Key points

Introduction

Bullying of lesbian, gay, bisexual, and transgender (LGBT) youth persists in the United States, with harmful and sometimes fatal consequences. Media reports about LGBT youth who have died by suicide frequently describe experiences of bullying victimization. For example, after being the target of bullying for several years, Adam Kizer died by suicide at age 16, 6 months after coming out as bisexual. Adam’s father reported that he was bullied starting at age 9, when his peers identified him as “different.” Adam suffered substantial mistreatment from his peers that was both verbal (eg, suggestions that he should kill himself) and physical (eg, tied to a tree, doused in gasoline, and almost set on fire). Another example is that of Taylor Alesana, a young transgender woman who experienced significant bullying victimization at school and online, and died by suicide at age 16. She described social isolation and rejection on Transgender Day of Remembrance, stating in a YouTube video: “Finding friends when you’re transgender, that to me is one of the hardest parts because you don’t find a lot of friends. And when you do, a lot of them will leave you just because you’re different.” The ridiculing comments on YouTube continued even after Taylor’s suicide.

Adam and Taylor’s experiences of bullying by peers are common among LGBT youth. Although extreme in their consequences, these examples underscore the need to address bullying of LGBT youth. Pediatricians can play an important role in preventing and reporting LGBT bullying, supporting LGBT youth who are bullied, and promoting the health and well-being of LGBT youth. In this article, we define key concepts relevant to LGBT bullying; discuss its prevalence in the United States; review evidence of its psychological, behavioral, and physical health consequences; and make recommendations for how pediatricians can address it.

Introduction

Bullying of lesbian, gay, bisexual, and transgender (LGBT) youth persists in the United States, with harmful and sometimes fatal consequences. Media reports about LGBT youth who have died by suicide frequently describe experiences of bullying victimization. For example, after being the target of bullying for several years, Adam Kizer died by suicide at age 16, 6 months after coming out as bisexual. Adam’s father reported that he was bullied starting at age 9, when his peers identified him as “different.” Adam suffered substantial mistreatment from his peers that was both verbal (eg, suggestions that he should kill himself) and physical (eg, tied to a tree, doused in gasoline, and almost set on fire). Another example is that of Taylor Alesana, a young transgender woman who experienced significant bullying victimization at school and online, and died by suicide at age 16. She described social isolation and rejection on Transgender Day of Remembrance, stating in a YouTube video: “Finding friends when you’re transgender, that to me is one of the hardest parts because you don’t find a lot of friends. And when you do, a lot of them will leave you just because you’re different.” The ridiculing comments on YouTube continued even after Taylor’s suicide.

Adam and Taylor’s experiences of bullying by peers are common among LGBT youth. Although extreme in their consequences, these examples underscore the need to address bullying of LGBT youth. Pediatricians can play an important role in preventing and reporting LGBT bullying, supporting LGBT youth who are bullied, and promoting the health and well-being of LGBT youth. In this article, we define key concepts relevant to LGBT bullying; discuss its prevalence in the United States; review evidence of its psychological, behavioral, and physical health consequences; and make recommendations for how pediatricians can address it.

Key concepts

Sexual orientation is a relational construct involving a pattern of romantic relationships with, or desires for, people of a particular gender. Sexual orientation is inclusive of behavior (eg, whether individuals are sexually engaged with same-gender and/or opposite-gender partners), identity (eg, how individuals understand and represent themselves based on identities such as “gay,” “lesbian,” “bisexual,” or “heterosexual”), and/or attraction or desire. The first 3 letters of the LGBT abbreviation (LGB; lesbian, gay, bisexual) refer to a range of sexual minority orientations that are not exclusively heterosexual. We include individuals who are “queer” or “questioning” under the LGBT umbrella.

Gender identity is one’s internal sense of being male, female, or outside these categories, and gender expression is the manifestation of culturally defined feminine or masculine traits in personality, appearance, and behavior. The last letter of the LGBT abbreviation (T; transgender) refers to a range of gender minority identities and expressions that are not aligned exclusively with one’s assigned sex at birth. Some LGBT people display a nonconforming gender expression during development; some do not. Children with a conforming gender expression may grow up to be LGB or heterosexual; they may be transgender or they may not. People have a sexual orientation, gender identity, and gender expression, and these are related in complex ways throughout youth development (for a discussion of the development of sexual orientation and gender, including their associations, see Stewart L. Adelson and colleagues’ article, “ Development and Mental Health of LGBT Youth in Pediatric Practice ,” in this issue).

Having perceived to have a minority sexual orientation, gender identity, and/or gender expression may increase youths’ risk of being bullying. Bullying is defined by the Centers for Disease Control and Prevention and US Department of Education as:

Bullying is any unwanted aggressive behavior(s) by another youth or group of youths who are not siblings or current dating partners that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated. Bullying may inflict harm or distress on the targeted youth including physical, psychological, or educational harm.

This definition emphasizes that bullying behavior is unwanted, meaning that the bullied youth wants the behavior to stop. It is aggressive, meaning that it involves the intentional use of harmful behavior. A power imbalance refers to a real or perceived ability of the perpetrator to control the target’s behaviors or outcomes. Power can be drawn from a variety of sources, such as physical strength, popularity, or wealth. Incidents are considered repeated if they occur multiple times or there is a concern that they are likely to recur. Moreover, bullying may result in harm involving negative experiences or injuries.

Mistreatment of LGBT youth is also referred to by other terms in the literature, including discrimination and bias. Although we use the term bullying in this article, we acknowledge that LGBT bullying is stigma-based and therefore fundamentally discriminatory in nature.

Scope of problem

Data from US national samples suggest that the majority of LGBT youth experience some form of bullying. In 2011, the Gay, Lesbian and Straight Education Network surveyed more than 8500 LGBT youth aged 13–20 years old in all 50 US states and Washington DC. All forms of bullying were prevalent among these youth ( Table 1 ). Most (92.3%) reported experiencing verbal bullying , involving harmful oral or written communication including taunting, name calling, and threats. Close to one-half (44.7%) reported physical bullying , including the use of physical force such as hitting, kicking, tripping, and spitting. About one-fifth (21.2%) reported more extreme physical assault, such as being punched, kicked, or injured with a weapon. Most (89.5%) reported social or relational bullying , involving behavior intended to harm reputations and relationships including spreading rumors, posting embarrassing media content, and socially isolating the target. Nearly one-half (47.7%) reported damage to property , such as stealing, damaging, or altering property. More than one-half of youth (55.2%) reported bullying via technology, or cyberbullying . Although youth attributed experiences of bullying to multiple socially devalued characteristics (eg, religion, race/ethnicity, disability), they attributed the majority of bullying to their sexual orientation or gender expression. Other data sources suggest similarly high prevalence estimates of bullying among LGBT youth.

LGBT youth generally experience more bullying than non-LGBT youth. In an online study of youth ages 13 to 18 years, LGB youth reported more than twice as much online and in-person peer victimization as heterosexual youth. Moreover, these different rates of bullying seem to begin before youth generally identify as LGB: youth who identify as LGB in 10th grade are more likely to have reported bullying than non-LGB youth when they were in 5th grade. Similar differences are documented for transgender youth: approximately 83% of transgender or gender nonconforming youth reported bullying victimization in the past year in comparison with 58% of cisgender (ie, nontransgender) youth in a recent study. Adolescent boys who are bullied because they are perceived to be gay owing to nonconforming gender expression (even if they do not identify as gay themselves) also experience more verbal and physical bullying than boys who are bullied for other reasons.

Although understudied, some work suggests variability in the prevalence of bullying among LGBT youth. For example, LGBT youth who have disclosed their sexual orientation or gender identity to their peers or school staff report greater bullying relative to youth who have not disclosed their LGBT status, although it is possible that LGBT youth who are bullied are more likely to disclose to adults and be discovered as being LGBT by peers. Youth who identify as bisexual also seem to report greater bullying. The prevalence of bullying also seems to vary by social context. LGBT youth report more bullying in states that do not have laws that prohibit bullying or harassment on the basis of sexual orientation or gender identity, and LGBT youth in the Midwest and South report more bullying than youth in the North and West. Moreover, LGB youth who live in neighborhoods with high rates of LGBT assault hate crimes are more likely to report relational and cyberbullying, possibly because violence toward LGBT adults in neighborhoods signals acceptance of LGBT bullying.

Causes and consequences of lesbian, gay, bisexual, and transgender bullying

Multiple factors contribute to youths’ engagement in bullying against LGBT individuals. At the societal level, LGBT stigma (social devaluation and discrediting of LGBT people) leads to discrimination and bullying of LGBT youth (see Mark L. Hatzenbuehler and John E. Pachankis’ article, “ Stigma and Minority Stress as Social Determinants of Health among LGBT Youth: Research Evidence and Clinical Implications ,” in this issue). At the social level, youth socialize and influence LGBT bullying within their peer groups. Certain norms within peer groups contribute to greater LGBT bullying, including traditional masculinity norms, dominance norms, and overall aggression levels. Having fewer LGBT friends is associated with greater engagement in LGBT bullying. At the individual level, a prominent contributing factor is prejudice, or negative attitudes toward others based on their minority sexual orientation and/or gender identity and expression that are rooted in LGBT stigma. Greater engagement in LGBT bullying is also associated with holding stronger attitudes in support of social dominance, hierarchies, and power differentials among peers as well as at a broader societal level against socially devalued groups (eg, racial minorities, women). Heterosexual youth who place greater importance on their heterosexual identity as part of their overall sense of identity and those who are less empathic tend to perpetrate more LGBT bullying. Boys tend to engage in LGBT bullying more than girls. Also, youth who engage in bullying in general are more likely to perpetrate LGBT bullying specifically.

LGBT bullying undermines the mental, behavioral, and physical health of youth, ultimately leading to health inequities for LGBT compared with non-LGBT youth that may last across the lifespan. As highlighted in the introduction, suicidal ideation and suicide attempts and completion are a concern for youth experiencing LGBT bullying. Sexual minority youth are more likely to think about and attempt suicide than non-LGBT youth, and bullying plays a role in these thoughts and behaviors. Other mental health effects of LGBT bullying include greater symptoms of depression and anxiety, and lower self-esteem. Longitudinal evidence among youth in general suggests that bullying is associated with worse mental health outcomes over time, with past experiences of bullying predicting worse psychosocial quality of life, more depression symptoms, and worse self-worth. Some evidence suggests that youth who disclose their sexual orientation or gender identity to school peers and staff report greater psychological well-being than those youth who do not, despite experiencing greater bullying. It is possible that youth who choose to disclose a sexual or gender minority status at school gain resilience resources, such as social support, after disclosing. More research is needed to understand associations among disclosure, bullying, and well-being, including the ways in which resilience resources and supportive environments affect these associations.

Bullying plays a role in harmful health behaviors among LGBT youth. LGBT bullying is associated with greater engagement in substance use, including tobacco, alcohol, marijuana, and other illicit drugs (eg, methamphetamines, inhalants). It is also associated with engagement in risk behaviors related to substance use, such as drunk driving. Although the topic is understudied, LGBT youth who are bullied may engage in high levels of sexual risk behaviors (eg, condomless sex, substance use before sex, transactional sex), similar to LGBT adults. Also of concern, LGBT middle and high school students who experience greater bullying have higher rates of school absenteeism (often related to fears of being bullied at school), lower grade point averages, and lower postgraduation educational aspirations.

Bullying further affects the physical health of LGBT youth. LGBT youth who are physically bullied may suffer cuts, bruises, broken bones, and other direct health sequelae of physical violence. Other physical health outcomes are understudied among LGBT youth specifically, but a robust body of research describes outcomes of bullying among youth in general. Youth who experience bullying are more likely to experience a range of physical health symptoms, including increased abdominal pain, headache, poor appetite, sleeping problems, and skin problems, as well as greater body mass index, higher systolic and diastolic blood pressures, and decreased self-rated health, relative to youth who are not bullied. These health outcomes seem to be driven, in part, by the mental and behavioral health consequences of bullying. That is, similar to the ways in which discrimination affects health among adults, depression, anxiety, and other poor mental health effects of bullying may lead to worse physical health. Additionally, youth may engage in harmful coping behaviors (eg, substance use to manage anxiety), which ultimately undermine physical health.

The consequences of bullying among LGBT youth seem to be worse than the consequences among non-LGBT youth. Youth who experience LGBT-based bullying engage in greater substance use and other risk behaviors (eg, drunk driving), and experience higher rates of depression than youth who experience bullying that is not bias-based. Similarly, adolescent boys who are bullied because they are perceived to be gay experience greater anxiety and depressive symptoms than boys bullied for other reasons.

Although rates of bullying among LGBT youth seem to decrease with age, the mental, behavioral, and physical health consequences of bullying may last into adulthood. LGBT young adults who self-report frequent bullying as adolescents are more likely to be depressed, have had a suicide attempt, engage in sexual risk behaviors including condomless sex, and be diagnosed with a sexually transmitted infection. Similarly, adults who experienced bullying associated with having a nonconforming gender expression as youth report greater depressive symptoms and lower life satisfaction as young adults. LGBT adults who experienced greater bullying as youth are more likely to report posttraumatic stress disorder.