Young people use a variety of terms to describe their sexual and gender identities (e.g., pansexual, demisexual, nonbinary, fluid); However, very few public health surveillance surveys include these terms as response options.1,2 Information on specific identities is critical because preliminary evidence in convenience samples of youth and national samples of adults demonstrates that lesbians , gay, bisexual, transgender, queer (LGBTQ+) are not homogeneous.
Rates of health outcomes, risk, and protective factors vary significantly by sexual and gender identity.1–4 As a result, gaps in surveillance survey response options lead directly to gaps in knowledge of disparities. and limit the ability of physicians, providers, and communities to promote health equity, particularly among LGBTQ+ youth.5,6
A substantial subset of LGBTQ+ youth use terms for their sexual and gender identities that are beyond the response options typically used in epidemiological surveys (e.g., gay, lesbian, bisexual, transgender).7–11
Examples of terms commonly used at the time of writing include pansexual , a term for people who are attracted to any gender.12 Queer is a word that younger generations have reclaimed and is often used as an umbrella term for people who are not cisgender and/or heterosexual.1
Asexual describes people who experience little or no sexual attraction or who may experience sexual attraction only under specific circumstances. Non-binary describes alternative genders that are not exclusively girl and boy or woman and man.
Some non-binary youth may also identify as transgender while others do not, and non-binary is a term that can be used to describe a person’s aesthetic and presentation between both cisgender people and transgender people.12
Gender queer describes a person who identifies as a man or boy and a woman or girl, neither, or somewhere in between, or may feel restricted by gender descriptors.12 Gender fluid describes individuals whose gender identities and/or presentation fluctuate with time.12
Although previous work indicated that the prevalence of these identities was relatively low,13 language and identities have changed rapidly over the past 15 years. Evidence from recent national convenience samples of LGBTQ+ adolescents illustrates the importance of assessing these identities. Watson and colleagues found 14 distinct sexual identities and 12 gender identities in their national survey of LGBTQ+ teens, with 24% of this sample selecting terms beyond traditional survey options.2
One-third of the youth in the sample identified as nonbinary, transmasculine, transgender boys, transfeminine girls, and transgender (in decreasing order of prevalence). Another large convenience sample of American adolescents found that in open-ended responses to sexual and gender identity questions, pansexual and asexual were the most commonly written terms in sexual orientation.14
Gender fluid and non-binary were the most commonly given responses of gender identity.14 Convenience samples, however, especially those that specifically sample LGBTQ+ youth, do not provide generalizable estimates, and population-based estimates are not available. large scale among American adolescents, to the authors’ knowledge, specifically including diverse identities. This further limits the ability to determine best practices for health screening and clinical practice, including clinical data collection.
In addition to accurately counting LGBTQ+ populations, the inclusion of a range of response options is necessary to track health disparities and guide prevention efforts. Some of the studies suggest that people who use emerging labels may experience greater health disparities than their peers using traditional labels.4 For example, among American college students, a report of pansexual and queer students report more symptoms of depression and anxiety than their gay and lesbian peers.15
Nonbinary youth have higher rates of nonsuicidal self-injury and emotional distress than binary transgender youth.16 Experiences of bias-based bullying, instigation, and discrimination, considered a distal minority stressor for LGBTQ+ youth that drives key health disparities, It may also vary by identity, with emerging evidence indicating that non-binary and bisexual youth or pansexual youth carry more of the burden.17,18
The goal of this study was to provide the first prevalence estimates of LGBTQ+ identities in a large state survey using new response options rarely included in surveillance instruments generally, by sex (they used the term sex in this paper, rather than assigned sex at birth, because the available survey item asks about biological sex, a term that many transgender and gender diverse youth find insensitive12), and by race, because of cultural differences in the use of identity labels.2
Additionally, they explored differences in select indicators where health disparities are well established (i.e., depressive symptoms and bias-based bullying), focusing on disparities between the new labels and more traditional identity labels.
They also aim to understand how youth who select another unlisted identity compare to LGBTQ+ youth and cisgender heterosexual youth in these outcomes. The findings will shed light on future survey development and have implications for clinicians and researchers working with LGBTQ+ youth.
| Methods |
The data used were from the Minnesota Student Survey (MES), a triennial, anonymous survey of public school students in select grades. The University of Minnesota Institutional Review Board exempted this study from review due to its use of existing de-identified data.
All districts are invited to participate (81% participated in 2019), and passive parental consent procedures are used. Students reported their sex (“biological sex”: male or female), grade (8th, 9th, or 11th), race and ethnicity, and whether they received free or reduced-price lunch (yes, no, or not sure). The EEM team recorded the school’s location within 7 county metropolitan cities or other areas of Minnesota.
The response options for sexual orientation were: heterosexual, bisexual, gay or lesbian, questioning or not sure, pansexual, queer, I do not describe myself in any of these ways, and I am not sure what this question means. One question modified 1 step whether students were “transgender, gender queer, or gender fluid” (responses: yes; no; I am not sure about my gender identity; and I am not sure what that question means).10
The students who responded were not considered cisgender. For those who answered yes, a follow-up question of specific identity terms was provided: (1) masculine, transmasculine, trans man; (2) feminine, transfeminine, trans woman; (3) nonbinary, genderqueer, or genderfluid, or (4) I prefer to describe my gender as something else. Participants could select only 1 response option for each question.
Youth also completed the Patient Health Questionnaire-2 (PHQ-2), a commonly used screener for depressive symptoms in the past 2 weeks.19 Responses to the 2 questions (0 to 3 scale) were summarized.
Scores of 3 or more were considered a positive screen for depressive symptoms, indicating the need for further evaluation. Respondents also reported their experiences of harassment based on (1) sexual orientation (“because you are gay, lesbian, bisexual, or because someone thought you were”) and (2) gender (“your gender [being male, female, transgender, etc.]”) in the last 30 days (recoded as none or any of them).20
> Analysis plan
Data from 9th and 11th grade students were analyzed by sexual orientation. (N = 79,793) and 8th, 9th, and 11th grade by gender identity (N = 124,778), based on question availability. To understand the full range, they calculated the prevalence of all sexual and gender identity responses for the analytic sample and by sex, grade, and race/ethnicity.
χ 2 tests identified significant differences in prevalence for these key demographic characteristics. Multivariate analysis of variance (ANOVA) with the total sample examined for sexual and gender identity identifies differences in positive screening for depression and bias-based bullying, adjusting for grade, sex, race and ethnicity, free or reduced-price lunch, and region.
ANOVA allows comparison between all groups without the need to specify a reference group; the estimated marginal means can be interpreted as predicted prevalences.21,22 Bonferroni posthoc tests demonstrated significant main effects, α was set at 0.05, and IBM SPSS v27 was used.
| Results |
Overall, 9.4% of high school students identified as lesbian, gay, bisexual, queer, or pansexual (4.5% of them reporting their sex as male and 14.2% of those reporting their sex as female), the 9.1% of 9th grade students and 9.8% of 11th grade students.
An additional 2.1% (1.0% report male, 3.2% report female) questioned their sexual orientation, 2.3% of 9th graders and 1.8% of 11th graders. It should be noted that 8.4% of young people indicated that they did not use any of the sexual orientation terms (8.7% of those who reported male sex, 8.0% of those who reported female sex).
By gender identity, 1.4% of 8th, 9th, and 11th grade students indicated that they were transgender, gender queer, or gender fluid (0.7% of them reported male sex, 2.0% of them reported female sex) , which was consistent across grades. Overall, 1.7% of youth were unsure of their gender identity (1.2% of them report male sex and 2.1% of them report female sex), 2.1% of 8-year-old students grade, 1.6% of 9th graders, and 1.2% of 11th graders.
Among those who identified as transgender, genderqueer, or genderfluid and also reported their sex as male, nearly half identified as man, transman, or transmasculine, nearly a quarter as nonbinary, and ≈14% each as woman, trans woman, transfeminine, or other identity.
For transgender, genderqueer, or genderfluid youth who identified their sex as female, half identified as nonbinary, one-third as male, transman, or transmasculine; and 11% as a woman, trans woman or transfeminine; and ≈6% as another identity. χ 2 tests indicated that these response patterns differed significantly by sex.
Bisexual (20.5%) and pansexual (28.8%) were common sexual orientation identities among those who identified as transgender, genderqueer, or genderfluid. The prevalence of sexual and gender identities varied by race and ethnicity as well.
Among American Indian and multiracial youth, common sexual identities were bisexual (10.7% and 9.3%, respectively) and pansexual (4.0% and 3.6%), and rates of transgender, genderqueer, or fluid gender (2.7% and 2.5%) were higher relative to other races and ethnic groups. Race and ethnicity differences arose from not understanding sexual orientation and gender identity questions, and white and multiracial youth were less likely to choose this option than other groups.
Multivariate ANOVA results indicated significant differences in depressive symptoms and prejudice-based bullying experiences due to gender orientation and identity. Pansexual youth and queer youth had similar rates of depression and bias-based bullying, and their rates of gender-based bullying were higher than any other group.
Students who identified as gay or lesbian had the highest predicted prevalence of harassment based on sexual orientation. Youth who selected “I don’t describe myself in any of these ways” for their sexual orientation did not differ from youth who did not understand the question about both forms of bias-based harassment and was the same as with heterosexual youth in depression.
Among youth who identified as male , those who identified as nonbinary had higher rates of depression and bias-based bullying than those who identified as men, trans men, transmasculine, and insecure about their gender identity. More than 70% of young people who report their sex as female and identify as non-binary or masculine, trans men or transmasculine screened positive for depression, higher than all other groups.
Gender-based harassment was also particularly high among nonbinary and masculine youth, trans men, or transmasculine youth who reported their sex as feminine. Youth who identified with a gender identity not included in the survey had rates of depression and bias-based bullying consistent with youth identified as transmasculine, transfeminine, nonbinary, or unsure of their gender identity and higher than those surveyed. cisgender.
| Discussion |
This study is the first to report statewide youth surveillance data that includes more contemporary response options for sexual and gender identity. Results indicate that these identities are relatively common and important to capture among LGBTQ+ youth. Similar proportions of students indicated that they were pansexual (1.7%) as well as gay or lesbian (1.6%).
Nonbinary youth comprised about half of transgender or gender diverse youth who reported their sex as female and about a quarter of youth reported their sex as male.
Critically, rates of depression and bias-based bullying differed by identity, sometimes dramatically, demonstrating the importance of examining sexual and gender identities in clinical practice and research. These findings underscore the need to include updated response options, such as pansexual and nonbinary, in epidemiological surveys and clinical consultations.
Some unexpected findings emerged regarding gender identity. Half of transgender and gender diverse youth who indicate male sex also define their gender identity as man, trans man, or transmasculine, which may be related to a number of factors. The wording of the sex question (i.e., “What is your biological sex?”) is problematic for transgender youth, who may have answered this question differently than intended by the survey developers. For example, youth Transgender and gender diverse youth may report the option closest to their gender identity as their biological sex, rather than responding with their sex assigned at birth.
The inclusion of the term masculine in the gender identity response option may be problematic for transgender people and gender diverse youth, who likely spent time differentiating the terms sex (e.g., masculine) and gender (e.g., male). , cisgender man, transgender man or transmasculine).23
It is also possible that youth may have answered yes to being transgender, genderqueer, or genderfluid with more thought about gender presentation than gender identity (e.g., a youth assigned male at birth who identifies as a boy or a man and has a fluid gender presentation).24
Developmental considerations, including where youth are in their exploration of gender identity, may come into play, especially for youth who are still determining the most appropriate descriptors. Cognitive testing with youth, updated from previous foundational work, is needed given rapid changes in conceptions of sexuality and gender identity,10,11 to understand the ways in which gender diverse youth approach these issues.
The results of this analysis raise several questions about how best to recruit participants who use an identity term that is not among the intended response options. Unexpectedly, 8.4% of youth selected “I do not describe myself in any of these ways” for sexual orientation and the results showed that youth who selected this option were much more similar in terms of depression and bullying based more prejudiced toward heterosexual youth and youth who did not understand the sexual orientation question than any other group of LGBQ+ youth.
Current recommendations suggest including this option in adolescent surveys as a response option for LGBTQ+ youth who use identity descriptors not provided in the survey (e.g., asexual or omnisexual for EEM).10,16,25 However, The fact that more youth endorsed this response than any other non-heterosexual option in this survey suggests that further study is warranted to determine how these youth identify and why they selected this option.
These youth may be navigating specific cultural identities alongside their sexual and gender identities, rejecting sexual and gender identity labels altogether, or selecting this option for other reasons.26 They may also be youth who identify as heterosexual. but they do not select the heterosexual option. Given the percentage of the sample that selected this option, it is likely that most or all of these reasons are represented. As such, the interpretation of this response category is ambiguous, due to the significant heterogeneity in this group.
For gender identity, the option to indicate an identity beyond those listed was only offered to youth who first indicated that they identified as transgender, genderqueer, or genderfluid. As a result, youth who selected this option were more similar to transgender or gender diverse youth than to cisgender youth on depression and bias-based bullying. The conclusion from these results is that general response options for youth to indicate using a term other than those listed, particularly when the inclusion of an open text or writing field is not feasible, should be approached with caution.
Based on this study, the authors suggest that these options should only be presented to youth who have indicated some LGBTQ+ identity; however, additional pilot testing and cognitive testing will ensure robust and accurate data collection. Finally, rates of depression and bias-based bullying varied by sexual and gender identity with important implications for prevention. For example, positive PHQ-2 depression screens were particularly high among nonbinary and transmasculine youth who indicated their sex as female, suggesting the need to strengthen screening, services, and support specific to this group of youth.
From a prevention perspective, these findings are consistent with established disparities in rates of bias and emotional distress among transgender and gender diverse youth compared to cisgender youth,27,28 supporting known needs for school- and community-wide interventions. to create a supportive and inclusive climate.29
Additionally, findings point to prevention needs, such as addressing gender-based bullying of transmasculine and non-binary youth assigned female at birth. These efforts must address conceptions of masculinity and gender in more complex ways than the acceptance of transgender and gender diverse youth in general.
The current study has several limitations. The EEM is a school-based survey; Given that LGBTQ+ youth are more likely than their heterosexual and cisgender peers to drop out or miss school (e.g., due to bullying victimization),30 the results may underestimate the true population prevalence.
Although this survey included some new response options, others were not included (e.g., asexual), and youth were unable to provide open-ended responses. Additionally, the single-step issue of gender identity can be difficult for youth who do not identify as transgender or cisgender. Phrasing the sex question as biological sex is limiting because this term is considered offensive or not preferred by transgender and gender diverse youth.12 It is also not clear whether all youth interpreted this question similarly.
These results should be interpreted with caution and replicated with survey questions specifically about sex assigned at birth, as recommended.9-11 This preliminary exploration of sexual and gender identity did not allow for an in-depth examination of multiple, socially marginalized identities.
Preliminarily, this descriptive analysis presented here supports the need for future in-depth studies of the ways in which these identities shape lived experiences. Finally, the PHQ2 is only a screening for depression symptoms; a more complete evaluation was not possible in this large sample.
Evidence from this state survey of adolescents indicates the importance of including identities that are not commonly used in surveys and patient demographic forms. LGBTQ+ youth are a diverse group, and more screening and targeting interventions are needed to adequately address emotional distress and experiences of prejudice, particularly given emerging evidence that intervention needs may vary by sexual and gender identity. 31
Clinicians should become familiar with the range of sexual and gender identities used by young people and assist them with experiences of bullying or bias and emotional distress among all LGBTQ+ youth, but particularly pansexual and queer youth and transmasculine and non-binary youth who indicate their sex as female.
Accurate measurement of sexual orientation and gender identity including diverse response options among adolescents is critical to documenting prevalence, identifying and monitoring health disparities, and ultimately developing interventions to promote health among LGBTQ+ youth.
| Comment |
This work highlights the need to expand the response options in surveys, research papers and forms on sexual and gender identity to achieve more inclusive and appropriate public health policies for all young people.
On the other hand, it determined that in the population studied, pansexual and queer, transmasculine and non-binary young people who define their sex as female suffer a greater burden of harassment and discrimination. More studies in extracurricular settings will be necessary to generalize these results.
