Mental health is improving, and discrimination and violence are decreasing, for adolescents who are lesbian, gay, bisexual, mostly straight, or questioning their sexual orientation, according to a new survey conducted in British Columbia, Canada. Progress has fallen short of researchers’ expectations, however.

The Not Yet Equal: The Sequel report from the Stigma and Resilience Among Vulnerable Youth Centre and the McCreary Centre Society, both based in Vancouver, Canada, found that sexual minority youth were more likely than straight youth to encounter challenges such as an unstable or unsafe home environment, reduced healthcare usage, increased exposure to violence and abuse, and a greater likelihood of substance use.

“We still saw higher rates of violence, high rates of mental health challenges, high rates of discrimination, all those kinds of issues,” study coauthor Annie Smith, executive director of the McCreary Centre Society, told Medscape Medical News. “Where we did see a narrowing of the gap, it wasn’t necessarily a positive because straight [youth’s] mental health was getting worse, and not necessarily because we saw improvements for sexual minorities. Overall, we were hoping for better.”

Adolescent Health Survey  

The reports draw from the 2018 British Columbia Adolescent Health Survey, which collected information from adolescents ages 12-19 years in public schools. The survey has been repeated every 5 years since 1992, and its population sample has included more than 38,000 participants in 58 of British Columbia’s 60 school districts.

In the new report, sexual minority boys, girls, and nonbinary youth reported worse mental and physical health than straight individuals did. About 71% of straight girls reported good or excellent mental health, compared with 28% of bisexual girls, 33% of lesbians, and 56% of girls who were questioning their sexuality.

But the report contained positive news, too. Compared with a 2007 survey of lesbian, gay, and bisexual youth, researchers saw a more than 50% reduction in physical assault against lesbian girls and smaller reductions in assaults against bisexual girls and boys. These reductions narrowed the gap between sexual minority youth and straight youth.

Change in Sex Education  

The researchers’ hope for improvement stems in part from the introduction in 2016 of the Sexual Orientation and Gender Identity (SOGI) 123 program throughout British Columbia schools. It encourages conversations about sexual orientation and gender identity and emphasizes the importance of treating everyone with dignity and respect. The program includes age-appropriate lesson plans from kindergarten through grade 12.

Despite these efforts, sexual minorities continue to endure more bullying and violence than their straight peers. “I know it’s really disappointing to school districts that have been trying to put a lot of energy into creating safer spaces. To still see that disparity in experiences of bullying and safety at school was disappointing,” said Smith.

Although the SOGI 123 program caused backlash among conservative parents, Smith believes it is generally accepted as part of the curriculum. “Our hope is that as those policies get more established, we’ll start to see more progress. The surveys are repeated every 5 years, so the next one will be in 2023. Hopefully by then, we’ll see more changes,” she said.

The approach also could expand beyond schools. Sexual minority youth often access healthcare less frequently than straight youth, sometimes because of previous negative interactions with providers. The onus is on healthcare providers to be welcoming, said Smith, which can include modifying a clinic’s decor and layout. “Youth clinics are often welcoming and inclusive, and they’re the kind of healthcare settings where you see the rainbow sticker on the door as you go in. And young people have told us that they feel like safe, welcoming spaces, whereas the family doctor might not,” said Smith.

The McCreary Centre Society also is developing other curricula, including Taking Pride, a workshop that focuses on domestic and intimate partner violence for sexual and gender diverse youth. The program was intended to address the absence of relationship skills from the sexual health curriculum.

“It talks about healthy relationship skills and how to deal with the situation if you’re experiencing violence or coercive behavior within a relationship, but also how to say no nicely, and how to dump somebody nicely,” said Smith. “Sex ed tends to often focus on the biology and the mechanics and less about the negotiation, and what healthy relationships actually look like.”

“Great News”

Commenting on the survey for Medscape, Joey Bonifacio, MD, a staff pediatrician and adolescent medicine specialist at Saint Michael’s Hospital in Toronto, Ontario, Canada, said that the observed improvements were welcome. “Looking at the rates of mood disorders, as somebody who provides care for depression and anxiety, seeing those improvements was really meaningful for me. And I see that in clinical practice, as well. I think this is great news,” said Bonifacio.

Rates are still elevated, he noted, so there is more work to be done. “We’re not out of the woods yet.” Bonifacio outlined steps that physicians can take to improve care of sexual minority youth, including normalizing sexual orientation and gender identity as part of healthcare by periodically asking patients about them. “Many people are exploring their gender or their romantic or sexual orientation, and we do know that it is common for these identities to change over time,” said Bonifacio.

He also stressed the importance of being knowledgeable about local resources for sexual minority youth in the healthcare setting and in the larger community. “Sometimes they do require, as this report shows, more mental supports in place, so learning how to navigate what’s in your community and being able to give that information to youth in a timely [manner] is important,” he said.

The report was funded by the Canadian Institutes of Health Research. Smith is an employee of McCreary. Bonifacio reports no relevant financial disclosures.

Jim Kling is a science and medical writer in Bellingham, Washington.

For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube.