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Written By Mia Ballard
May 24, 2021

Fox, K. R., Choukas-Bradley, S., Salk, R. H., Marshal, M. P., & Thoma, B. C. (2020). Mental health among sexual and gender minority adolescents: Examining interactions with race and ethnicity. Journal of Consulting and Clinical Psychology, 88(5), 402–415. 

Relevance in Today’s World  

Sexual orientation and gender are important aspects of a young person’s identity, and LGBTQ+ identities are becoming increasingly common in youth. In an era where more people support LGBTQ+ rights and same-sex marriage is legalized in all 50 states, the sociopolitical climate is improving for the LGBTQ+ population. However, LGBTQ+ identifying youth continue to experience disproportionate interpersonal and structural level stressors. This is particularly true for individuals who identify as QTPOC (queer or trans in addition to being a racial/ethnic minority). QTPOC individuals face unique struggles with both racism and homophobia/transphobia. This study examines the differences in mental health outcomes across these identities. Understanding these identities better can help improve how we assess and treat their mental health.

Importance of the Study   

Research documents elevated risk for psychopathology (mental health symptoms) and self-injurious thoughts and behaviors (including suicidal thoughts and attempts, as well as non-suicidal self-injury, like cutting and burning without wanting to die) among adolescents who identify as lesbian, gay, bisexual, queer, or questioning — pretty much any sexual orientation other than heterosexual (sometimes termed sexual minorities, or SM). There is also evidence that adolescents identifying with a gender different from sex assigned at birth, which includes genders like nonbinary, transgender, or genderqueer (sometimes termed gender minorities, or GM), show elevated risk for these negative outcomes as well. 

The Meyer (2003) minority stress model attempts to explain this elevated risk. The model is built from several sociological and psychological theories about the effects of stigma and prejudice on affected individuals and groups. However, Meyer (2003) distinguishes minority stress from other forms of stress because individuals experience minority stress as a result of their minority identity. In this model, there are a few assumptions made about minority stress as well: it is (a) unique in the sense that it is experienced in addition to the general stressors that impact all people, (b) chronic, or relatively stable, and (c) socially based and beyond individual events or conditions. The model suggests that there are several direct (proximal) and indirect (distal) stressors that have a positive or negative effect on the mental health outcomes of SM individuals. The indirect stressors are objective and do not depend on an individual’s perceptions, whereas direct stressors are subjective and connected to self-identity. An example of an indirect stressor would be daily discrimination, while examples of direct stressors include expectations of rejection or internalized homophobia. Meyer suggests that social support can have a positive outcome on the mental health of LGBTQ+ individuals. Recent research also supports the application of this model to GM populations since they experience some of the same stressors.  

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Some researchers expand on the minority stress, proposing that belonging to multiple minority groups may lead to greater experiences of stress and discrimination. If this is the case, then people who identify as LGBTQ+ as well as a racial/ethnic minority may be even more at risk for psychopathology and SITBs. Two models could help to explain such higher risk: “double jeopardy” (belonging to 2+ minority groups inherently increases risk) or intersectionality (a term coined by Kimberlé Crenshaw, in which both risk and resilience varies across specific identities). However, previous studies exploring this heightened risk have produced mixed results or involved small samples, often conflating theories of double jeopardy and intersectionality.   


Recognizing a gap in the current knowledge, we set out to investigate depression severity and SITB risk across cisgender heterosexual, sexual minority, and gender minority groups and across racial groups. The researchers inferred that if interactions among SGM and racial/ethnic identification result in higher levels of depressive symptoms and endorsement of SITBs, the results would support the idea that multiple minority identification is associated with higher levels of risk. If, in contrast, interactions across specific identities conferred differential risk, results would support theories of intersectionality.


To protect participants’ privacy and safety, the study didn’t require parental permission and collected data anonymously. After clicking on the advertisement, interested participants were presented with the study details, assented to participate, and began the study. Participants who completed the study were given the opportunity to enter a drawing for a $50 electronic gift card.  


Demographic information like racial or ethnic identity, age, and gender assigned at birth was collected via participants selecting from a range of provided labels and/or open-ended self-report. A measure of socioeconomic status, called subjective social status was assessed with the MacArthur Scale of Subjective Social Status–Youth Version. Depressive symptoms were assessed based on a total score out of 60 on the Center for Epidemiologic Studies Depression Scale, with higher scores indicating more severe depressive symptoms. Multiple measures were used to assess lifetime history of suicidal thoughts and suicide attempts. Participants responded to the question, “Have you ever seriously thought about killing yourself?” to assess suicide ideation history. To assess suicide attempt history, participants were asked, “In your lifetime, how many times have you actually tried to kill yourself?” Then, non-suicidal self-injury (abbreviated as NSSI) was assessed with the question, “In your lifetime, have you ever done anything to purposefully hurt yourself without wanting to die (for example, cutting your skin or burning yourself?” Gender minority participants also completed scales to assess five gender minority-specific psychosocial factors: expectations of rejection, appearance congruence, gender identity acceptance, disclosure of identity to parents/caregivers, and disclosure of identity to friends. Finally, participants completed the Transgender Congruence Scale to further assess appearance congruence and gender identity acceptance.    

The sample consisted of 2,948 adolescents aged 14 to 18 who identified as SM, GM, both SM and GM, or cisgender heterosexual. Most (97.09%) GM participants also identified as SM. The researchers excluded those who identified as American Indian or a race/ethnicity not specified, and those who identified as intersex due to the low number of participants in these groups. Paid ads were posted on social media like Facebook and Instagram to reach a large number of youth. The average age of participants was 15, most reported being assigned female at birth (82.69%) and White (66.52%). Most GM participants reported being transmasculine or female to male (52.20%), and most SM participants identified as bisexual (23.13%).


Compared with the cisgender heterosexual participants, SM and GM participants reported more depressive symptoms and higher rates of all SITBs. Looking at NSSI in particular, SM and GM participants were two to five times more likely to report engagement compared to the cisgender heterosexual group, and the odds of reporting NSSI were even higher among GM compared to SM participants. The interaction between race/ethnicity and SGM status was not significant overall (see figure below), but GM participants experienced more bullying and less support from their families in comparison to the cisgender heterosexual participants. This finding suggests that GM youth experience challenges in their social environment, and these challenges may be unique and more severe.   


A few differences across intersectional identities emerged. For example, White participants were more likely to engage in NSSI compared with Asian participants, and Latino/a/x participants reported 1.5 times the odds of attempting suicide compared with White participants. Moreover, Black SM and Black GM participants reported fewer depressive symptoms, non-suicidal self-injury, suicidal thoughts, and suicide attempts compared to cisgender White participants. Overall, the results did not support the theory of 'double jeopardy'-- that multiple minority identification uniformly confers the highest risk for psychopathology. 


Conclusions & Future Directions  

Overall, the results indicate that risk for psychopathology varies across intersections of race/ethnicity and SGM status in adolescents. Future studies with larger samples of diverse youth may produce more reliable results of mental health risk across these intersections. Studies with larger, more diverse samples may be better suited to test these questions. Moreover, only a minority of participants identified as male, and several racial groups (e.g., American Indian) were excluded due to low participation. Future studies including these demographics are needed.  




Fox, K. R., Choukas-Bradley, S., Salk, R. H., Marshal, M. P., & Thoma, B. C. (2020).

        Mental health among sexual and gender minority adolescents: Examining                  interactions with race and ethnicity. Journal of Consulting and Clinical                          Psychology, 88(5), 402–415.   


Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and            bisexual populations: Conceptual issues and research evidence. Retrieved                from American Psychological Association. doi:10.1037/0033-2909.129.5.674   

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