key: cord-1043629-017vr8nc
authors: Ormiston, Cameron K; Williams, Faustine
title: LGBTQ youth mental health during COVID-19: unmet needs in public health and policy
date: 2021-12-22
journal: Lancet
DOI: 10.1016/s0140-6736(21)02872-5
sha: f3a92c7b9975eb432fa1c0e7f549408e3dd43a66
doc_id: 1043629
cord_uid: 017vr8nc

nan

Although the negative impacts of COVID-19 on youth and young adult global mental health are recognised, 1 less attention has been paid to LGBTQ youth-a historically neglected population in health care, policies, and research, despite evidence of high unmet mental health needs. [2] [3] [4] Unfortunately, the pandemic is likely to have far-reaching negative effects on LGBTQ health and wellbeing.

Before COVID-19, LGBTQ youth bore a disproportionate burden of mental health problems, with their sexual and gender identity being risk factors for victimisation, trauma, discrimination, and abuse. 5 Also, LGBTQ youth, especially non-binary and transgender youth, are at a higher risk for depression, suicide, substance use, and anxiety. 2,3,6,7 COVID-19 control measures, such as lockdowns, working from home, school shutdowns, and remote learning, are likely to have exacerbated these mental health disparities. Although knowledge on the long-term impacts of COVID-19 on the mental health of LGBTQ youth is still evolving, preliminary research suggests that LGBTQ youth are disproportionately affected by the pandemic. 3,8 Moreover, LGBTQ youth who live in unsupportive homes are vulnerable to abuse, do not feel safe to express themselves, or are cut off from supportive peers. 3 Since the start of the COVID-19 pandemic, more than 50% of sexual and gender minority youth in the USA have reported increased anxiety or depressive symptoms. [7] [8] [9] Factors likely to be implicated in such findings are isolation from support systems, absence of family support (only 33% of LGBTQ youth report living in an LGBTQ-affirming home during the pandemic), and disruptions to health services. [7] [8] [9] [10] The lack of family support is especially alarming given LGBTQ youth who experience parental rejection are at increased risk of suicide and depression. 2,4 Although less is known about transgender youth, research before COVID-19 suggests transgender youth experience higher rates of parental rejection than cisgender youth. 10 Additionally, youth with intersectional identities, such as Black, Indigenous, and people of colour (BIPOC), people with low socioeconomic status, and homeless LGBTQ youth, are especially vulnerable during the pandemic. 6 BIPOC and low socioeconomic status LGBTQ youth may also have diminished access to services due to barriers resulting from the combination of their sexual and gender identity, ethnicity, and socioeconomic status. 4 Furthermore, Asian and Pacific Islander LGBTQ youth in the USA may experience an increase in abuse and discrimination given the uptick in anti-Asian rhetoric and hate crimes in the past year. 11 Addressing the disproportionate toll of COVID-19 on LGBTQ youth is therefore of urgent concern.

Crucially, the pandemic has disrupted mental health services at a time when the need for such

LGBTQ youth mental health during COVID-19: unmet needs in public health and policy SPB reports grants and institutional support for clinical trials from NuCana, Sierra Oncology, Redx Pharma, UCB Pharma, Astex Pharma, Tesaro, and BerGenBio, all unrelated to the area of work commented on here. services has increased, with young people and schoolbased services being especially affected. 12 LGBTQ youth have been affected by these disruptions. 8 For example, transgender and gender diverse youth report substantially more unmet needs and disruptions in mental health and substance use services than cisgender youth. 8 Additionally, LGBTQ youth and young adults will have reduced access to essential counselling, identity-based resources, and physical and mental health support programmes due to the closures of schools and universities, which often provide such services. 4 Moreover, school-based mental health services in high-income countries are predominantly used by BIPOC, homeless, and low socioeconomic status LGBTQ youth, making school closures especially harmful for intersectional LGBTQ youth. 4 Although the reopening of schools can mean returning to supportive communities and spending less time in isolation or in an abusive or unsupportive home, in-person schooling can also mean returning to school-based trauma for some individuals. 3 Parents, school administrators, teachers, and clinicians must be aware of the heterogeneity in experiences of LGBTQ youth and the impact the return to in-person schooling could have on LGBTQ youth. Health practitioners, researchers, teachers, policy makers, and community members all have a role in supporting the mental health of LGBTQ youth. First, health practitioners need training on LGBTQ-affirming care and the unique issues LGBTQ youth may be facing due to the impacts of the COVID-19 pandemic. Training should be intersectional and include topics such as identity development, non-stigmatising language, and the specific concerns and needs of LGBTQ youth. 2,7 Health providers should continue providing confidential telehealth services for youth who do not have access to in-person services while recognising the potential privacy issues for youth living in unsafe or uncomfortable environments. 13 Second, school leaders and administrators must provide and promote safe, inclusive spaces for LGBTQ youth as they return to school, including the provision of inperson and online mental health services, LGBTQaffirming education and resources that LGBTQ youth can access (eg virtual communities, text-based mental health support platforms, and local identitybased organisations), and help educate parents and families. Schools with affirming, safe environments empower LGBTQ youth and strengthen resilience. 14 Third, evidence-based policy and interventions should include LGBTQ-specific language and issues and increase access to affordable and affirming services. Addressing structural barriers, including prejudiced and discriminatory institutions and policies, 4,5 is also essential.

Finally, a knowledge gap on LGBTQ youth issues continues to persist in health research. Studies should be better designed to accurately and comprehensively capture the health and wellbeing of LGBTQ youth. 13 LGBTQ youth mental health is a global issue and research should reflect and investigate the experiences of LGBTQ youth in lowincome and middle-income countries. 5 Researchers should collaborate with LGBTQ populations and LGBTQ health experts and provide options to disclose sexual and gender orientation when collecting sociodemographic data. Studies should aim to comprehensively understand the diverse and evolving needs of LGBTQ youth as they navigate the pandemic; better research better informs policies to improve the health and wellbeing of LGBTQ youth. We must create spaces that foster resilience and agency for LGBTQ youth in our communities and institutions. Ultimately, we must engage with LGBTQ youth to design effective, participatory solutions that protect youth from COVID-19-related mental health outcomes and build a better, healthier future for all. 

Challenges and opportunities in global mental health: a research-to-practice perspective

Implications of COVID-19 for LGBTQ youth mental health and suicide prevention: The Trevor Project

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

Mental health among transgender and gender diverse youth: an exploration of effects during the COVID-19 pandemic

The Trevor Project. 2021 national survey on LGBTQ youth mental health

Lesbian, gay, bisexual, and transgender youth and family acceptance

Anti-Asian hate crime during the COVID-19 pandemic: exploring the reproduction of inequality

Impact of the COVID-19 pandemic-a mental health service perspective

Sexual and gender minority adolescents must be prioritised during the global COVID-19 public health response

Beyond risk: resilience in the lives of sexual minority youth

The UN adopted the Convention on the Suppression and Punishment of the Crime of Apartheid in November, 1973, making this systematised form of racial discrimination an international crime. 1 The vote was overwhelmingly in favour of the designation, with only Portugal, South Africa, the USA, and the UK voting against it. Subsequently, the 1998 Rome Statute, which created the International Criminal Court, further established apartheid as one of 11 crimes against humanity. 2 Initially linked specifically to the apartheid regime of South Africa, the crime has been since been more broadly invoked-in the war crimes tribunals of the former Yugoslavia and the Rwandan genocide, 3,4 and in the abuses against the Rohingya minority in Myanmar. 5 The late Archbishop Emeritus Desmond Tutu (1931-2021) was among the leaders in the struggle against apartheid in his own beloved South Africa. His voice was ever after one of the world's moral arbiters against apartheid regimes and acts wherever they occurred, including the genocidal policies against the Rohingya, 6 China's treatment of the Tibetan people, 7 and the treatment of Palestinians under Israeli occupation. 8 Tutu saw and understood that discrimination on the basis of race, ethnicity, and faith was always a crime. But his vision of inclusivity was broader still. Tutu led the effort for the full ordination of women in his church. 9 He became an outspoken and passionate supporter of the inclusion of the LGBTQ community. In 2010, when many African governments were debating anti-LGBTQ laws, Archbishop Tutu wrote "Hate has no place in the house of God. No one should be excluded from our love, our compassion or our concern because of race or gender, faith or ethnicity-or because of their sexual orientation". 10 And he became an outspoken advocate against the exclusion, the stigma, and discrimination faced by people living with HIV/AIDS and tuberculosis. 11 In the pages of The Lancet 12,13 his voice has been heard on the full inclusion of LGBTQ people in all societies, and on the rights of prisoners and detainees to health care, in what are now known as the Nelson Mandela Rules. 14 Tutu's vision of radical inclusivity, and his deep grasp of the connections between exclusion and poor health outcomes, were at the core of his calls for the inclusion of all the human family in compassionate care.