	1 (3)	0 (0)	1 (9)	0 (0)
Student Aide	1 (3)	0 (0)	1 (9)	0 (0)
Years worked in kindergarten through grade 12	—
<5 years	5 (17)	0 (0)	4 (36)	1 (14)
5–9 years	8 (28)	3 (27)	3 (27)	2 (29)
10–14 years	7 (24)	5 (45)	1 (9)	1 (14)
15–19 years	6 (21)	2 (18)	3 (27)	1 (14)
≥20 years	3 (10)	1 (9)	0 (0)	2 (29)
School type	—
Public	25 (86)	9 (82)	9 (82)	7 (100)
Private	4 (14)	2 (18)	2 (18)	0 (0)
School urbanicity	—
Rural	9 (31)	2 (18)	4 (36)	3 (43)
Urban	20 (69)	9 (82)	7 (64)	4 (57)

Regarding the distribution of participants by structural stigma stratum, 11 staff worked in schools located in states with low structural stigma, 11 worked in schools located in states with medium structural stigma, and seven worked in schools located in states with high structural stigma. Within each of these structural stigma strata, there was diversity of participants across all sociodemographic characteristics.

Discussion

This paper describes our novel study design for recruiting, sampling, and interviewing SGMY and school staff to gather rich qualitative data about school environments for SGMY, thereby contributing to nuanced understanding social influences for SGMY that can inform future interventions, which are two priority research areas identified by the National Academy of Medicine (formerly known as the Institute of Medicine) (Institute of Medicine, 2011). For example, our study can identify strategies performed by school staff that are endorsed as helpful to SGMY that can then be included in future SGMY training interventions for school staff. Because our resultant study sample is sociodemographically diverse and from environments with varying levels of structural stigma, this paper highlights new ways of successfully conducting qualitative research with SGMY and school staff that is rigorous, inclusive, and overcomes many limitations of prior research. Specifically, the current paper adds to the existing literature by demonstrating how to recruit participants from areas with varying levels of structural stigma; enroll sexual and gender minority youth, including transgender girls, transgender boys, and nonbinary youth; enroll large proportions of racial/ethnic minority SGMY; recruit via social media; and enroll staff participants who hold diverse roles in schools. By implementing our study design, we learned several important lessons—which can inform future research studies that adopt similar methodological design features (Table 5).

Table 5.

Lessons Learned and Recommendations for Recruiting, Sampling, Enrolling, and Interviewing Sexual and Gender Minority Youth and High School Staff.

Study Domain	Lesson Learned	Recommendations
Online recruitment and sampling methods	Sampling based on structural stigma is challenging. First, the only validated scale of structural stigma is a state-level variable, but there is likely within-state variation in structural stigma at more local levels. In lieu of a validated local structural stigma scale, we used urban versus rural areas as a proxy for local structural stigma. Second, gender minority youth who are also sexual minority youth are dually burdened by both sexual orientation- and gender-based structural stigma—but a single state could have different levels of sexual orientation-based structural stigma versus gender-based structural stigma, making it challenging to classify participants into a single structural stigma category	Consider how participants may be affected by local levels of structural stigma, in addition to state-level structural stigma
		Develop validated scales of local structural stigma for sexual and gender minority youth
		Decide a priori how to classify the structural stigma level for participants who face multiple forms of structural stigma. This can be accomplished by considering your primary research questions, populations, and study goals
	Recruiting SGMY and high school staff from high structural stigma locations was challenging	Make concerted efforts and save extra resources to recruit youth and school staff from more stigmatizing locations
	Without sampling quotas and tailored advertisements, certain subgroups of SGMY would have been over-enrolled and others under-enrolled. For example, transgender girls and racial/ethnic minorities would likely be under-enrolled	Ensure a priori sampling quotas to ensure your intended distribution of SGMY subgroups. For example, a large number of SGMY who were assigned female at birth completed screening surveys compared to SGMY who were assigned male at birth Create tailored advertisements for specific subgroups (e.g., racial/ethnic minority SGMY; transgender and nonbinary youth who were assigned male at birth). This can be accomplished with SGMY subgroup flags, language, images of people you are trying to recruit, and keywords of the interests for specific subgroups
	Recruiting school staff through social media was challenging—and obtaining a diverse sample of school staff who hold certain positions was much harder (e.g., teachers were more likely to complete screening surveys than superintendents)	Ensure a multi-pronged approach of recruiting school staff into qualitative interviews study. Consider leveraging researchers’ established networks as well as obtaining funds to pay to place advertisements in email newsletters and magazines of professional associations (e.g., The School Superintendents Association)
	SGMY’s identities are complex—many selected more than one identity (e.g., nonbinary and transgender boy; lesbian/gay and queer)	Allow participants to select multiple identities and provide a space for them to add their own. If using sampling quotas, decide a priori where to place participants who endorse multiple identities
Enrolling participants	Despite growing acceptance of sexual and gender minority people and the growing population size of SGMY, many SGMY were not “out” as LGBTQ to their parents/guardians but still wanted to participate in interviews. Subsequently, they went out of their way to find to a private location (e.g., library, coffee shop) to participate in the interview	Obtain a waiver of parental consent, if possible, otherwise the research study may exclude an important and vulnerable subset of sexual and gender minority youth
		Ensure that participants are in a safe location to discuss SGMY-related issues, and train interviewers to refrain from asking anything potentially sensitive or LGBTQ-related when someone else (e.g., family members) unexpectedly enter the room
	SGMY were much more likely to respond to text messages than to respond to emails	Allow participants to provide multiple methods for research staff to contact them, especially text message
Interviewing methods	Trauma-informed qualitative interviewing skills are necessary when interviewing sexual and gender minority youth. During interviews, some SGMY participants appeared to be nervous and explicitly mentioned being socially anxious. Additionally, many gender minority youth did not want to turn their cameras on during interviews, perhaps because of gender dysphoria (for example, youth might experience conflict about how their gender appears physically vs. the gender they identify with)	Find ways to build trust with the interviewee. This includes validating their experiences, wearing a rainbow pin, and having LGBTQ+ interviewers who are willing to come out to youth in an effort to foster connection and put SGMY at ease
		Allow youth, especially gender minorities, the option to participate in interviews without their video
		Provide SGMY with SGMY-inclusive support resources after the screening survey and completion of the interview
	SGMY voluntarily discussed their own mental health struggles without prompting from the interviewer and without the interview guide containing such questions	Have a suicide assessment and safety protocol when conducting any type of interviews with SGMY, regardless of interview topics
		Provide support (e.g., debrief meetings, resources) to interviewers to mitigate secondary trauma
	Most school staff preferred to be interviewed via phone as opposed to Skype videoconferencing. (However, it is important to note that our study was conducted prior to the COVID-19 pandemic, which has forced many school staff to become acquainted with videoconferencing.)	Allow multiple interview formats as adults may prefer telephone interviews over videoconferencing interviews

SGMY = sexual and gender minority youth; LGBTQ = lesbian, gay, bisexual, transgender, or queer.

Recruiting and Sampling Sexual and Gender Minority Youth and School Staff

Our stratified sampling frame using structural stigma strata allowed us to systematically acquire data from participants who attended or worked in schools from varying U.S. contexts is a strength of our study because it purposefully samples participants from a wide variety of social contexts, more so that prior qualitative literature that has focused on smaller geographical locations (Grossman et al., 2009; Newman et al., 2017; Marshall et al., 2015; Ken, 2017; Mayo, 2013; Valenti & Campbell, 2009; Steck & Perry, 2017; Reisner et al., 2020; McCormick & Krieger, 2020; Higa et al., 2014). Furthermore, our carefully constructed sampling quotas allowed us to oversample particularly vulnerable and underrepresented groups, such as youth of color, gender minority youth, and staff in rural locales. The success of our sampling plan was aided by fruitful recruitment of SGMY from social media, but required a multi-pronged strategy to successfully recruit school staff. A priori sampling quotas and tailored social media advertisements were critical.

We learned lessons from our study’s recruitment methods and sampling frame that can inform future studies that use similar methods (Table 5). First, sampling based on structural stigma is challenging because, to our knowledge, structural stigma is only measured at the state-level, and there is likely within-state variation in local structural stigma at more local levels. Therefore, it is important to have other sampling quotas to ensure more geographic diversity, such as sampling for rural versus urban as we did in this study. Additionally, recruiting SGMY and school staff from high structural stigma areas proved challenging, and was likely inhibited by structural stigma itself. Allocating additional funds for advertising and outreach to people in high structural stigma strata is essential.

Second, social media recruitment was much easier for recruiting SGMY than high school staff but recruiting certain subgroups of SGMY and high school staff proved challenging (Table 5). For SGMY recruitment, youth who were assigned female at birth and whose race/ethnicity was non-Hispanic White were more likely to complete screening surveys than SGMY assigned male at birth or who were youth of color. The combination of a priori sampling quotas regarding gender and race/ethnicity and tailored advertisements featuring images and language representing these groups were important to our study’s success. Additionally, certain school staff were harder to reach via social media, thereby requiring us to reach out to our social networks as well as professional organizations to recruit school staff.

Interviewing SGMY and School Staff

Our interview data from SGMY and school are expected to yield a wealth of qualitative data on a variety of topics pertaining to SGMY-staff relationships and the overall school experiences of SGMY—but this would not have been possible without using specific features of our study design. First, trauma-informed qualitative interviewing is critical when conducting research with SGMY (Table 5) (Office of Justic Programs, 2020; Strand & Heitman, 2017). Many SGMY participants were nervous and explicitly mentioned having social anxiety. This required that our interview build rapport and trust with SGMY by validating their experiences, wearing a rainbow pin, allowing youth to keep their video cameras off, providing lists of SGMY-inclusive resources, and coming out as queer and/or transgender during the interview when deemed appropriate.

Second, implementing a suicidality safety protocol was particularly important for when interviewing SGMY (Table 5). Despite not asking interview questions about mental health, many of participants broached this topic on their own and without prompting, which may be unsurprising given the high prevalence of suicidality among SGMY (Marshal et al., 2011). In response, we developed a suicidality safety protocol that assessed suicidal risk and, if warranted, directly referred SGMY to help. Our suicidality protocol is particularly useful to the field because our SGMY interviews were all conducted via Skype, thereby making direct referral challenging. As such, our methods provide useful methods for implementing safety protocols when conducting long distance virtual research with particularly vulnerable groups (as described in the Consent Process section).

Third, we obtained a waiver of parental consent to interview SGMY and we always advised SGMY to complete the interview in a location where they feel safe (Table 5). These methods allowed us to interview a particularly vulnerable group of SGMY: those who are not out to their parents/guardians. As a result, this waiver may have protected closeted SGMY from outing themselves to unaccepting parents/guardians and causing potential unnecessary trauma to the youth as the result of our research procedures.

Finally, despite limited resources, Skype and telephone interviewing methods allowed us to efficiently interview participants from across the U.S (Table 5). With youth, Skype worked well except we noted that some gender minority youth did not want to turn their cameras on—and we allowed this. We also noted that many school staff, who were all adults, preferred to speak with us over the telephone as opposed to over Skype, suggesting the importance of offering multiple interview methods. However, it is important to note that we implemented our study prior to COVID-19, when many school staff across the U.S. have been obliged to become acclimated to using videoconferencing software for teaching their students on a regular basis.

Future Directions

The ultimate goal of this study is to provide foundational and formative data to inform SGMY-inclusive best practices across a wide variety of school contexts. We obtained data that allow us to accomplish this goal by asking SGMY and high school staff about existing and desired support while also considering that their experiences and needed support are likely to differ by gender, race/ethnicity, and structural stigma. Given the diversity of our sample, planned analyses will explore variation in themes by key sociodemographic characteristics, such as structural stigma, gender, and race/ethnicity, increasing our understanding about the intersectional experiences of SGMY. These data provide information about existing school environments, in an effort to identify practical protective strategies and policies that are transportable across various school contexts, thereby providing foundational knowledge for development of future school-based interventions. Overall, our study’s methods were vital to yielding a dataset that allows us to explore the heterogeneity of SGMY’s experience in schools and their relationships with school staff.

Limitations

Despite the numerous strengths of our study design and methods, they are not without limitations. Our resultant qualitative data will not necessarily be generalizable to all U.S. SGMY and high school staff. However, this was not our purpose; instead, we aimed to gather a heterogeneity of perspectives from participants living in a wide variety of social contexts. Additionally, given our limited financial resources and social networks, we struggled to recruit SGMY and staff who attended/worked in schools located in states with high structural stigma, limiting our knowledge about SGMY-staff relationships in these areas. Furthermore, our SGMY recruitment was restricted to individuals with a Facebook or Instagram account, leading to selection bias; however, this strategy may be less biased than recruiting youth from SGMY-related school clubs as youth who may not be out to their peers or school community may have chosen to participate in this study. We also obtained waivers of parental consent, allowing particularly vulnerable SGMY to participate more freely. This study is subject to self-selection (or volunteer) bias as there may be a lower likelihood of participation from high school staff with high levels of anti-LGBTQ sentiment. To compensate for this limitation, we asked school staff participants to describe their colleagues’ attitudes and actions in an attempt to capture anti-LGBTQ beliefs.

Conclusions

This study’s methods and lessons learned contribute to the existing qualitative research on SGMY and high school staff in important ways. Our methods can be adopted by future researchers who want to recruit, sample, and interview sociodemographically diverse SGMY and high school staff, thus intentionally capturing the experiences of marginalized people who are underrepresented in research. Future research can also consider the important lessons we learned while implementing this study. Additionally, the rich qualitative dataset derived from our methods will address gaps in the existing literature pertaining to school-based support for SGMY, with a particular emphasis on how school-based support for SGMY varies across schools located in states with different levels of structural stigma, contributing to the knowledge of how geopolitical environments relate to individuals experiences with common risk factors (e.g., bullying) and support (e.g., SGMY-inclusive practices in schools). This study is a critical step to developing evidence-based practices that can be integrated into school settings, thereby helping to promote health equity among SGMY across the U.S., including the most vulnerable SGMY, such as racial/ethnic minority SGMY and those living in areas with high structural stigma.

Footnotes

Acknowledgments

We would like to thank the UPMC Children’s Hospital of Pittsburgh Youth Research Advisory Board, our School Advisory Board, and our Pediatrics Postdoctoral Group for their contributions, which are described in the manuscript.

Authors' contributions

Conceptualization of the study: RWSC, Study Design: RWSC, ERH, SLC, CDC, JEE, and EM, Data analysis: RWSC, ERH, SLC, CDC, CEM, ERP, NR, AR, KG, Writing and drafting the initial manuscript: RWSC, ERH, SLC, KG, Interpretation of results, substantial revision to the manuscript, and approval of the final version: all authors.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research Lesbian Health Fund (award to RWSC), the National Center For Advancing Translational Sciences of the National Institutes of Health (TL1TR001858 to RWSC and KG), the National Institute on Alcohol Abuse and Alcoholism (K01

AA027564 to RWSC), the National Institute of Mental Health (T32

MH094174 to ERH), and Eunice Kennedy Shriver National Institute of Child Health and Human Development (T32

HD087162 to CDC; and K24

HD075862 to EM). The funders did not play any role in the study design, data collection and analysis, preparation of the manuscript, nor the decision to publish. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Lesbian Health Fund or the National Institutes of Health.

Availability of Data and Materials

Data are available to researchers who meet the criteria for access, which will be determined by Principal Investigator Robert W.S. Coulter in according with the University of Pittsburgh Institutional Review Board.

ORCID iD

Robert W. S. Coulter

Appendix

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