KEY FINDINGS from “Sexual Identity, Sex of Sexual Contacts, and Health-Related Behaviors among Students in Grades 9–12 - United States and selected sites, 2015” Research translation by NSVRC A nationally representative survey of high school students has shown for the first time that students who identify as gay, lesbian, and bisexual* (GLB) face significant health disparities. GLB students are shown to have higher prevalence rates for many violence and high-risk behaviors including bullying, sexual and dating violence, and human immunodeficiency virus (HIV) infection when compared to their classmates who identify as straight or heterosexual. * This study did not offer students the option to identify as transgender. See additional information in sexual minority status chart, p.2. The national Youth Risk Behavior Survey (YRBS) is part of the larger Youth Risk Behavior Surveillance System (YRBSS) developed by the Centers for Disease Control and Prevention (CDC) to collect health-risk behavior information on students in grades 9-12. The YRBSS is considered the principal source of data for tracking health-risk behaviors among high schoolers. Health-risk behaviors are those considered by CDC to contribute to the leading causes of death, disability, and social problems among youth and adults (p. 2). These behaviors often establish themselves during childhood and adolescence and extend into adulthood (p. 2), thus potentially influencing health, educational achievements, and employment prospects. THE SURVEY The biennial survey is conducted by multiple partners. The national YRBS is conducted by CDC with students in public and private schools. The YRBS is also conducted by states and large urban school districts who are representative of mostly public high school students in those jurisdictions (p. 1). The standard 2015 YRBS questionnaire contained 89 questions, and states and local school districts have the ability to add or delete questions (p. 4). This report summarizes data from the national survey in addition to 25 state surveys and 19 large urban school districts. For the 2015 cycle, two questions were added for the first time to the national survey to determine sexual minority status (see chart below). As result, data were able to be analyzed for 118 health-related behaviors plus obesity, overweight, and asthma by sexual identity and sex of sexual contacts. It also provides the first national estimates of the percentage of high school students who identified as gay, lesbian, and bisexual, or chose “not sure” of their sexual identity, as well as those students who indicated sexual contact with only the same sex or with both sexes. (Detailed information around methodology and sampling is available at http://www.cdc.gov/yrbs.) SEXUAL MINORITY STATUS DEFINED Sexual minority status was defined and captured by responses to two questions (pp. 5-6): Question 1: “Which of the following best describes you?” Pie chart shows 88% identify as heterosexual, 6% as bisexual, 3.2% not sure, and 2% as gay or lesbian. Question 2: “During your life, with whom have you had sexual contact?” Options were “female” and “male.” Responses: • 48% of students had sexual contact with only the opposite sex, • 1.7% had sexual contact with only the same sex, • 4.6% had sexual contact with both sexes, and • 45.7% had no sexual contact. • To obtain a sufficient sample size for analyses, students who selected “gay,” “lesbian,” or “bisexual” were combined into a single subgroup and referred to as gay, lesbian, and bisexual students. • Students were not offered an option to identify as transgender. However, the CDC, in consultation with national advocates and partners, has since proposed a question intended to measure transgender status that interested states and large urban school districts will be able to pilot during the 2017 YRBS cycle. COMMON DEFINITIONS AND TERMS • Gay: A man who is predominantly or exclusively emotionally, physically, spiritually, and/or sexually attracted to men. • Lesbian: A woman who is predominately or exclusively emotionally, physically, spiritually, and/or sexually attracted to women. • Bisexual: A person who is emotionally, physically, spiritually, and/or sexually attracted to women and men. • GLB: Acronym for gay, lesbian, and bisexual. Frequently seen as LGB, which is a different ordering of the words lesbian, gay, and bisexual. • LGBTQ: Acronym used to refer to individuals who identify as lesbian, gay, bisexual, transgender, or queer; often used interchangeably with GLBTQ. • Heterosexual/Straight: The sexual orientation in which a person’s emotional, physical, spiritual, and/or sexual attraction is to individuals of the opposite sex. • Transgender: Often used as an umbrella term to encompass a wide range of people whose gender identity or expression may not match the category society has placed them in. Transgender is sometimes used to include people who self-identify as transsexual, intersex, two-spirit, genderqueer, drag queens, cross dressers, and others. People who are transgender may be lesbian, gay, bisexual, or heterosexual. • Cisgender: A person whose assigned sex at birth matches their identity and assigned gender. For example, someone who was assigned female at birth and is comfortable living and presenting as female may identify as a cisgender woman. • Genderqueer: Some people identify as genderqueer because their gender identity is androgynous. Some people use the term genderqueer because they oppose the binary gender system. Genderqueer can be a political term. • Gender Non-conforming: Can include anyone who does not conform to gender stereotypes. For additional discussion of these and other terms, please see the National Sexual Violence Resource Center publication “Talking About Gender and Sexuality” (NSVRC, 2012b). For the 2015 national YRBS, over 15,000 questionnaires were completed in 125 public and private schools. Data was collected on the following six categories of behaviors: • Behaviors that may contribute to violence or unintentional injuries were measured through 18 questions that included activities such as drove when drinking alcohol, texted/emailed while driving, carried a weapon, was involved in or injured in a physical fight, was electronically bullied, didn’t go to school because of safety concerns, experienced physical dating violence or sexual dating violence, made a suicide plan, or attempted suicide. • Tobacco use was assessed through a series of 13 questions that included current use of cigarettes, cigars, and electronic vaping devices, age at first use, and buying patterns. • Alcohol and other drug use inquiries assessed students’ use of marijuana, cocaine, heroin, methamphetamines, inhalants, alcohol, age of first use, and amount and times of alcohol consumption for a total of 19 questions. • Sexual behaviors were gauged by responses to 13 behavioral questions. Respondents were asked about their sexual activity, number of sex partners, age of first sexual intercourse, use of birth control including condom use/birth control pill /other, drinking alcohol or using drugs before sexual intercourse, and having ever been tested for HIV status. • Dietary behaviors assessments included over 20 questions about behaviors such as drinking soda pop, eating breakfast, eating fruits and/or vegetables, and drinking water. • Physical activity/inactivity measurements included nine questions on daily levels of physical activity, playing on sports teams, television watching, and computer use. RESULTS Students who identified as sexual minority students provided information that showed a high prevalence rate for many health-risk behaviors — some rates were two to three times higher than their classmates who identified as straight. Below are examples of specific behaviors that were included within the violence-related and unintentional injury category. Across the 18 behaviors that were measured, the prevalence rate for 16 was higher among gay, lesbian, and bisexual students. For nine of the behaviors, this group of students had a twofold or greater prevalence rate than heterosexual students. • Having been in a physical fight was higher among gay, lesbian, and bisexual students (28.4%) and “not sure” students (34.5%) than heterosexual students (21.7%) (p. 12). • Having been injured in a physical fight was higher among gay, lesbian, and bisexual students (4.9%) and “not sure” students (8.7%) than heterosexual students (2.5%) (p. 13). • Not having gone to school because of safety concerns was higher among gay, lesbian, and bisexual students (12.5%) and “not sure” students (10.8%) than heterosexual students (4.6%) (p. 14). • GLB students were twice as likely to report being threatened or injured with a weapon on school property (10.0%) while “not sure” students weighed in at 12.6% and heterosexual students reported 5.1% (p. 11). • The prevalence of having been bullied on school property was higher among gay, lesbian, and bisexual students (34.2%) than heterosexual students (18.8%) (pp. 15-16). • Being electronically bullied (through e-mail, chat rooms, instant messaging, websites, or texting) was higher among gay, lesbian, and bisexual students (28.0%) and “not sure” students (22.5%) than heterosexual students (14.2%) (p. 15). • Having ever been forced to have sexual intercourse was higher among gay, lesbian, and bisexual students (17.8%) and “not sure” students (12.6%) than heterosexual students (5.4%) (p. 16). • Of students who indicated they dated or went out with someone, physical dating violence was higher among gay, lesbian, and bisexual students (17.5%) and “not sure” students (24.5%) than heterosexual students (8.3%) (p. 17). • Sexual dating violence (forced to do sexual things including being kissed, touched, or physically forced to have sexual intercourse) was higher among gay, lesbian, and bisexual students (22.7%) and “not sure” students (23.8%) than heterosexual students (9.1%) (p. 18). • Sixty percent (60%) of GLB students reported having been so sad or hopeless they stopped doing some of their usual activities for at least two or more weeks in a row during the preceding 12 months compared to 26.4% of straight students (p. 18). • More than 40% of GLB students have seriously considered suicide in the preceding 12 months before the survey, and 29% reported having attempted suicide during the past 12 months (p. 19). [Image of a group of high school students walking down the hall.] Similar results were found across the other five categories of behaviors. • Within the 13 tobacco use-related risk behaviors, the prevalence of 11 of these behaviors was higher among gay, lesbian, and bisexual students than heterosexual students (p. 77). • GLB students are more likely than other students to report using illegal drugs. Higher prevalence rates for 18 alcohol and drug-related behaviors were reported for GLB students versus their heterosexual peers including: tried marijuana before age 13 years, ever used hallucinogenic drugs, ever used cocaine, ever used ecstasy, ever used heroin, ever used synthetic marijuana, ever used methamphetamines, ever took steroids without a doctor’s prescription, ever used inhalants, and ever injected any illegal drug as well as higher rates of consuming alcohol (pp. 77-78). The only behavior that appears to not show a higher prevalence rate for this group of students was “obtained the alcohol they drank by someone giving it to them in the 30 days prior to the survey” (Table 48, p. 132). • The same pattern emerged across sexual risk behaviors that relate to unintended pregnancy and sexually transmitted infections, including HIV. Higher prevalence rates were recorded for five of the six behaviors measured including: sexual intercourse before age 13, being currently sexually active, having had sexual intercourse with four or more persons, and less likely to use a condom (pp. 46-53), but no clear differences for birth control use (p.2). GLB students indicated higher rates of HIV testing (p.164). The report further notes that “not sure” students (those who responded “not sure” when asked about their sexual identity) and gay, lesbian, and bisexual students often have a similar prevalence for many health-risk behaviors, and “not sure” students often have a higher prevalence of many health-risk behaviors than heterosexual students (p. 78). This means that when researchers looked at prevalence rates for three discrete groups: “not sure,” GLB students, and heterosexual students, the “not sure” group indicated higher prevalence rates for some behaviors than either GLB or heterosexual students. Students who had no sexual contact at all had a much lower prevalence of most health-risk behaviors compared with either sexual minority students or heterosexual students who indicated sexual contact (p.78). Finally, the report notes no clear pattern of differences emerged for birth control use, dietary behaviors, and physical activity (p. 2). DISCUSSION While some of the prior YRBS state-level surveys and large urban school districts have been assessing student behaviors by sexual identity for some time, the ability to have national estimates on the prevalence of these health-risk behaviors for this group of students is important information for school districts (and others) to use as a guide in program development and a basis for action. As noted earlier, this survey tool is designed to monitor behaviors thought to contribute to negative health outcomes and potentially life-long negative impacts. For sexual minority students, the presence of many high-risk behaviors, some with prevalence rates many times higher than non-GLB-identified students, suggests that this group bears significant burdens. The YRBS report, noting that schools have an important role to play in addressing the health-related behaviors of this group of students, suggests a number of public health actions schools can take to create and promote a healthy school environment including: • “Encourage respect for all students and not allowing bullying, harassment, or violence against any student. • Identify ‘safe spaces’ (e.g., counselors’ offices, designated classrooms, or student organizations) where sexual minority students can get support from administrators, teachers, or other school staff. • Encourage student-led and student-organized school clubs (e.g., gay/straight alliances) that promote school connectedness and a safe, welcoming, and accepting school environment for all students. • Ensure that health classes and educational materials include information that is relevant to sexual minority students and use inclusive words or terms. • Implement professional development opportunities and encourage all school staff to attend on how to create safe and supportive school environments for all students, regardless of sexual minority status. • Make it easier for students to have access to community-based health care providers who have experience providing health services, including HIV/STI testing and counseling and social and psychological services, to sexual minority youth. • Promote parent engagement through outreach efforts and educational programs that provide parents with the information and skills they need to help support sexual minority youth” (p. 79). Noting that schools can address behaviors such as bullying and healthy relationships through both policies and practices, the report provided several examples of schools who used the YRBS data to develop programs focused on improving their school climate, including: • The School District of Philadelphia, who used their YRBS data to implement professional development programs for teachers and other school staff designed to “increase understanding and sensitivity to the issues facing sexual-minority youth” (p. 80). • The San Diego School District used their YRBS data to inform key stakeholders including superintendents, principals, and others to gain support for sexuality education, sexual health services, and revisions to their sexual health education curriculum that included support for gender minority students (p. 80). Other examples included state departments of education or school districts that used their YRBS data to leverage support for programs that target sexual minority youth directly or educate teachers and other personnel on working effectively with this group of students (p. 80). LIMITATIONS The report notes eight limitations (pp. 80-81) regarding the survey findings, three of which (Not in school, Language, and Causality) are noted below. Not in school The YRBS data reflects information available only from students attending school at the time the survey was administered. The report acknowledges that sexual minority youth might represent a significant percentage of those students who drop out or do not attend school (p. 80). Language Researchers noted a possible limitation regarding language choices with several questions that could be subject to interpretation by different students (p. 81). For example, questions used to identify sexual minority status focused only on sexual identity and sex of sexual contacts. Questions focused on sexual attraction might have identified a different subgroup of sexual minority students and different estimates of health-related behaviors. They also indicated no definition was provided for “sexual contact.” As noted earlier, YRBS data did not provide students the opportunity to identify as transgender. Compared to GLB students, studies have found transgender, gender queer, and other non-cisgender students face the most hostile school climates (Kosciw, Greytak, Palmer, & Boesen, 2014, p. xxiii). Causality The authors make no assessment of causality, i.e. what caused these behaviors? The data is based on cross-sectional surveys and can only provide an indication of association, not causality. CONCLUSIONS The report finds that GLB students are not found in only one area of the country or ethnic, racial, or economic class, but are as varied and diverse as many other student populations. For schools to respond effectively to the needs of all students, the report stresses the importance of continuing to obtain high-quality, scientific data on the prevalence of health-related behaviors among sexual minority students. While a diverse group, these students represent a relatively small proportion of all students, so obtaining large, population-based samples such as the YRBS is key to obtaining the highest-quality data. Toward that end, all schools should continue to participate in collecting this level of data that will provide information specific to these students. As noted earlier, this allows schools to monitor key health-risk behaviors and use this data as a basis for starting or expanding programmatic interventions that could work to eliminate disparities for sexual minority students. ADDITIONAL CONSIDERATIONS In addition to this most recent YBRS study on gay, lesbian, and bisexual students, other studies confirm that school can be a difficult environment for sexual minority students. The Gay, Lesbian & Straight Education Network (GLSEN) conducts a biennial school climate survey that illustrates the challenges that sexual minority students face in their school experiences. The 2008 National Climate Survey found nearly nine out of ten gay, lesbian, bisexual, and transgender (GLBT) students (86.2%) experienced harassment at school in the past year, three-fifths (60.8%) felt unsafe at school because of their sexual orientation, and about a third (32.7%) skipped a day of school in the past month due to feeling unsafe (Kosciw, Diaz, & Greytak, 2008). Note that this series of surveys conducted by GLSEN includes transgender students and the subsequent acronym change (GLBT). The 2013 National School Climate Survey, drawing on survey responses from almost 8,000 students across the nation, found that sexual-minority students who indicated high levels of victimization: • were more than three times as likely to have missed school in the past month than those who experienced lower levels of victimization (61.1% vs. 17.3%); • had lower grade point averages (GPAs) than students who were less often harassed (2.8 vs. 3.3); • were twice as likely to report that they did not plan to pursue any post-secondary education (e.g., college or trade school) than those who experienced lower levels (8.7% vs. 4.2%); and • had higher levels of depression and lower levels of self-esteem (Kosciw et al., 2014, p. 6). Details on psychological well-being and analysis can be found on p. 48 of the full report. The report suggests that responses to the 2013 survey showed some improvements to school climate over prior years, but continues to assert that “schools nationwide are hostile environments for a distressing number of GLBT students, the overwhelming majority of whom routinely hear anti-GLBT language and experience victimization and discrimination at school” (Kosciw et al., 2014, p. xvi). A 2015 study published in the New England Journal of Health found that over a five-year period, GLB youth were 91% more likely to be bullied and 46% more likely to be victimized than their heterosexual peers (Schuster et al., 2015). (Note: The GLSEN series of National School Climate surveys offer rich detail in their reporting of student experiences. The reports are available on their website: http://www.glsen.org.) The McClellan Institute at the University of Arizona looked at two studies exploring the longer-term impacts of bullying that happened in the lives of GLBT teens — effects lasting at least a decade beyond original victimization. (Note that this study included people who identify as transgender.) Young GLBT adults ages 21-25 were asked about their experiences of school bullying occurring between the ages of 13-19. Those who reported high levels of school victimization were almost three times as likely to report clinical levels of depression and almost six times as likely to report previously attempting suicide. Conversely, respondents reporting lower levels of school bullying reported higher levels of self-esteem, life satisfaction and social integration in their current lives (Muraco & Russell, 2011, p. 2). Improving school climate The National Center on Safe Supportive Learning Environments, funded by the U.S. Department of Education’s Office of Safe and Healthy Students, provides assistance to schools in improving learning conditions. School climate they define as the conditions that influence student learning, asserting that a “positive school climate is the product of a school’s attention to fostering safety; promoting a supportive academic, disciplinary, and physical environment; and encouraging and maintaining respectful, trusting, and caring relationships throughout the school community no matter the setting”(National Center on Safe Supportive Learning Environments [NCSSLE], n.d.). Further, they assert that positive school climate is tied to higher or improving attendance rates, test scores, promotion rates, and graduation rates. A negative school climate is linked to lower student achievement, graduation rates, and creates opportunities for violence, bullying, and even suicide (https://safesupportivelearning.ed.gov/school-climate). A group of researchers hoping to identify indicators of positive school climate beyond student self-reporting examined earlier YRBS data. They compared school attributes that included the presence of harassment policies which specifically named sexual orientation, staff training specific to GLB spaces, and Gay-Straight Alliance clubs and other safe spaces for GLB students, in addition to others. The researchers were able to show that GLB youths living in states and cities with more protective school climates were significantly less likely to report past-year suicidal thoughts than GLB youths living in states and cities with less protective school climates (Hatzenbuehler, Birkett, Van Wagenen, & Meyer, 2014). The Safe and Supportive Schools Model posits that a healthy school climate involves: • “Engagement. Strong relationships between students, teachers, families, and schools and strong connections between schools and the broader community. • Safety. Schools and school-related activities where students are safe from violence, bullying, harassment, and controlled-substance use. • Environment. Appropriate facilities, well-managed classrooms, available school-based health supports, and a clear, fair disciplinary policy” (NCSSLE, n.d.). PATHS FORWARD The following areas present opportunities for schools to create a more positive school environment for GLB students. Consistent with the YBRS recommendations (pp. 6-7), as well as other research and recommendations above, schools could make modest investments that could have important impacts for this student population. Training and development The 2013 GLSEN report indicated that 51.4% of students reported hearing homophobic remarks from their teachers or other school staff, and 55.5% of students reported hearing negative remarks about gender expression from teachers or other school staff (Kosciw et al., 2014). In a newer GLSEN Report on bullying and bias that included both youth and teachers, teachers indicated that they are not receiving sufficient support to address anti-GLBTQ bullying and harassment (Greytak, Kosciw, Villenas, & Giga, 2016). A third (33%) of teachers reported having professional development on GLBT issues and approximately a quarter (24%) reported having professional development on transgender issues. Teachers reported feeling least comfortable addressing bullying based on sexual orientation and gender identity/expression compared to other types of bias-based bullying (Greytak et al., 2016, pp. xv-xvi). A critical personnel skill is cultural competency or “the ability to interact effectively with people from a variety of backgrounds” (National Alliance to End Homelessness [NAEH], 2012). Teachers and staff should be provided opportunities to participate in cultural competency trainings that will promote understanding, empathy, and the ability to interact comfortably with sexual minority youth as well as understand gender expression. Anti-discrimination policies All of the studies referenced throughout this report recommend that every school have anti-discrimination policies in place that protect GLB, transgender, and gender non-conforming students. In the 2015 GLSEN survey, a majority (87.4%) of students indicated their school had a general anti-bullying policy. Among those who had a policy, only half (54.5%) reported their policy enumerated protections for sexual orientation and gender identity/expression (Greytak et al., 2016, p. xiv). Programs and outreach School programs that offer supportive outreach that are GLBTQ affirming could make a substantial impact on making sexual minority students feel welcomed and involved. All research cited in this translation has noted that GLB students who experience victimization and discrimination in school experience worse educational outcomes and poorer psychological well-being. Conversely, the GLSEN survey showed that students who feel safe and affirmed report better school experiences and academic success. Students who had access to GLBT-related school resources such as Gay-Straight Alliances (GSA) or similar student clubs report better school experiences and feel more connected to their school community (Greytak et al., 2016, p. xix). The LGBTQ Academy, a project of the Gay Alliance of the Genesee Valley (NY), recommends creating “SafeZone” spaces. SafeZones are defined as “confidential places where all people can bring their authentic selves and feel welcome, safe and included” (Gay Alliance, n.d.). This is a proactive step that can encourage and support LGBTQ individuals as well as provide a positive counterpoint to hostile school environments. Healthy sexuality education Healthy sexuality education involves much more than teaching about sex — it includes “approaching sexual interactions and relationships from a perspective that is consensual, respectful and informed” (NSVRC, 2012a). Healthy sexuality provides knowledge and empowers people to express sexuality in ways that enrich their life and by definition, excludes violence and coercion — a premise that would seem applicable to all students regardless of their sexual orientation. (Additional resources on healthy sexuality and sexual violence prevention can be found on the NSVRC website at http://www.nsvrc.org/saam/healthy-sexuality-resources.) Importantly, schools do not have to do this alone. There are community groups and advocacy organizations that exist in many local areas throughout the country who would welcome the opportunity to partner with school districts in their efforts to support students. Partnering with community organizations who can teach about healthy sexuality and HIV prevention, train on cultural competency to work effectively with sexual minority students, and provide education on anti-bullying and bystander intervention provides benefits for all students, not just those labeled sexual minority students. The high school years can be difficult, confusing, and exhilarating for all students as they learn to navigate multiple challenges. The additional burdens experienced by sexual minority students, shown through this YRBS report and other studies, should present a clear and urgent call to action for schools. Principal Source Kann L., Olsen, E. O., McManus, T., Harris, W. A., Shanklin, S. L., Flint, K. 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