Behavioral Health

“Behavioral health” is an umbrella term that includes issues and services related to both mental health and substance use. This section synthesizes information relevant to these two areas.

Mental Health and Suicide

As the Institute of Medicine has noted, LGBT youth are typically well adjusted and mentally healthy.¹ However, they experience higher rates of mental health challenges and increased health complications arising from these challenges compared to their heterosexual peers.² Research on transgender youth outcomes as separate from lesbian, gay, and bisexual youth outcomes is more limited, though growing. Some recent nonrandom surveys of self-identified transgender people indicate that up to one-third reported attempting suicide at least once, with higher rates for youth and young adults than for older adults.³ Moreover, suicide is the third leading cause of death among youth ages 15 to 24, and LGBT youth are more likely to attempt suicide than their peers.⁴ This does not mean, however, that LGBT identity itself is the cause of these challenges. Rather, these higher rates may be due to bias, discrimination, family rejection, and other stressors associated with how they are treated because of their sexual identity or gender identity/expression.⁵ These challenges, which researchers refer to as “microaggresions,”⁶ can contribute to anxiety, depression, and other mental health challenges, as well as to suicide and self-harming behavior.

Research has found that lesbian, gay, and bisexual youth have much higher levels of suicidal ideation than their heterosexual peers.⁷ Also, recent population-based studies suggest that the reported rates of suicide attempts for high school students who identify as LGBT are two to seven times higher than rates among high school students who describe themselves as heterosexual.⁸ LGBT youth are also twice as likely to have thoughts about suicide.⁹ The 2009 Youth Risk Behavior Surveillance System found that during the 12 months before the survey was administered, across the sites evaluated,

• the percentage of students who reported having felt sad or hopeless ranged from 19.3 percent to 29.0 percent among heterosexual students, from 28.8 percent to 52.8 percent among lesbian and gay students, and from 47.2 percent to 62.9 percent among bisexual students;
• the percentage of students who seriously considered attempting suicide ranged from 9.9 percent to 13.2 percent for heterosexual students, but from 18.8 percent to 43.4 percent among lesbian and gay students; and
• the percentage of students who attempted suicide one or more times ranged from 3.8 percent to 9.6 percent among heterosexual students, but from 15.1 percent to 34.3 percent among lesbian and gay students.¹⁰

Strategies to improve mental health and prevent self-harming behavior and suicide include

• providing safe and supportive environments, particularly through affirming relationships with family and peers;¹¹
• enacting legislation to protect the safety of LGBT youth;
• re-evaluating institutional practices that undermine positive child and youth development; and
• building community awareness and capacity to understand and address stressors that LGBT youth may experience.¹²

Substance Use

LGBT youth may be more likely to use substances to cope with bias and stress and may be more likely to experience increased rates of depression and anxiety than their non-LGBT peers.¹³ Challenges such as family rejection of, or anticipated reaction to, one’s LGBT identity are also associated with substance use. For example, one study found that youth who experienced a moderate level of family rejection were 1.5 times more likely to use illegal substances than those who experienced little to no rejection; youth experiencing high levels of family rejection were 3.5 times more likely to use these substances.¹⁴ Also, youth who have run away from home have higher rates of alcohol and illicit drug use.¹⁵

Additionally, an analysis of more than 18 studies between 1994 and 2006 examining the use of tobacco, alcohol, and illicit drugs (e.g., methamphetamines, marijuana) found that lesbian, gay, and bisexual youth had higher rates of usage for all these substances than their heterosexual peers.¹⁶ Lesbian and bisexual girls were 9.7 times more likely than heterosexual girls to smoke cigarettes,¹⁷ and a quarter of young gay men reported regular binge drinking.¹⁸

Transgender youth have a high risk for developing substance dependency issues. Transgender people have higher rates of usage for some drugs and may have higher rates of methamphetamine, injectable drug, and tobacco usage.¹⁹ Additionally, transgender youth face more barriers to accessing behavioral health care. These barriers include experiencing physical/verbal abuse by other clients and staff; being required to wear clothing based on their sex rather than their identified gender; and being required to shower/sleep in areas based on their sex rather than their identified gender.²⁰ Providers with culturally and linguistically competent practices can help improve the quality of care for transgender youth and address these barriers.

Reducing the rates of bias, discrimination, and victimization that LGBT youth experience can help reduce substance use. A related strategy includes creating safe spaces for LGBT youth in drug-free environments such as community centers. Also, accepting/positive family behaviors toward LGBT youth during adolescence can protect against not only suicide and depression but also substance use.²¹

Resources

Centers for Disease Control and Prevention: Lesbian, Gay, Bisexual, and Transgender Health
This website from the U.S. Department of Health and Human Services Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC) contains specific health topics for the LGBT community, with specific resources for gay and bisexual men; youth; lesbian and bisexual women; transgender persons; and health services.

Centers for Disease Control and Prevention: Lesbian, Gay, Bisexual, and Transgender Health: Youth
This website from the CDC focuses on information for LGBT youth. The site highlights the experiences that LGBT youth face and provides information for schools and parents related to responding to violence for LGBT students.

A Guide for Understanding, Supporting, and Affirming LGBTQI2-S Children, Youth, and Families (PDF, 8 pages)
This guide, written by members of the U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration’s National Workgroup to Address the Needs of Children and Youth Who Are LGBTQI2-S and Their Families, provides information for service providers, educators, allies, and community members who seek to support the health and well-being of children and youth who are lesbian, gay, bisexual, transgender, questioning, intersex, or two-spirit (LGBTQI2-S) and their families. This guide can support efforts to promote full and affirming inclusion of LGBTQI2-S youth and families in communities and provider settings (e.g., child welfare, juvenile justice, mental health, schools). The guide’s last page includes a place for organizations to add their endorsement electronically. Both the National Association of School Psychologists (NASP) and the National Association of Social Workers (NASW) have endorsed the guide. You can access the guide with the NASP and NASW endorsements through the guide link above.

Gay Male and Lesbian Youth Suicide (PDF, 310 pages)
Paper 8 in this report from the Secretary of the U.S. Department of Health and Human Services Task Force on Youth Suicide in 1989 highlights the risks associated with gay male and lesbian youth suicide. It speaks about many topics, such as religion, substance abuse, school, social isolation, and coming out, and provides information for addressing and ending gay and lesbian youth suicide.

The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding
This comprehensive Institute of Medicine report on LGBT people, commissioned by the National Institutes of Health, concludes that future research and data collection must address LGBT people because the lack of research yields an incomplete picture of the health status and needs of LGBT people.

Healthy People 2020 Topics & Objectives: Lesbian, Gay, Bisexual, and Transgender Health
The Healthy People 2020 website has a specific focus to improve the health, safety, and well-being of LGBT individuals. It provides resources and subtopics to address specific health challenges that the LGBT community faces. Moreover, a new Healthy People 2020 LGBT Workgroup was formed recently to help advance efforts to identify LGBT healthcare disparities, needs, and potential ways these needs can be addressed.

HIV/AIDS and Substance Use Disorders in Ethnic Minority Men Who Have Sex with Men
This online training curriculum, prepared for the SAMHSA Center for Substance Abuse Treatment (CSAT), provides extensive background on providing behavioral health services to African Americans, American Indians and Alaska Natives, Hispanic/Latino Americans, and Asian/Pacific Islanders/Native Hawaiians who have substance abuse disorders and are at risk for HIV. The curriculum can be found here, but you must register to access the actual curriculum.

Medline Plus: Gay, Lesbian, and Transgender Health
This website, managed by the U.S. National Library of Medicine, the U.S. Department of Health and Human Services, and the National Institutes of Health, provides resources and information for the specific health issues related to gay, lesbian, bisexual, and transgender individuals.

The Movement Advancement Project (PDF, 4 pages)
The Movement Advancement Project offers key recommendations for talking about suicide in safe and accurate ways with LGBT youth.²² Learn more about how the mental health system can support LGBT youth by reading endever*’s story.

A Practitioner’s Resource Guide: Helping Families to Support Their LGBT Children (PDF, 18 pages)
This resource from SAMHSA offers information and resources to help practitioners throughout health and social service systems implement best practices in engaging and helping families and caregivers to support their LGBT children.

Practice Brief 1: Providing Services and Supports for Youth Who Are Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex, or Two-Spirit (PDF, 8 pages)
This practice brief, commissioned by the Council on Coordination and Collaboration of the Child, Adolescent and Family Branch (CAFB), Center for Mental Health Services (CMHS), SAMHSA, outlines key information for working with, and providing culturally and linguistically competent services to LGBTQI2-S youth.

A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals
This manual, prepared for the SAMHSA CSAT, seeks to inform administrators and clinicians about appropriate diagnosis and treatment approaches that will help ensure the development or enhancement of effective LGBT-sensitive programs. SAMHSA has also funded the development of a 22-module training curriculum to accompany this publication.

Recommended Actions to Improve the Health and Well-Being of Lesbian, Gay, Bisexual, and Transgender Communities
This statement by the Secretary of the U.S. Department of Health and Human Services addresses the work the Department has engaged in and future recommended actions to address and improve the health and well-being of the lesbian, gay, bisexual, and transgender communities.

SAMHSA Office of Behavioral Health Equity
SAMHSA’s website for the Office of Behavioral Health Equity provides a variety of LGBT-focused data and resources on substance abuse and mental health.

Suicide and Bullying: Issue Brief (PDF, 8 pages)
The Suicide Prevention Resource Center, supported by SAMHSA, includes recommendations for bullying and suicide prevention and targeted facts related to LGBT people’s experiences with bullying and risk of suicide.

Suicide Risk and Prevention for Lesbian, Gay, Bisexual, and Transgender Youth (PDF, 63 pages)
This report, prepared for the SAMHSA CMHS highlights the higher risk of suicidal behavior among LGBT youth and provides recommendations for youth services (e.g., schools, health practices, suicide prevention programs) and funders to promote the health, safety, and inclusion of LGBT youth.

National Workgroup to Address the Needs of Children and Youth Who Are LGBTQI2-S and Their Families
The Child, Adolescent and Family Branch (CAFB), Center for Mental Health Services, supported by SAMHSA, initiated the National Workgroup to Address the Needs of Children and Youth Who Are LGBTQI2-S and Their Families to support and enhance services for children and youth who are LGBTQI2-S. The workgroup helps guide CAFB efforts to develop policies, programs, materials, and other products that help address the needs of children and youth who are LGBTQI2-S. The workgroup has developed a system of care toolkit of more than 150 resources from various organizations and has delivered learning events at conferences/meetings and in communities to build capacity to improve services and outcomes for LGBT youth and their families.

Top Health Issues for LGBT Populations Information and Resource Kit (PDF, 100 pages)
This toolkit, prepared for SAMHSA CSAT, presents an overview of current health issues among LGBT populations. Although many challenges exist with regard to the availability of data, this toolkit aims to create awareness among prevention specialists and healthcare providers of the needs, experiences, and health status of LGBT Americans.

The Trevor Project
The Trevor Project is the leading national organization focused on crisis and suicide prevention services to LGBT and questioning young people ages 13 to 24. It operates the only accredited, nationwide, around-the-clock crisis and suicide prevention helpline for youth who are LGBTQ at 866-4-U-TREVOR (866-488-7386). The Trevor Project also facilitates TrevorSpace, a peer social networking site for LGBTQ youth and their allies; AskTrevor, an online forum through which youth can anonymously ask experts questions about sexuality and gender issues; TrevorChat, an online messaging service that allows youth in crisis to live chat with volunteers who can provide support; TrevorText, a free, confidential messaging service; the Lifeguard Workshop Program, which educates participants through a structured curriculum about recognizing and responding to the warning signs of depression and suicide; and additional valuable resources for youth, families, and educators.