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Health inequalities among sexual minority youth: a need for sexual orientation and gender expression sensitive school environment
  1. Hirut T Gebrekristos
  1. Correspondence to Professor Hirut T Gebrekristos, Department of Epidemiology, School of Public Health and Tropical Medicine Tulane University 1440 Canal street, New Orleans, LA 70112, USA; hgebrekr{at}

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Sexual minority youth bear a disproportionate burden of HIV, other sexually transmitted infections, depression, suicide, homelessness and substance abuse compared with heterosexual youth.1–5 The term, ‘sexual minority youth’, has been used in the literature to refer to bisexual, gay, lesbian, transgender, queer and questioning youth. Without dissolving the distinction and diversity among and within the various groups that make up sexual minority youth, it is also important to acknowledge some similarities that may promote the health inequalities. Discrimination, stigma, rejection and violence characterise the lives of sexual minority youth. This editorial will summarise the current state of interventions for sexual minority youth with a particular focus on school-based programmes. The discussion will also highlight the importance of political support in establishing sexual orientation and gender sensitive school environments and outline lessons learnt from existing programmes.

Adolescence is a challenging transition for all youth. However, sexual minority youth face additional obstacles from an often hostile social environment. The most current National School Climate Survey provides a glimpse into the hostile school context present in secondary schools in the USA.6 A sample of 7261 sexual minority youth ages 13–21 in the USA were included in a survey conducted in 2009. Approximately 85% and 64% of sexual minority youth reported being verbally harassed at school because of their sexual orientation and gender expression, respectively. Sexual minority youth reported being physically harassed at school in the past year because of their sexual orientation (49%) and gender expression (27%).6 The majority of students (62%) believed school staff would not be helpful and selected not to report their harassment experiences to school personnel.6 Approximately 40% of sexual minority youth reported that school staff were present, but did not intervene or challenge the other students when they experienced verbal and physical harassment.6 The hostile school context is not unique to the USA, but is common across the globe. Similar reports of hostile school environments for sexual minority youth have been presented for secondary schools in the UK.7

It is under these hostile social environments that sexual minority youth experience health and social inequalities. A hostile social context marked by homophobia, violence and discrimination remains a challenge for establishing sexual minority sensitive services, counselling and programmes in schools.8 The burden of a hostile school environment with restrictive sexuality and health education falls disproportionately on sexual minority youth.9 The absence of sexuality and health education for sexual minority youth results in misinformation about HIV risk behaviours.10

Early health and sexuality education in the school setting has been proposed to ameliorate these health inequalities. The school setting is generally the first point of entry and an opportunity that provides access to a large proportion of youth. In settings where education is only affordable for a smaller fraction of youth, community-based services and programmes are a good alternative. In a school-based intervention among gay, lesbian and bisexual (GLB) secondary school students in Massachusetts, Blake et al1 report gay-sensitive HIV instruction led to a statistically significant decrease in the number of sex partners when comparing GLB youth receiving gay-sensitive HIV instruction with those without gay-sensitive HIV instruction. The authors also report a statistically significant decrease in substance use before last sex act among GLB youth receiving gay-sensitive HIV instruction compared with those who were not receiving gay-sensitive HIV instruction.1 This study is one of few that evaluated a HIV risk reduction intervention among sexual minority youth.

A discussion of early health and sexuality education that may work to mitigate health and social inequalities among sexual minority youth cannot occur without noting that the root of the problem is structural, social and political. For example, the intervention study noted above by Blake et al1 is unlikely to have been possible without new recommendations made by the Governor of Massachusetts that called for a safe school environment for GLB youth. School environments that support the well-being of sexual minority youth cannot come to fruition without the support of national and local governments. Grassroots organisations and non-governmental organisations have been important for advocacy work that supports changing the hostile structural conditions impeding the well-being of sexual minority youth. In less supportive political environments, non-governmental organisations have also provided counselling and other supportive services to sexual minority youth.

We have learnt about aspects of school environment that promote a positive space for sexual minority youth.1 7 Developing policies and engaging all youth and staff in the schools' efforts to improve the hostile and homophobic environment is an important step. Along with sexual minority sensitive policies, staff training and integration of sexual orientation and gender expression education into curriculum provide additional support. It is also helpful for schools to conduct assessment of both staff and students prior to incorporating the strategies that will challenge the homophobic conditions. These baseline assessments will also serve the school well in evaluating the impact of their sexual minority sensitive initiatives.

In summary, sexual minority youth bear a disproportionate burden of sexually transmitted infections, mental health problems, homelessness and substance abuse compared with heterosexual youth. However, there are few sexuality education and risk reduction interventions that have been evaluated among sexual minority youth in the school settings. Evaluation studies must become a higher priority. The laudable goal of providing counselling and HIV prevention services in schools to sexual minority youth is complicated by hostile school environment. Changing this hostile environment is important for increasing the resources available to sexual minority youth in schools. National and local government policies and laws that support the well-being of sexual minority youth are critical to developing sexual orientation and gender expression sensitive school environments.


I thank Drs David Seal and Denese Shervington for their thoughtful comments on an earlier draft.



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  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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