“Being Queer,It Was Really Isolating”: Stigma and Mental Health Among Lesbian,Gay,Bisexual,Transgender,and Queer (LGBTQ+) Young People During COVID-19

Abstract

Lesbian, Gay, Bisexual, Transgender, Queer, and other sexual and gender minority (LGBTQ+) youth and young adults (YYAs) have poorer mental health outcomes than their cisgender, heterosexual peers in large part due to multilevel stigmatization and minority stress. This was exacerbated by psychological stressors stemming from the COVID-19 pandemic; these experiences intersected with YYA unique developmental stage. Here we explored LGBTQ+ YYA’s pandemic-related experiences, focusing on intersections between stigma and belonging, developmental processes, and their relationship to mental health. We conducted qualitative interviews from August to November 2021 with 34 LGBTQ+ YYA ages 14 to 24; interviews were nested within a quantitative study on YYA experiences during COVID-19. Interviews were transcribed and coded using thematic analysis. YYA described how pandemic impacts like quarantine and isolation directly impacted their mental health; these coalesced around four types of thematic shifts: shifts in (1) time, (2) living situations, (3) community supports, and (4) social and political climate. Multilevel stigmatization also created new mechanisms of norm enforcement for LGBTQ+ YYA. Interviews demonstrated how the pandemic also impacted key developmental processes including identity formation and autonomy seeking. The potential consequences of these pandemic-related shifts largely depended on YYA’s experiences of stigma and/or belonging throughout the pandemic. Findings suggested that isolation from the COVID-19 pandemic intersected with existing socio-ecological structures in LGBTQ+ young people’s lives. Efforts to investigate longitudinal impacts of the pandemic, as well as to intervene to reduce the stigmatization experienced by LGBTQ+ YYA, remain urgent.

Keywords

COVID-19 mental health youth young adults LGBTQ+stigma

Introduction

The impacts of the COVID-19 pandemic were not equally distributed due to existing vulnerabilities caused by systemic discrimination (Purtle, 2020). This includes minority stress affecting lesbian, gay, bisexual, transgender, queer (LGBTQ+) youth and young adults (YYAs) (Brooks, 1977; Meyer, 2003; Salerno et al., 2020) which exacerbated pre-existing disparities in anxiety, depression, suicidality, and substance use (Akre et al., 2021; Green et al., 2020; Kamal et al., 2021).

Adolescence and early adulthood are important developmental stages and include processes like identity formation, risk taking, and autonomy seeking (Arnett, 2000). COVID-19 likely impacted these developmental processes. For LGBTQ+ YYA in particular, COVID-19 introduced instability that may have disrupted typical psychosocial development, including identity formation and autonomy seeking (Hussong et al., 2021) and could exacerbate existing psychological vulnerabilities. LGBTQ+ YYA commonly explore their sexuality and/or gender identity and begin seeking out LGBTQ+ communities (Alix, 2020; DeHaan et al., 2013). Still, many remain reliant on potentially unsupportive families of origin for social, financial, and material support (Needham & Austin, 2010; Ryan et al., 2010), making them vulnerable to adverse psychological outcomes (Russell & Fish, 2016).

Moreover, COVID-19 forced many YYA to move home and kept YYA already living at home away from supportive peers which lessened community support and increased isolation (Salerno et al., 2023). The fact that many LGBTQ+ community groups moved online or stopped meeting altogether (Yurcaba, 2021) may have also affected this sense of isolation. Research suggests that social distancing among LGBTQ+ individuals led to a decreased sense of connection alongside an increase in depression, suicidality, and substance use (Fish et al., 2020; Scroggs et al., 2021). These effects were compounded by the passage of exclusionary social policies, and the rise of anti-LGBTQ+ rhetoric and legislation (e.g., Florida’s “Don’t Say Gay” bill, limits on gender affirming care) (Movement Advancement Project, 2020), particularly around the 2020 election. Per the socio-ecological model, the pandemic and political and social unrest adversely affected different social, structural, and community levels (Bronfenbrenner, 1999; Johns et al., 2018). This was magnified for LGBTQ+ YYA; according to intersectionality theory (Crenshaw, 1994), members of multiple minoritized communities may experience intersecting and cumulative forms of minority stress (Brooks, 1977; Meyer, 2003). During the COVID-19 pandemic, this included backlash against the Black Lives Matter movement, increased anti-Latinx immigrant rhetoric and policy, anti-Asian sentiment, and violence for many LGBTQ+ YYA (Eskenazi et al., 2019; Pew Research Center, 2020; Roche et al., 2018).

Stigma is a valuable explanatory concept in understanding COVID-19 health inequities among LGBTQ+ YYA, particularly how events and dynamics at multiple socio-ecological levels interact with and impact the individual. Existing literature suggests that stigma can be used to keep people down (e.g., keep marginalized populations marginalized), keep people in (e.g., enforce norms to prevent individuals from engaging in stigmatized behaviors), and keep people away (e.g., on the margins of society and away from opportunities that facilitate liberation) (Phelan et al., 2008). During the pandemic, LGBTQ+ YYA may have been “kept down” due to community support services being scaled-back, moved online or eliminated (Felt et al., 2023); they may have been “kept in” through family-mediated enforcement of social norms while quarantining in an unaccepting environment (Fish et al., 2020). This typology of stigma is extended by social safety theory which postulates that it is both the presence of stigma, and the absence of social safety, that exacerbate psychological difficulties for LGBTQ+ populations (Diamond & Alley, 2022), particularly when lack of social safety is compounded with universal COVID-19-related stressors for YYA, like economic insecurity (Panchal et al., 2021). Given the pandemic’s continued population-level psychological repercussions (Theberath et al., 2022), it is critical to understand the scope of these mental health consequences for LGBTQ+ YYA (Dawson et al., 2021). We therefore sought to expand on the emerging literature of COVID-19 disparities in LGBTQ+ populations using a series of qualitative interviews with LGBTQ+ YYA. Our research aims focused on understanding potential mental health implications of COVID-19 among LGBTQ+ young people whose specific development stage and intersectional identities may shape their experiences.

Methods

Participants

Interviewees were recruited from a nationwide survey (“The YYA COVID-19 Study”) (Phillips et al., 2023) that explored COVID-19 experiences among minoritized YYA from February 2021 to March 2022. Participants completed the survey at two time points and answered questions about COVID prevention and mental health. Participants in the parent study were recruited through paid social media advertisements, emails to individuals in Institutional Review Board (IRB)-approved research registries, and outreach from community-based organizations that serve minoritized YYA. Eligibility criteria included: being 14 to 24 years of age, residing in the United States or its territories, ability to read and write in English, and providing informed consent.

Among those who had completed the parent survey at the time of qualitative data collection (n = 869), 610 agreed to contact for an interview. We interviewed 34 YYA from August to November 2021. We purposively sampled participants from the YYA COVID-19 Study based on a diversity of experiences (e.g., race/ethnicity, age, COVID-19 vaccination status, LGBTQ+ identity). Rather than seek to fill a specific quota for each identity, our goal was to obtain a range of experiences among LGBTQ+ folks and reach thematic saturation in interviews (Morse, 2015).

Procedure

Northwestern University’s IRB approved this study with a waiver of parental permission for minor adolescents. We obtained informed consent for interviews electronically using the secure, web-based software platform REDCap (Harris et al., 2009). Sociodemographic data were collected in the larger survey described by Phillips et al. (2023). For participants under 18 years, we assessed decisional capacity using a modified version of the Evaluation to Consent Form (Moser et al., 2002; UCSD Task Force on Decisional Capacity, 2003). All participants passed. One-on-one interviews were scheduled with eligible participants, lasted 60 to 90 minutes (M = 65 minutes) and were conducted by a trained study team member over Zoom. Interviewees were compensated with a $50 digital gift card.

Interview Guide

The semistructured interview guide was informed by social-ecological and intersectionality models (Bronfenbrenner, 1999; Crenshaw, 1994), as well as the parent study’s survey findings on youth’s quantitative experiences of mental health, COVID-19 prevention motivations, stigma, and social support (Phillips et al., 2023). Interview questions were organized semichronologically and explored participants’ social, familial, and romantic relationships (Jairath et al., 2021); how these relationships and their lives changed as a function of the pandemic and sociopolitical events; how youth might have experienced stigma or growth related to their different identities and social contexts during the pandemic; and perceptions of COVID-19 risk, prevention, and responsibility (Table 1).

Table 1.

Interview Guide Contents.

Section	Theme	Sample questions
Part 1: Background Information	Family, Supports, Occupation/Student Status, Living Situation, Romantic Relationships, Identity	– What is your living situation? Do you live with anyone? How long have you lived with them? (inquire about any others they lived with during pandemic) – Can you tell me about your family—both your family of origin, and your chosen family? (inquire about where family members live relative to participant) – If something happened in your life that was really hard, do you have somebody you could reach out to for support? Who is that? – How would you describe your identity? What parts of yourself are most important to shaping who you are?
Part 2: Beginning of the Pandemic	Pandemic-related changes, life pre-pandemic, early feelings toward pandemic and day to day shifts	– So, think back to March of 2020, or just before the pandemic began. What were you up to? – What moment do you remember thinking “things are going to change?” Tell me about that. – What was your day-to-day like during the early days of the pandemic? – How did your friends/family feel about the pandemic when it first started?
Part 3: Summer and Fall of 2020	Black Lives Matter and political uprisings, the 2020 elections, intersections between COVID, identity, and politics, vaccination experiences	Now I’m going to shift to the early summer and fall of last year. There were a lot of things going on at that time, like calls for racial justice after the police murders of George Floyd, Tony McDade, and Breonna Taylor, race-related hate crimes, the presidential election, among other things. – What was that time like for you? – How if at all did these social and political events shape your experience of COVID-19? – You mentioned earlier that you identify as [list identities here]. How did your identities shape your experience of the pandemic? By the fall, there was more talk about COVID-19 vaccines. – What do you remember thinking about the vaccines? – Did you talk about or share your vaccination status with others? How did that go?
Part 4: Social & Personal Relationships	COVID infections within social network, COVID risk and prevention in social network, individualism vs. collectivism, responsibility	– What was your experience like talking with friends and family about COVID-19 prevention? Were there people you were close to who were more or less concerned about COVID than you? – How did these conversations affect your social life? Family life? Dating or sex life? – Whose responsibility do you think it is to prevent illnesses like COVID-19? (e.g., it is everybody? Just those most at risk?). What role do young people like yourself play?
Part 5: Prevention and Messaging	Information sources, thoughts on prevention messaging, trust in medical system	– Thinking about the last year+, how has COVID-19 changed or made you think differently about your / other people’s health? It’s common to get your health information from different sources, like your doctor, the internet, social media, and your friends and family. – When it comes to your health, whose advice do you listen to? Who or what do you trust the most? Who or what are you skeptical of? – Has your trust in a particular source changed during the pandemic, and if so, why? – Based on your experience, what would you say to people who are developing educational materials, or messaging, about illnesses like COVID-19?
Part 6: Conclusion	Reflections, Other Experiences	– Say a disease like COVID-19 happened again in 10 years, what suggestions would you have for young people about how to get through it? What suggestions would you have for health officials about how to respond to COVID-19? – Were there any other key events that happened over the last year that we didn’t talk about that were important to how you experienced or understand the pandemic?

Data Analysis

We recorded and professionally transcribed interviews. Analysis was conducted using an iterative, inductive-deductive thematic analysis approach (Braun & Clarke, 2006). Deductive codes were drawn from the existing literature which informed the interview guides. After reviewing the transcribed data, inductive codes arose from a collaborative initial line-by-line team coding session. We refined inductive codes and expanded upon them during three rounds of coding, in which coders reviewed three to four transcripts per round. Additional inductive codes were added as other patterns were identified across transcripts.

Three staff with training in qualitative methods applied codes to a sub-set of interview transcripts within Dedoose (SocioCultural Research Consultants, n.d.); additional codes were added as identified in subsequent transcripts. The coders met weekly to refine codes and definitions and identify themes and subthemes. Subthemes were added as they organically emerged and were used to identify differential patterns within the same theme (e.g., differing amounts or causes of stigma). To ensure agreement, the first two transcripts were coded collaboratively to ensure coders had a shared understanding of code definitions; these were reviewed and discussed with the senior author. Following this initial check, transcripts were randomly distributed among coders who independently coded the transcripts, with complex excerpts from all transcripts brought to weekly coding group meetings to ensure consensus. Twelve transcripts, chosen based on their variation of interviewees and themes discussed, were double-coded by two coders to ensure convergence, with final agreement determined via comparison and discussion. When necessary, coders consulted the senior authors to ensure coding agreement.

Regarding positionality, the study team included individuals from different disciplines (e.g., public health, psychology) who varied regarding their sexual orientation, gender identity, and racial/ethnic identity. Most authors work at an LGBTQ+ health research institute where we regularly discuss how our different axes of identity may impact research conduct and findings. Individuals were told that this study was being conducted by an LGBTQ+ health research institute. Most individuals involved in study design, interviewing, coding, and manuscript preparation identify as LGBTQ+ and/or a racial/ethnic minority, and possible biases relating to group identity were discussed during coding team meetings and during manuscript framing and preparation.

Results

Participants came from 18 states and were an average of 18.7 years old (Table 2). The sample was racially and ethnically diverse. Nearly all identified as sexual minority (n = 33) and most (n = 18) identified as transgender and/or with a term under the nonbinary umbrella.

Table 2.

Participant Demographics (N = 34).

	n	%
Gender identity
Woman/girl	11	32.4%
Nonbinary	9	26.5%
Questioning	2	5.9%
Man/boy	9	26.5%
Agender	1	2.9%
Two-spirit	2	5.9%
Gender modality
Cisgender	14	41.2%
Trans and gender diverse	18	52.9%
Not sure	2	5.9%
Sexual identity
Asexual/ace spectrum	2	5.9%
Bisexual/pansexual	15	44.1%
Gay/lesbian	9	26.5%
Queer	5	14.7%
Questioning	2	5.9%
Straight	1	2.9%
Age
14–17	15	44.1%
18–21	12	35.3%
22–24	7	20.6%
Race/ethnicity
Hispanic	16	47.1%
Multiracial	8	23.5%
Black	5	14.7%
White	3	8.8%
American Indian/Alaska Native	1	2.9%
Asian	1	2.9%
U.S. Census Region
North East	9	26.5%
South	5	14.7%
Midwest	11	32.4%
West	7	20.6%
Pacific	2	5.9%

The way COVID-19 affected the lives of YYA converged around four primary transitions: shifts in time, shifts in living situations, shifts in community support systems, and shifts in political and social climate that impacted mental health (Table 3).

Table 3.

Themes and Subthemes.

Main themes	Subthemes	Related quotes
Shifts in Time—experiencing more free time and social isolation (e.g., due to lockdown restrictions)	Identity exploration/self-exploration	“Like, who am I? It made me question myself even more than I was before the pandemic. Like, I thought I was straight, but then when Covid came around, I was inside, and I was definitely questioning my identity, like, who was I? Why am I here? Why do I belong here type of thing. And I think that helped shape the thought of my identity to what it is right now.”—Age 17, Questioning/Bisexual or Pansexual, Cisgender Woman
	Acceptance or lack of acceptance of LGBTQ identity from others based on newly discovered/expressed identity (e.g., family, friends)	“I became really, really active on. . .a forum that is. . .for, like, LGBT youth and stuff. And I was kind of like confronted with that. And my mom kind of knew for a while, and then she told my dad. . . and then they kind of took all of my, like, electronics and stuff from me and stuff.”—Age 16, Bisexual or Pansexual, Trans Non-Binary
	Negative or positive changes in mental health depending on acceptance at home (e.g., anxiety and depression)	“There was a memorial service that my mom and I were going to for this woman I’ve known since I was like three. And my mom told me that I could not go if I didn’t wear a dress. I told her that I didn’t want to and that I wanted to wear pants. And I would feel more comfortable wearing pants. And she was like, “That’s too bad. If you don’t want to wear a dress then you can just stay at home.” And yeah, that was pretty hurtful. But I decided—like I also am like very much in the habit of invalidating myself.”—Age 17, Queer, Trans Non-Binary
Shifts in Living Situations—experiencing changes in one’s living environment (e.g., having to be isolated with one’s whole family, moving back home from college)	Negative or positive changes in mental health depending on acceptance at home (e.g., anxiety and depression)	“Personally, I’m closeted, because I don’t feel comfortable coming out to my parents. My siblings know, but not my parents. So it’s another four years of school where I’m not going to be able to transition at all. I may have to stay home for an extra one or two years just to pay off my student loans and then move out, because that’s what my parents want me to do. So it can really just—as much as there are good things about being trans, it can really just make it difficult just to function on a normal level.”—Age 19, Asexual, Agender
	Loss of support, often due to stigmatization by parents (e.g., taking away one’s phone)	“Let’s say my friends and my family felt like it was devastating. Like you know when your normal life has been disrupted, and this time you have to like deal with the current situation. But the situation doesn’t allow you to do what you used to before. And it feels like you are in a prison, or you are shackled, and you cannot be free as you used to. So my family and my friends, it has created a lot of stress and anxiety in my home, and my friends too.”—Age 22, Bisexual or Pansexual, Cisgender Man
Shifts in Community Support Systems—experiencing changes in how one finds community (e.g., cancelation of Pride effects, lack of in-person spaces)	Negative or positive changes in feelings of safety	“It was a little scary because my area isn’t the most accepting of queer-identifying people, so anytime I went out, I had to be very careful. And it was very difficult to connect with other queer people during this time because I couldn’t meet with my youth group anymore. . .and they were a big part of my support circle for a while, so it was difficult not getting to see them.”—Age 17, Bisexual or Pansexual, Trans Non-Binary
	Negative or positive changes in support	“I think one of the biggest things is having things accessible from your house or from your car has made a big difference for me life-wise. . .I have mobility problems because I have joints that bend too far. And having things brought to my car like that has been making a big difference. Having things accessible from home has made a big difference. I can go to support groups, and I can make appointments, and I can get evaluated for different things, and I can go to therapy online and from home, and that’s made a big difference. And I think a lot of other people have found the benefit that also have disabilities, and that’s been a big thing for me.”—Age 17, Asexual, Bisexual or Pansexual, Queer; Trans Non-Binary, Gender Queer
	Loss of vital community events (e.g., Pride events)	“In terms of being gay, I would say that was put on the back burner for everybody, especially where I live. . .all the pride events and stuff were completely shut down because everyone is making that effort to try to keep the spread as minimal as possible.”—Age 23, Lesbian, Cisgender Woman
	Greater reliance on online spaces	“. . .it got to the point where I started just neglecting my work because I was so isolated and I was lonely, and I just wanted to spend all my time with my online friends. And, by the grace of god, I graduated. . .But yeah, we all started living online, just bored together, and you were just that little green online dot that was always green.”—Age 23, Lesbian, Cisgender Woman
	Negative or positive changes in mental health depending on acceptance at home (e.g., anxiety and depression)	“Then later on, moving to, like, virtual meetings and stuff [for therapy]. And specifically with that, being, like, something really difficult to do. . .because in certain ways, like, online therapy kind of does have the ability to be easier and more accessible but also specifically with being, like, queer in an [unsupporting] environment and also just generally kind of a worried person with kind of just, like, my parents and stuff like that, having that kind of lack of privacy, making it harder to kind of open up about mental health and stuff. Environments that aren’t necessarily private.”—Age 16, Bisexual or Pansexual, Trans Non-Binary
Shifts in Political & Social Climate and Impact on Mental Health—experiences of social and political change (e.g., hateful political rhetoric toward LGBTQ+ folks)	Negative mental health outcomes due to tumultuous political & social climate	“There was a lot of action surrounding hatred against the LGBT community. And I’d be looking at the news, and I’d see all these—there was people trying to take away me and my friends’ rights all around the country, and that was kind of scary to look at.”—Age 14, Asexual, Lesbian; Cisgender Girl
	Negative changes in mental health depending on social & political beliefs of the home (e.g., anxiety and depression)	“So it’s just I felt I just mentally had to just step out and just I couldn’t be in the moment. It was just very hard. Yeah, and then my family is also crazy. So there’s, you know, just a lot of pressure. . .it [COVID pandemic and protests against police brutality] definitely shaped my mom’s. . .she’s become more extremist because it was like the protests, and then there’s the. . .like lockdown, you know. . .so she kind of felt like this. . .larger theme with the government trying to control people, and take away their rights, and kill them.”—Age 24, Asexual, Queer; Trans Non-Binary

Shifts in Time

For many YYA, COVID-19 caused shifts in time, that is, more free time and social isolation as events were canceled. Many LGBTQ+ YYA shared how this additional time led to identity exploration, facilitating a normative task of adolescent development. For those with supportive living environments, additional free time improved their mental health by facilitating their understanding of self. For some who came out during COVID-19, this time allowed for acceptance by family, which provided strength and resilience. One individual explained how increased amounts of time for self-reflection led to self-discovery, and therefore higher familial support.

I was able to discover more about myself during the pandemic. I was questioning for a solid five years there, and I finally was able to figure it out. And I also had the opportunity to come out to my mom and my aunt and some of my younger brothers about it as well. – Age 14, Cisgender Girl, Lesbian

For others, self-exploration and identity discovery occurred within unsupportive environments which meant facing a sudden lack of acceptance as family members responded negatively to their LGBTQ+ identity disclosure, regardless of their living situations. This compounded the already-difficult psychological impacts of COVID-19. One participant described how their quarantine-induced mental health difficulties were more challenging after coming out as nonbinary, a self-discovery process facilitated by an increased amount of free time:

Being more or less stuck at home and also coming to the realization that I’m even more of a deviant than my parents thought has just been like super stressful.—Age 22, Transgender Nonbinary, Bisexual

Therefore, shifts leading to increased free time and social isolation could make already tense family situations even unhealthier for YYA when free time led to an identity discovery and coming out meant increased stigma from their home environment.

Shifts in Living Situations

YYA described new interpersonal dynamics that emerged through shifts in living situations, including families isolating together and YYA being forced to move back home. YYA shared how sheltering in place was often associated with negative mental health outcomes due to increased exposure to stigmatization, including some being forcibly outed when they moved back home or spent more time with family. Unwanted discovery of one’s sexual or gender identity could result in undesirable changes in youth’s family interactions and contribute to their feelings of shame and isolation. This manifestation of stigmatization was associated with depression and suicidality for one individual as sheltering-in-place with their family led to rejection.

[Getting outed] was really hard . . . And then right after that, I got checked into a local psychiatric hospital for suicidal ideation. Because it was just too much for me to bear. You know, the thought of losing that unconditional love.—Age 17, Transgender Nonbinary, Queer

Here, the stigma from quarantining at home led to a complete loss of support and subsequent depression and suicidality. Multiple participants reported that their parents or guardians confiscated their phones upon learning youth were LGBTQ+ because they wanted to restrict contact with friends in this community. Several participants described feeling stigmatization after being outed and having their electronics taken away, sentiments that were captured by this quote from one participant:

The additional, like, stir craziness and also just the knowing of, like, the environment of being, like, unsupportive, it kind of drives a little, like [fear]. Age 16, Trans Nonbinary, Bisexual

Therefore, not only did lack of parental acceptance reduce feelings of safety and increase feelings of sadness and isolation, but it also decreased this young person’s ability to access existing online supports at home. Thus, shifts in living situations created intense stigmatization for certain YYA, particularly those who had moved home after being away at college, which drastically impacted their mental health.

Shifts in Community Supports

Participants frequently shared how the pandemic reshaped their community (i.e., shifts in community supports). Many social support spaces transitioned online, and participants described how this had mixed impacts on their mental health: It allowed some to access supports that were otherwise unavailable due to distance, but also reduced availability of in-person support. This seemed particularly challenging for participants, as during late adolescence, autonomy and identifying one’s own communities are important parts of transitioning to adult life (Jamil et al., 2009; Melendro et al., 2020). That said, some individuals who discovered their LGBTQ+ identity during COVID-19 were able to identify new communities online, for example, through LGBTQ+-specific Discord servers or Reddit pages. These facilitated positive connections and improved mental health by decreasing loneliness and depressive symptoms:

. . . I latched onto [my gender identity] pretty fast because it meant I could join the community online and that would just make me less lonely from sitting around by myself all the time.—Age 15, Nonbinary, Asexual

These accepting communities provided a nonstigmatizing environment for YYA to receive support and reduce loneliness. Some participants who joined online communities reported that they “flourished” despite the circumstances, specifically due to the LGBTQ+ community they found during the pandemic. One individual explained that queer online communities acted as a “safety net” that helped them during particularly lonely moments:

Going on like Reddit and talking to people online in the queer community like helped me a lot in the pandemic, being able to have that like safety net, and just people . . . during the pandemic, it was my only connection to the community which I’d been so involved in before. –Age 15, Non-Binary, Asexual

Some participants felt increased safety during COVID-19 due to shifts in day-to-day environments, including avoiding unsupportive peers in high school. This alleviation of stigma could bolster resilience, thereby helping to prevent poor mental health outcomes:

. . . I would talk to my friends daily, so like really long, and all my friends are very supportive—like a lot of us were able to reflect more on our identities in a supportive environment without having to worry about putting up a front for school, to not be ostracized or anything.—Age 17, Trans Boy, Bisexual

However, for some, quarantine meant loss of access to vital supports, community events, and affirmative spaces. This included the cancelation of in-person pride and LGBTQ-specific events due to pandemic shut-downs:

In terms of being gay, I would say that [LGBTQ community events] was put on the back burner for everybody, especially where I live.—Age 23, Cisgender Woman, Lesbian

The closing of key resources like community centers meant that some YYA in unaccepting environments lacked a space that supported social safety, leading to isolation and stress:

It was a little scary because my area isn’t the most accepting of queer-identifying people, so anytime I went out, I had to be very careful. And it was very difficult to connect with other queer people during this time because I couldn’t meet with my youth group anymore. . . so it was difficult not getting to see them.—Age 17, Trans Non-Binary, Bisexual

YYA shared how accessing supportive communities became particularly challenging, which then made it difficult to deal with stigma coming from family and more general COVID-19 related mental health challenges, as illustrated by one participant:

. . . being, like, queer, it was really, like, isolating in this way of, like . . . it’s just, like, it was just so much harder to kind of maintain [my support system].—Age 16, Trans Non-Binary, Bisexual

Shifts in Social and Political Climate and Impact on Mental Health

There were intense shifts in social and political climate in the United States that occurred alongside COVID-19, including anti-LGBTQ+ and racist rhetoric during the 2020 U.S. presidential election, backlash to social justice movements, and an increase in hate crimes and harmful legislation (Movement Advancement Project, 2020; Southern Poverty Law Center, 2020). YYA described how intersectional stigma exacerbated the adverse mental health impacts of COVID-19, as on top of general pandemic-related stress, the sociopolitical environment was hostile to participants’ minoritized identities. For example, some participants expressed intense fear that a Trump re-election would lead to further dismantling of LGBTQ+ rights, as described by this youth:

. . .I internalized a lot of it. At least for the presidency, I was very scared for my rights and very scared for my friends’ rights and people around me . . .—Age 17, Cisgender Girl, Lesbian.

These concerns were particularly true for racial and ethnic minority YYA, who reported experiencing intersectional stigma due to the political climate. When asked, a participant described the social upheaval and economic uncertainty of 2020 by saying,

. . . I’m a trans person of color, and I work with queers of color and, just like everything, it’s so sad and bad.—Age 21, Trans Nonbinary, Queer

Political polarization, governmental distrust, and conspiratorial thinking encouraged by COVID-19 in some circles appeared to negatively impact the supportiveness of YYA’s families.

When I first came out as gender fluid, my grandfather told me that that was stupid and not real. And then he told my mom that gender fluidity was made up by Joe Biden to trick all the teenagers. So Joe Biden made me gender fluid and I don’t know how I feel about that.—Age 15, Nonbinary, Asexual

The increased amount of stigma participants experienced from relatives appeared to worsen youth’s mental health, including contributing to isolation and depression. The shifts in the sociopolitical climate toward more polarization, the political and social controversies around COVID-19 prevention and mitigation, combined with shifts in community connectedness and living situations, seemed to exacerbate the mental health impact of stigma that participants reported.

Discussion

Overall, these findings suggest COVID-19 pandemic-related isolation intersected with existing socio-ecological structures in LGBTQ+ young people’s lives, as well as shifts in YYA’s time, living situations, community, and social and political climates. Together, these impacted YYA’s mental health in sometimes positive ways but predominantly detrimental ways. Similar effects were found during other stark shifts (e.g., Hurricane Katrina) (Comer et al., 2010; Gershoff et al., 2010; McLaughlin et al., 2009).

The pandemic conditions created new ways to “keep people in” and “keep people down,” as existing forms of stigmatization either diminished or were reinvigorated during the pandemic (Hatzenbuehler et al., 2013). Interviews showed how some families attempted to “keep people in” by removing access to technology, forced outing, and depicting LGBTQ+ identity as outside of cisgender, heterosexual social norms (Link et al., 2017), (i.e., labeling it as “deviant” or a “trick”), resulting in experiences of minority stress (Brooks, 1977; Meyer, 2003). These mechanisms of stigmatization, which existed prepandemic, may have had increased power during COVID-19 because of isolation associated with quarantine and social distancing, which limited YYA’s access to protective factors.

For YYA, community-level shifts in the form of losses in “social safety nets” contributed to adverse mental health outcomes. Losing in-person access to community spaces and supportive friends due to social distancing guidelines left many feeling vulnerable in psychologically unsafe environments. However, the long-term negative effects resulting from insufficient social supports may be as harmful as direct experiences of stigmatization (Diamond & Alley, 2022).

On the societal level, the political environment and anti-LGBTQ+ legislation that occurred during the pandemic created explicit stress and exclusion among YYA, which they associated with poor mental health. This form of stigmatization—using social policies to communicate who belongs and whose lives have value—is a clear attempt to “keep people down.” The passage of such policies can harm the mental health of LGBTQ+ young people (Aivadyan et al., 2023; Hatzenbuehler et al., 2010, 2013). Although COVID-19 did not directly cause these policies, the overlapping timing meant that were particularly detrimental to LGBTQ+ YYA mental health outcomes. Specifically, they heightened levels of structural stigma while simultaneously limiting access to in-person supports and placing YYA in physical spaces with higher level of stigma (e.g., moving home).

None of these shifts or experiences of stigmatization occurred in isolation. For example, structural-level anti-LGBTQ+ stigma trickled down to impact interpersonal-level stigma among YYA whose family rejected them due to political beliefs. However, LGBTQ+ affirming community contexts, particularly online, provided participants who otherwise lost sources of social safety with ways to better cope. These various constraints intersected in ways that affected YYA differently based on their social situations. For example, individuals who reported higher stigmatization in their living environments due to the pandemic may have been motivated to find support online, thereby enhancing their feelings of social safety in certain contexts. Given the stigmatization and racism experienced by racial and ethnic minority YYA (Liu et al., 2023), experiences of stigma may have operated differently in multiply marginalized YYA (Reid & Ritholtz, 2020). Future work should emphasize an intersectional lens.

Not all YYA experienced worsened mental health during COVID-19. YYA in low stigma environments, or for whom quarantine protected them from stigmatization, reported improved mental health through increased social safety (Diamond & Alley, 2022). Previous research found accepting environments to be protective against depression, substance abuse, and suicidal ideation (Ryan et al., 2010; Saewyc et al., 2020). Even the act of finding an identity label, which many YYA were able to do because of time to reflect, may act as a protective factor, providing healing and resilience (Wagaman, 2016). These patterns indicate that studying multiple levels of stigmatization in tandem is crucial for improving our understanding of LGBTQ+ youth mental health in a pandemic context and for effectively creating interventions to support LGBTQ+ YYA. Example interventions can include federal-, state-, and local-level antidiscrimination policies, community supports, virtual resources, and affirming mental health resources; we also need ongoing longitudinal investigation into the lasting pandemic effects for YYA. Furthermore, results support the importance of clinicians and health educators speaking with LGBTQ+ YYA—and when appropriate and safe for YYA, their families—about their whole selves and whole lives to ensure they can be linked to appropriate mental health services and LGBTQ+ youth programs; this in turn necessitates that health professionals familiarize themselves with local, state, and national factors which could contribute to stigmatization as well as resources available to support LGBTQ+ YYA. As others have concluded, and as our results regarding political environment support, there are also urgent opportunities for health care professionals to also become further involved in advocacy for LGBTQ+ youth (Lynne-Joseph, 2023; Thompson et al., 2023).

These findings also highlight the potential for long-term effects due to disruptions in normative developmental processes for LGBTQ+ YYA (Hussong et al., 2021). Increased stigmatization and shifts in perceived security may complicate the process of identity development, as youth may be overly focused on protecting their mental health and safety, affording them with less psychological and physical space to explore their LGBTQ+ identities. Indeed, social support can moderate the association between victimization and difficulty in processing identity (Kiperman et al., 2022). Striving for autonomy is a normative part of YYA development, but that was also interrupted by the pandemic, especially for LGBTQ+ YYA. For example, YYA described multiple ways in which they lost autonomy, including being forced to move back home, losing access to social and community outlets, or having their access to technology limited. Youth described this as associated with increases in enacted stigma and mental health consequences. Special attention must be given to the long-term mental health effects of the pandemic for LGBTQ+ YYA, particularly the psychosocial consequences of long-term losses of autonomy and identity development opportunities (Weaver et al., 2022).

Limitations

Internet access was a requirement to participate; this may have excluded some populations from participating, including those who were the most marginalized, such as YYA in highly rural areas or in low-income households (Swenson & Ghertner, 2021). In addition, because interviews were conducted virtually, participant responses may have omitted certain sensitive details if they were afraid of being overheard, and closeted individuals/individuals in unaccepting environments may have been less likely to participate. Taken together, these limitations may suggest that youth’s experiences during the pandemic could be worse than reported here.

Conclusion

Our interviews shed light on how racially and ethnically diverse LGBTQ+ youth experienced the initial year of the COVID-19 pandemic. For some, the pandemic improved mental health: they explored their identities, accessed new communities, and escaped stigmatizing environments. However, for most, the pandemic increased stigmatization as social norms were enforced in their family and community, and new forms of social and policy control occurred at the structural level. Clinicians and health educators should be mindful of the ways in which these interpersonal and social factors, overlaid with the impact of living through a pandemic, may uniquely impact LGBTQ+ YYA. More research is needed to explore the long-term impacts on LGBTQ+ YYA mental health and development.

Footnotes

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, authorship, and/or publication of this article: This study was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (grant no. R01 AA024409-05S1, Principal Investigator: Phillips). The study sponsors had no role in the creation of this manuscript.

ORCID iDs

Megan M. Ruprecht

Gregory Phillips

References

Aivadyan

Slavin

M. N.

(2023). Inclusive state legislation and reduced risk of past-year suicide attempts among lesbian, gay, bisexual, and questioning adolescents in the United States. Archives of Suicide Research, 27(1), 63–79. https://doi.org/10.1080/13811118.2021.1967237

Akre

E. R.

Anderson

Stojanovski

Chung

K. W.

VanKim

N. A.

Chae

D. H.

(2021). Depression, anxiety, and alcohol use among LGBTQ plus people during the COVID-19 pandemic. American Journal of Public Health, 111(9), 1610–1619. https://doi.org/10.2105/Ajph.2021.306394

Alix

F. A.

(2020). LGBTQ youth and technology. Intersect: The Stanford Journal of Science, Technology, and Society, 14(2), 1–11.

Arnett

(2000). Emerging adulthood: A theory of development from the late teens through the twenties. American Psychologist, 55(5), 469–480.

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101.

Bronfenbrenner

(1999). Environments in developmental perspective: Theoretical and operational models. In Friedman

S. L.

Wachs

T. D.

(Eds.), Measuring environment across the life span: Emerging methods and concepts (pp. 3–28). American Psychological Association. https://doi.org/10.1037/10317-001

Brooks

V. R.

(1977). Minority stress and adaptation among lesbian women. University of California Berkeley, 366 pp.

Comer

J. S.

Fan

Duarte

C. S.

Musa

G. J.

Mandell

D. J.

Albano

A. M.

Hoven

C. W.

(2010). Attack-related life disruption and child psychopathology in New York City public school children 6-months post-9/11. Journal of Clinical Child and Adolescent Psychology, 39(4), 460–469. https://doi.org/10.1080/15374416.2010.486314

Crenshaw

K. W.

(1994). Mapping the margins: Intersectionality, identity politics, and violence against women of color. The Public Nature of Private Violence.

10.

Dawson

Kirzinger

Kates

(2021). The impact of the COVID-19 pandemic on LGBT people. KFF. https://www.kff.org/coronavirus-covid-19/poll-finding/the-impact-of-the-covid-19-pandemic-on-lgbt-people/#:~:text=In%20this%20analysis%2C%20we%20find,49%25%20compared%20to%2023%25)

11.

DeHaan

Kuper

L. E.

Magee

J. C.

Bigelow

Mustanski

B. S.

(2013). The interplay between online and offline explorations of identity, relationships, and sex: A mixed-methods study with LGBT youth. Journal of Sex Research, 50(5), 421–434. https://doi.org/10.1080/00224499.2012.661489

12.

Diamond

L. M.

Alley

(2022). Rethinking minority stress: A social safety perspective on the health effects of stigma in sexually-diverse and gender-diverse populations. Neuroscience and Biobehavioral Reviews, 138, Article 104720. https://doi.org/ARTN10472010.1016/j.neubiorev.2022.104720

13.

Eskenazi

Fahey

C. A.

Kogut

Gunier

Torres

Gonzales

N. A.

Holland

Deardorff

(2019). Association of perceived immigration policy vulnerability with mental and physical health among US-Born Latino adolescents in California. JAMA Pediatrics, 173, 744–753.

14.

Felt

Floresca

Y. B.

Fernadez

E. S.

Korpak

A. K.

Phillips

II Wang

Curry

C. W.

Beach

L. B.

(2023). Instability in housing and medical care access: The inequitable impacts of the COVID-19 pandemic on U.S. transgender populations. Transgender Health, 8(1), 74–83. https://doi.org/10.1089/trgh.2021.0129

15.

Fish

J. N.

McInroy

L. B.

Paceley

M. S.

Williams

N. D.

Henderson

Levine

D. S.

Edsall

R. N.

(2020). “I’m kinda stuck at home with unsupportive parents right now”: LGBTQ youths’ experiences with COVID-19 and the importance of online support. Journal of Adolescent Health, 67(3), 450–452. https://doi.org/10.1016/j.jadohealth.2020.06.002

16.

Gershoff

E. T.

Aber

J. L.

Ware

Kotler

J. A.

(2010). Exposure to 9/11 among youth and their mothers in New York City: Enduring associations with mental health and sociopolitical attitudes. Child Development, 81(4), 1142–1160. https://doi.org/10.1111/j.1467-8624.2010.01459.x

17.

Green

Price-Feeney

Dorison

(2020). Implications of COVID-19 for LGBTQ youth mental health and suicide prevention. https://www.thetrevorproject.org/2020/04/03/implications-of-covid-19-for-lgbtq-youth-mental-health-and-suicide-prevention/

18.

Harris

P. A.

Taylor

Thielke

Payne

Gonzalez

Conde

J. G.

(2009). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381.

19.

Hatzenbuehler

M. L.

McLaughlin

K. A.

Keyes

K. M.

Hasin

D. S.

(2010). The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: A prospective study. American Journal of Public Health, 100(3), 452–459. https://doi.org/10.2105/AJPH.2009.168815

20.

Hatzenbuehler

M. L.

Phelan

J. C.

Link

B. G.

(2013). Stigma as a fundamental cause of population health inequalities. American Journal of Public Health, 103(5), 813–821. https://doi.org/10.2105/AJPH.2012.301069

21.

Hussong

A. M.

Benner

A. D.

Erdem

Lansford

J. E.

Makila

L. M.

Petrie

R. C.

Team

C.-R.

(2021). Adolescence amid a pandemic: Short- and long-term implications. Journal of Research on Adolescence, 31(3), 820–835. https://doi.org/10.1111/jora.12671

22.

Jairath

N. N.

Benetato

B. B.

O’Brien

S. L.

Agazio

J. B. G.

(2021). Just-in-time qualitative research methodological guidelines based on the COVID-19 pandemic experience. Nursing Research, 70(3), 215–221. https://doi.org/10.1097/Nnr.0000000000000504

23.

Jamil

O. B.

Harper

G. W.

Fernandez

M. I.

, & Adolescent Trials Network for HIV/AIDS Interventions. (2009). Sexual and ethnic identity development among gay–bisexual–questioning (GBQ) male ethnic minority adolescents. Cultural Diversity and Ethnic Minority Psychology, 15(3), 203–214. https://doi.org/10.1037/a0014795

24.

Johns

M. M.

Beltran

Armstrong

H. L.

Jayne

P. E.

Barrios

L. C.

(2018). Protective factors among transgender and gender variant youth: A systematic review by socioecological level. The Journal of Primary Prevention, 39(3), 263–301. https://doi.org/10.1007/s10935-018-0508-9

25.

Kamal

J. J.

Hahm

H. C.

Liu

C. H.

(2021). Psychiatric impacts of the COVID-19 global pandemic on U.S. sexual and gender minority young adults. Psychiatry Research, 299, Article 113855. https://doi.org/10.1016/j.psychres.2021.113855

26.

Kiperman

Schacter

H. L.

Judge

DeLong

(2022). LGBTQ plus youth’s identity development in the context of peer victimization: A mixed methods investigation. International Journal of Environmental Research and Public Health, 19(7), 3921. https://doi.org/ARTN392110.3390/ijerph19073921

27.

Link

B. G.

Phelan

Hatzenbuehler

M. L.

(2017). Stigma as a fundamental cause of health inequality. In Major

Dovidio

J. F.

Link

B. G.

(Eds.), The Oxford handbook of stigma, discrimination, and health (pp. 50–64). Oxford University Press.

28.

Liu

Poggi Davis

Palma

A. M.

Stern

H. S.

Sandman

C. A.

Glynn

L. A.

(2023). Experiences of COVID-19-related racism and impact on depression trajectories among racially/ethnically minoritized adolescents. Journal of Adolescent Health, 72(6), 885–891. https://doi.org/10.1016/j.jadohealth.2022.12.020

29.

Lynne-Joseph

(2023). “As a clinician, you have to be passionately involved”: Advocacy and professional responsibility in gender-affirming healthcare. Social Science & Medicine, 321, 115788.

30.

McLaughlin

K. A.

Fairbank

J. A.

Gruber

M. J.

Jones

R. T.

Lakoma

M. D.

Pfefferbaum

Sampson

N. A.

Kessler

R. C.

(2009). Serious emotional disturbance among youths exposed to Hurricane Katrina 2 years postdisaster. Journal of the American Academy of Child and Adolescent Psychiatry, 48(11), 1069–1078. https://doi.org/10.1097/CHI.0b013e3181b76697

31.

Melendro

Campos

Rodríguez-Bravo

A. E.

Arroyo Resino

(2020). Young people’s autonomy and psychological well-being in the transition to adulthood: A pathway analysis. Frontiers in Psychology, 11, 1946. https://doi.org/10.3389/fpsyg.2020.01946

32.

Meyer

I. H.

(2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674

33.

Morse

(2015). Analytic strategies and sample size. Qualitative Health Research, 25(10), 1317–1318. https://doi.org/10.1177/1049732315602867

34.

Moser

D. J.

Schultz

S. K.

Arndt

Benjamin

M. L.

Fleming

F. W.

Brems

C. S.

Paulsen

J. S.

Appelbaum

P. S.

Andreasen

N. C.

(2002). Capacity to provide informed consent for participation in schizophrenia and HIV research. American Journal of Psychiatry, 159, 1201–1207.

35.

Movement Advancement Project. (2020). The rise of hate crimes. Medium. https://lgbtmap.medium.com/education-action-during-covid-19-the-rise-of-hate-crimes-a261fd723c8a

36.

Needham

B. L.

Austin

E. L.

(2010). Sexual orientation, parental support, and health during the transition to young adulthood. Journal of Youth and Adolescence, 39(10), 1189–1198. https://doi.org/10.1007/s10964-010-9533-6

37.

Panchal

Kamal

Cox

Garfield

Chidambaram

(2021). Mental health and substance use considerations among children during the COVID-19 pandemic. Kaiser Family Foundation. https://www.kff.org/mental-health/issue-brief/mental-health-and-substance-use-considerations-among-children-during-the-covid-19-pandemic/

38.

Pew Research Center. (2020). Many Black and Asian Americans say they have experienced discrimination amid the COVID-19 outbreak. https://www.pewresearch.org/social-trends/2020/07/01/many-black-and-asian-americans-say-they-have-experienced-discrimination-amid-the-covid-19-outbreak/

39.

Phelan

J. C.

Link

B. G.

Dovidio

J. F.

(2008). Stigma and prejudice: One animal or two? Social Science & Medicine, 67(3), 358–367. https://doi.org/10.1016/j.socscimed.2008.03.022

40.

Phillips

II Xu

Curtis

M. G.

Ruprecht

M. M.

Davoudpour

Choi

Quiballo

Huang

Macapagal

(2023). Adaptation of the information, motivation, and behavioral skills framework for understanding COVID-19 prevention behaviors among youth and young adults by sexual identity, gender identity and race/ethnicity. Sexes, 4(4), 656–676. https://doi.org/10.3390/sexes4040042

41.

Purtle

(2020). COVID-19 and mental health equity in the United States. Social Psychiatry and Psychiatric Epidemiology, 55(8), 969–971. https://doi.org/10.1007/s00127-020-01896-8

42.

Reid

Ritholtz

(2020). A queer approach to understanding LGBT vulnerability during the COVID-19 pandemic. Politics & Gender, 16(4), 1101–1109. https://doi.org/PiiS1743923x20000707

43.

Roche

K. M.

Vaquera

White

R. M. B.

Rivera

M. I.

(2018). Impacts of immigration actions and news and the psychological distress of U.S. Latino parents raising adolescents. Journal of Adolescent Health, 62, 525–531. https://doi.org/10.1016/j.jadohealth.2018.01.004

44.

Russell

S. T.

Fish

J. N.

(2016). Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth. Annual Review of Clinical Psychology, 12, 12465–12487. https://doi.org/10.1146/annurev-clinpsy-021815-093153

45.

Ryan

Russell

S. T.

Huebner

Diaz

Sanchez

(2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing, 23(4), 205–213. https://doi.org/10.1111/j.1744-6171.2010.00246.x

46.

Saewyc

E. M.

Gower

A. L.

Watson

R. J.

Erickson

Corliss

H. L.

Eisenberg

M. E.

(2020). The link between LGBTQ-supportive communities, progressive political climate, and suicidal behaviour among sexual minority adolescents in Canada. Preventive Medicine, 139, Article 106191. https://doi.org/10.1016/j.ypmed.2020.106191

47.

Salerno

J. P.

Devadas

Pease

Nketia

Fish

J. N.

(2020). Sexual and gender minority stress amid the COVID-19 pandemic: Implications for LGBTQ young persons’ mental health and well-being. Public Health Reports, 135(6), 721–727. https://doi.org/10.1177/0033354920954511

48.

Salerno

J. P.

Doan

Sayer

L. C.

Drotning

K. J.

Rinderknecht

R. G.

Fish

J. N.

(2023). Changes in mental health and well-being are associated with living arrangements with parents during COVID-19 among sexual minority young persons in the U.S. Psychology of Sexual Orientation and Gender Diversity, 10(1), 150–156. https://doi.org/10.1037/sgd0000520

49.

Scroggs

Love

H. A.

Torgerson

(2021). COVID-19 and LGBTQ emerging adults: Risk in the face of social distancing. Emerging Adulthood, 9(5), 639–644. https://doi.org/10.1177/2167696820968699

50.

SocioCultural Research Consultants, L. (n.d.). Dedoose (Version 8.0.36). www.dedoose.com

51.

Southern Poverty Law Center. (2020). The year in hate and extemeism. https://www.splcenter.org/year-hate-and-extremism-2019

52.

Swenson

Ghertner

(2021). People in low-income households have less access to internet services – 2019 update. Office of the Assistant Secretary for Planning & Evaluation. https://aspe.hhs.gov/sites/default/files/private/pdf/263601/internet-access-among-low-income-2019.pdf

53.

Theberath

M. B. D.

Chen

Salinas

Mohabbat

A. B.

Yang

Chon

T. Y.

Bauer

B. A.

Dietlind

Wahner-Roedler

D. L.

(2022). Effects of COVID-19 pandemic on mental health of children and adolescents: A systematic review of survey studies. SAGE Open Med, 10. https://doi.org/10.1177/20503121221086712

54.

Thompson

H. M.

Wang

T. M.

Talan

A. J.

Baker

K. E.

Restar

A. J.

(2023). First they came for us all: Responding to anti-transgender structural violence with collective, community-engaged, and intersectional health equity research and advocacy. Health Education and Behavior, 51(1), 5–9. https://doi.org/10.1177/10901981231201146

55.

UCSD Task Force on Decisional Capacity. (2003). Procedures for determination of decisional capacity in persons participating in research protocols. UCSD. https://irb.ucsd.edu/_files/researchers/DecisionalCapacityAssessment1.pdf

56.

Wagaman

M. A.

(2016). Self-definition as resistance: Understanding identities among LGBTQ emerging adults. Journal of LGBT Youth, 13(3), 207–230. https://doi.org/10.1080/19361653.2016.1185760

57.

Weaver

R. H.

Srinivasan

E. G.

Decker

Bolkan

(2022). Young adults’ experiences with loss and grief during COVID-19. Death Studies, 46(1), 53–64. https://doi.org/10.1080/07481187.2021.1984339

58.

Yurcaba

(2021). For some queer teens, school clubs were their only safe space. Covid upended that. NBC News. https://www.nbcnews.com/feature/nbc-out/some-queer-teens-school-clubs-were-their-only-safe-space-n1261110