The Journal of School Nursing2021, Vol. 37(3) 185-194© The Author(s) 2019Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840519863094journals.sagepub.com/home/jsn
Research on enacted stigma, or stigma- and bias-based victimization, including bullying and harassment, among lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth often focuses on one context (e.g., school) or one form (e.g., bullying or microaggressions), which limits our understanding of these experiences. We conducted qualitative go-along interviews with 66 LGBTQ adolescents (14–19 years) in urban, suburban, town, and rural locations in the United States and Canada identified through purposive and snowball sampling. Forty-six participants (70%) described at least one instance of enacted stigma. Three primary themes emerged: (1) enacted stigma occurred in many contexts; (2) enacted stigma restricted movement; and (3) second-hand accounts of enacted stigma shaped perceptions of safety. Efforts to improve well-being among LGBTQ youth must address the diverse forms and contexts of enacted stigma that youth experience, which limit freedom of movement and potential access to opportunities that encourage positive youth development. School nurses can play a critical role in reducing enacted stigma in schools and in collaboration with community partners.
enacted stigma, lesbian, gay, bisexual, transgender, and queer youth, safety, bias-based bullying, harassment, school nursing
A solid body of research documents the role of bullying, violence, and victimization as important contributors to disparities in health for lesbian, gay, bisexual, transgender, and queer (LGBTQ) people (Almeida, Johnson, Corliss, Molnar, & Azrael, 2009; Bontempo & D’Augelli, 2002; Burton, Marshal, Chisolm, Sucato, & Friedman, 2013; Corliss, Cochran, Mays, Greenland, & Seeman, 2009; Russell, Sinclair, Poteat, & Koenig, 2012). At the same time, increasing understanding of the detrimental effects of victimization that is specifically rooted in bias and stigma on the health of LGBTQ youth has made clear that understanding and preventing general bullying is not sufficient to improving health for LGBTQ youth (Flannery et al., 2016). In this article, we use the term “enacted stigma” as an umbrella term to refer to victimization such as bullying, harassment, aggression/violence, and microaggressions (e.g., short, frequent experiences of stigma that may be overt or covert; Balsam, Molina, Beadnell, Simoni, & Walters, 2011) that are rooted in bias based on sexual orientation and gender identity/expression (Meyer, 2003; Veale, Peter, Travers, & Saewyc, 2017). Researchers have investigated health disparities for LGBTQ youth by focusing on enacted stigma such as bullying, harassment, and discrimination as a mediator (e.g., Birkett, Newcomb, & Mustanski, 2015; Birkett, Russell, & Corliss, 2014), yet these literatures are often siloed (e.g., they investigate only one location/context such as school) or ask about general victimization without consideration of the location (e.g., Burton et al., 2013; Pilkington & D’Augelli, 1995). Taking a more holistic approach, we describe the ways and contexts in which LGBTQ youth experience enacted stigma in their daily environments.
Despite significant increases in acceptance of LGBTQ people, stigma-based victimization remains a serious social and public health concern in North America with implications for health and well-being across the life span (Eisenberg et al., 2018; Goodenow, Watson, Adjei, Homma, & Saewyc, 2016; Russell, Ryan, Toomey, Diaz, & Sanchez, 2011). Contemporary research shows that as rates of bullying have decreased for heterosexual youth, bullying among LGB youth, particularly girls, is generally decreasing at much slower rates, as is the disparity in bullying between LGB and heterosexual youth (Goodenow et al., 2016). Both LGBTQ youth and adults report elevated rates of stigma and victimization compared to heterosexual people (e.g., Bucchianeri, Gower, McMorris, & Eisenberg, 2016; Hatzenbuehler & Pachankis, 2016).
LGBTQ youth report higher rates of depression and suicidality (Eisenberg et al., 2017; Marshal et al., 2011; Peter et al., 2017), substance use (Corliss et al., 2014; Corliss, Rosario, Wypij, Fisher, & Austin, 2008; Marshal et al., 2008), disordered eating (Austin, Nelson, Birkett, Calzo, & Everett, 2013; Watson, Adjei, Saewyc, Homma, & Goodenow, 2016), and myriad other health problems, relative to their straight, cisgender peers. From the perspective of the minority stress model (Hendricks & Testa, 2012; Meyer, 2003), experiences of stigma and victimization underlie associations between sexual orientation, gender identity, and mental/physical health problems. Meyer suggests that both proximal (e.g., internalized homophobia) and distal (e.g., victimization based on sexual orientation) stressors lead to negative health outcomes. For LGBTQ young people in particular, distal stressors are typically experienced in the form of enacted stigma, such as prejudice and sexual orientation–, gender identity–, and gender expression (e.g., a person’s clothing, mannerisms, appearance)–specific victimization, that are rooted in homophobia and transphobia (Burton et al., 2013; Meyer, 2003). Research has demonstrated that these distal stressors severely impact the well-being of LGBTQ people. Among youth in particular, experiences of enacted stigma such as bias-based victimization consistently mediate associations between sexual orientation/gender identity and depression, suicidality, substance use, sexual risk behaviors, and academic performance (Birkett et al., 2014; Bontempo & D’Augelli, 2002; Burton et al., 2013; Corliss et al., 2009; Gower, Rider, McMorris, & Eisenberg, 2018; Hatzenbuehler, 2009; Mustanski, Andrews, & Puckett, 2016).
Although scholarship has proliferated recently pertaining to enacted stigma, most research focuses on individual contexts of victimization. Examining one context at a time, such as school-based victimization or general experiences of victimization without reference to context, has understandably been the starting point for research with LGBTQ youth for a variety of pragmatic reasons. For example, the Gay, Lesbian, and Straight Education Network has focused on the school environment by surveying hundreds of thousands of youth in schools to understand links between bullying, academic achievement, and safety at school for the past decade (Kosciw, Greytak, Zongrone, Clark, & Truong, 2018). Measures of sexual orientation–based stigma that do not specify a location for this victimization have also been used (e.g., Burton et al., 2013). This work has yielded important insights, but more research is needed to understand the larger picture of enacted stigma in multiple, specific contexts experienced by LGBTQ youth.
According to applications of minority stress model to LGBTQ people, the more frequently enacted stigma is experienced and/or in multiple contexts, the greater the likelihood of proximal stressors (e.g., social withdrawal, identity concealment, internalized homophobia), which in turn can lead to emotional distress (Meyer, 2003). For example, youth who experience enacted stigma in several of the contexts in which they typically interact (e.g., school, the community, a faith community) may be less likely to participate in traditional youth development activities that also occur in those contexts, such as extracurricular activities, community or school athletics, and faith-based youth groups. Emerging evidence makes it clear that enacted stigma transcends multiple, overlapping contexts for all youth, and especially LGBTQ youth, who face stigma in many communities across North America. Understanding the ways in which experiences of enacted stigma occur across contexts will allow for the development of more effective prevention programs and services for LGBTQ youth facing victimization. The current study used the minority stress model to examine the contexts of several types of enacted stigma including bullying, harassment, and violence. Using semistructured interviews with a diverse sample of LGBTQ youth, we were primarily interested in how these LGBTQ youth described experiences with harassment, bullying, and violence related to sexual orientation, gender identity, and gender expression across contexts.
Data for this secondary analysis come from the parent study, Research and Education on Supportive and Protective Environments for Queer Teens (Project RESPEQT; Eisenberg et al., 2018). In total, 66 LGBTQ youth in British Columbia (Canada), Massachusetts, and Minnesota (United States) between the ages of 14 and 19 (Mage = 16.6 years) were recruited using purposive and snowball sampling through LGBTQ youth-serving organizations and school gay–straight alliances. Youth lived in four types of locations (urban, suburban, small city, and rural) in the three sites and were from diverse racial/ethnic backgrounds. Approximately one-third of participants self-identified as cisgender male, one-third as cisgender female, and one-third as transgender or gender nonconforming/nonbinary; participants indicated a wide variety of sexual orientation labels. Forty-six youth (nearly 70%) discussed enacted stigma (e.g., bullying, violence, or harassment related to their sexual orientation, gender identity, or gender expression) during their interview and are included in the current analytic sample. These young people were demographically similar to the full study sample (see Table 1). All study protocols were approved by Institutional Review Boards at the University of British Columbia, the University of Minnesota, and San Diego State University (for participants in Massachusetts).
Full details on the go-along interview methods are provided elsewhere (Porta et al., 2017). In short, go-along interviews allow the interviewer and participant to move through the participant’s space while discussing relevant topics (Garcia, Eisenberg, Frerich, Lechner, & Lust, 2012). In this study, participants and interviewers traveled via car, bus, or on foot during the interview, and interviews lasted an average of 78 min (range: 35–110 min). Interviewers were graduate students from a variety of disciplines (e.g., public health, anthropology, social work) who were trained in go-along methodology by the last author (C.M.P.). The six questions in the interview guide focused on aspects of communities and schools that were supportive for LGBTQ youth or not, and follow-up probes were used as necessary. Although stigma and victimization were not asked about specifically, these experiences were brought up organically by most participants, typically during descriptions of why a place felt unsafe or uncomfortable. Youth received gift cards of USD$40 or CAD$50 to a major retailer for their participation; amounts varied by site due to differences in the currency exchange rate at the time of the interviews.
Interviews were audio recorded, transcribed, and uploaded to atlas.ti (Version 7.5, GmbH, Berlin) to facilitate coding and management of the data. Transcripts were first coded descriptively and deductively. Coders from the interview team described above from each of the three sites participated in codebook development and coding; each transcript was coded by one coder, with a quality check subsequently completed by a second coder. This coding process yielded three codes relevant to our secondary analysis: violence (perpetration or target of violence), harassment (pressure or intimidation, offensive remarks, can be sexual in nature, can come from anyone), and bullying (any reference to peerto-peer bullying including response, solutions, or anxiety about bullying). Quotes that did not apply to the interpersonal and stigma-based focus of this study (e.g., gang violence, general comments about bullying being wrong) were not included, resulting in 121 quotes for analysis.
For our further analysis of these quotes, a quasi-deductive coding process was used (Saldaña, 2009). In established bullying and harassment literature, there are three important descriptive aspects of bullying/harassment/violence: the type or form of victimization, the content or reason for the victimization, and the physical context of the victimization (Espelage & Swearer, 2003; Gower, Rider, et al., 2018). Four researchers independently coded 10% of the text, coding for the various aspects of type, content, and context as follows. Type was identified as verbal, physical, or relational (Espelage & Swearer, 2003); content was coded as sexual orientation, gender identity and expression, both or other; and context included school and community. After that review, one additional descriptive code was inductively added to the codebook, specifying whether the participant was describing a first-hand account of something that happened to them or whether the harassment was second-hand (experienced by a stranger or someone known; D’Augelli, Pilkington, & Hershberger, 2002). These codes (i.e., type, content, context, first- vs. second-hand) were then applied to all 121 quotes by one of two coders, and all coded data were reviewed by a second coder, with any questions clarified among the coders. Within each code, we organized the data across participants by common, recurring themes and subthemes, which are summarized below with representative quotes to illustrate key points.
Youth described a wide range of experiences with enacted stigma, with an average of 2.7 quotes per participant among those who discussed the topic (range = 1–9). For each quote reported in this article, we include the participant’s age, sexual orientation, and gender identity, as reported by youth to the interviewer. Table 2 provides an overview of themes discussed. Enacted stigma was experienced in a variety of contexts, and these experiences led youth to move to spaces they felt were safer, either by personal experience or through second-hand knowledge of experiences of friends or acquaintances.
Enacted stigma occurred in many contexts. Youth talked about experiences of enacted stigma in a variety of contexts, primarily focused on schools and in the community. Forms of victimization varied, with youth describing microaggressions (e.g., a stranger clarifying it was a women’s restroom for a participant who identifies as genderqueer), microinsults (e.g., witnessing anti-LGBTQ jokes or slang, misgendering), verbal harassment (e.g., name-calling, expressions of disapproval for sexual orientation or gender identity), and physical violence (e.g., getting beaten up or strangled or threats of violence). General reports of being teased or bullied were also common.
Many youth described enacted stigma in the school context, including all the types mentioned above, and often noted the role of being out to peers and the responses of school personnel. Several youth felt that coming out made them a target for enacted stigma. One student in a rural setting responded to a question about whether there was a supportive community at the school she previously attended:
Not really. They had a really big issue with bullying, too, so no one really felt okay or safe enough to act how they wanted to. We didn’t have any gay or LGBT couples. There are more in the high school, but there are only two or three. There aren’t a lot of kids who are out, here. They don’t feel safe enough. (16 years old, lesbian female)
On the other hand, some suburban students noted that coming out put an end to victimization by classmates, as shared by one youth, “The more they think you’re trying to hide it, the more you’re going to get bullied for it” (16 years old, bisexual female).
Responses of school administrators, teachers, and staff to enacted stigma were frequently discussed. Youth consistently indicated that teachers or school administration did not get involved when enacted stigma was reported to or even witnessed by teachers. While describing being strangled by another student in front of a teacher for no specific reason the youth was aware of, one youth noted, “If it’s in a situation where it’s choosing a straight person over a trans person, they’re going to choose the straight person, and they just won’t care, I guess.” (16-year-old straight trans). Some youth described several experiences in which school staff were not supportive; for example, one youth shared that a social worker said they could not hold hands with the person they were dating at school.
However, other school staff interfaced with students in potentially meaningful ways when enacted stigma happened. In particular, administrators, social workers, and counselors were mentioned as school personnel youth expected would be helpful in dealing with victimization. When teachers did intervene or were supportive, youth often mentioned these instances in the context of there also being teachers who did not. For example:
... At my school, each classroom had PFLAG stickers that said ‘this is an LGBTQ safe zone.’ I wholeheartedly believed it for some classrooms; others, not so much. I think it was something that they just put up to have up. Some teachers were very much into ‘you bully once, you get out of my classroom and you don’t come back,’ regardless if it’s because you’re gay, fat, don’t play sports, whatever. There were some teachers who just didn’t care, really, and were focused on teaching their lesson and not really caring what else was happening in the classroom. (18 years old, gay trans/gender fluid)
Mentioning these experiences together seemed to be used by youth as a way of highlighting the fact that school environments were not experienced as universally safe and positive.
Participants also reported enacted stigma in the community—often mentioning restaurants, coffee shops, malls, and while walking down the street—always from strangers. Community stigma typically involved microaggressions/microinsults including disapproving looks and comments that were not always openly hostile but somewhat ambiguous. One participant (14-year-old lesbian female), in describing an interaction with a mother and her children at the mall, gave this example of the reaction they received:
Participant (P):
Like, if they’re between the ages of, like, seven and ten, and they ask questions ... - like, “Mom, why is she holding hands with a girl?” And I know they’re just curious, but—
Interviewer:
And how does that make you feel?
P:
Singled out. ‘Cause you can tell by the parents’ faces they’re—you feel like you put them in an awkward position with their child.
In terms of experiences of overt enacted stigma, one youth described an encounter in a restaurant,
I was told that I wasn’t allowed to be there because I was making them uncomfortable, and unless I came back and I was with a guy that I couldn’t come back. I never went back. I ate there once and I liked their pie, but their pie wasn’t worth being harassed. The pie wasn’t that good. (19 years old, “other” sexual orientation, neutral gender)
Similarly, an urban participant mentioned that, while walking down the street with a girlfriend, “... people would just stare at us. I remember it was late at night, and somebody threw their McDonald’s pop at us because we were holding hands, and I was like, ‘That’s not okay’” (17 years old, queer female). In a few cases, youth shared that they thought public sentiment toward same-sex couples was getting better, “But now I look around and girls are hugging up on each other and kissing each other and boys are holding hands ... no one even batted an eye. It’s become a normal thing” (18 years old, bisexual male). Most did not express this sentiment.
Experiences of enacted stigma restricted movement. Participants who discussed first-hand experiences with enacted stigma mentioned adjusting their routines and restricting their movement (i.e., confining themselves to certain areas or refraining from activities) as a preventive measure to avoid being the targets of enacted stigma. One common practice involved youth selectively patronizing certain places they deemed safe while actively avoiding venues where youth had previously been bullied or harassed. For instance, when asked why he chose to frequent one particular location of a coffeehouse chain, a participant shared:
Every other one I’m still a little sketchy around. Either I’ve had people beating me up. I’ve had people chuck stuff at me, spit at me or I’ve had names called at me or I’ve had really bad customer service. This one I’ve always had really good customer service. No one’s bothered me. No one spat at me. No one’s done anything to me. The worst I’ve gotten is, ‘excuse me, are you a guy or a girl?’ And that’s the worst I’ve gotten. (18 years old, rainbow sexual, N/A gender identity)
When asked why this location was different, the youth noted that there were several LGBTQ employees, and for this reason, the youth continued to select this location over others.
Youth’s efforts to reduce vulnerability to enacted stigma also limited access to extracurricular and socialization opportunities. For example, one participant shared that “every summer I would do a show [play] here in elementary school, until I got to seventh grade when I was scared to be called faggot or queer or all that stuff, because I was punched once” (18 years old, gay male). Other participants limited their opportunities for socializing, such as one participant who explained that due to being called vulgar names and obscenities in the past, he shies away from going out.
Participants at each study site explained how experiences with blatant LGBTQ-related stigma prompted them to change schools or relocate to a different community. One youth recalled an experience of physical bullying that served as the impetus for their transition from public school to homeschool:
People always assumed I was gay, so they were also like, ‘oh, F.A.G., little kid. You dress like a boy but you aren’t a boy.’ They would say things. I think the last day of school was a Friday, and a girl threw a book at me from across the room and it hit me. I went home and I sat on my dad’s lap and I cried. I was like, ‘I don’t understand why everyone hates me!’ He was like, ‘well, me neither, which is why you’re not going back to school Monday.’ (18-year-old, lesbian, genderqueer)
Another youth recalled receiving a note from a peer threatening rape when classmates found out they were bisexual and shared that “My mom got so mad, she took me out of that school, because I was so far gone that she was afraid that I wasn’t going to come back and be me again” (19-year-old, “other” sexual orientation, neutral gender). According to the youth, changing communities or schools caused temporary and enduring personal challenges but was a beneficial adjustment overall. A participant who transitioned to homeschooling noted,
There’s still certainly backlashes with that that are still here today, like I’m not good at talking with people, for one. Talking with people scares the crap out of me. There are so many social things I lost ... But yeah, it [homeschooling] was definitely a good thing.
Another youth noted their new school had “a lot less” LGBTQ-related bullying than their previous school:
... no one teases anyone for stuff like that. It really isn’t an issue at the arts school because so many people are [LGBTQ]. I can look around my class and name off, like, five or six in each class. And that’s awesome. (16 years old, bisexual female)
Despite the difficult adjustment periods and challenges that accompanied changing schools or communities, these efforts did improve safety and reduce enacted stigma exposure for these youth. However, youth felt forced out of schools to new schools or homeschooling situations that were not their or their family’s first choice for education and often involved other trade-offs, such as longer commutes or a change in school format (e.g., from traditional school to alternative learning center).
While first-hand experiences with enacted stigma were important, participants also discussed second-hand stories of victimization. These narratives became a form of storytelling that shaped perceptions of safety and freedom of movement. Youth described accounts of enacted stigma that happened to friends, classmates, or acquaintances. One participant shared that a parent’s friend experienced bullying daily in high school as a way to describe the supportiveness (or lack thereof) of their community. Most youth described verbal harassment, such as general use of slurs about LGBTQ people that made youth feel “uneasy” and verbal harassment from peers at school, such as name-calling and mocking related to sexual orientation, gender identity, or gender presentation.
Youth also discussed second-hand stories of enacted stigma targeted to people they did not know, but they were concerned enough to talk about in the interview. For example, a 17-year-old gay male described a nearby neighborhood where queer people who live there are “terrorized and made fun of and mocked.” Others described physical violence including beatings and shootings. These extreme events, though rare, carried weight for the youth who did share, likely due to the severity.
Some youth commented that they had only occasionally witnessed harassment in the community, “ ... I have seen people—I haven’t seen it very much—but just not get treated really well. Nothing dangerous, but it might ruin their time, maybe. It would be a rare instance, though” (18 years old, homosexual male) or that “a lot of the gay hate has either gone down or gone into hiding” (18 years old, bisexual male). However, even while acknowledging progress, they mentioned witnessing multiple instances of enacted stigma, particularly microaggressions.
In fact, second-hand stories often indicated an underlying worry or hypervigilance about safety, as indicated by a participant who described not being the target of harassment themselves, but still feeling fear, “It’s just you see it advertised and you hear it happening, and you’re like, that could be me.” (17 years old, bisexual female) These stories often were used to describe places youth avoided going, including neighborhoods, areas of public transit, and organizations.
We sought to understand experiences of enacted stigma as described by LGBTQ youth, with an emphasis on the contexts in which these events occurred. Given the critical role of enacted stigma in contributing to health disparities among LGBTQ young people, a broader understanding of this type of victimization is informative for the development of effective prevention and intervention efforts that take into account young people’s holistic experiences. This article builds on previous literature by demonstrating the range of contexts in which youth report being the targets of enacted stigma, the ways these experiences limit movement and restrict engagement in typical adolescent activities, and the ways youth use information about others’ experiences to guide their actions.
Of particular note are the diverse contexts in which LGBTQ youth reported experiences of enacted stigma. While much is known about disparities in bullying victimization, particularly at school (Bucchianeri et al., 2016; Goodenow et al., 2016), victimization in the community is typically investigated broadly. With enacted stigma in contexts such as schools, restaurants, malls, streets, neighborhoods, and parks, youth demonstrated the wide variety of locations in which they experience harassment. These findings underscore the need for coordinated community action to provide safe schools and communities as well as programs aimed at prevention. This might include activities such as campaigns focused on improving social norms in the community that explicitly address sexual orientation–and gender identity/expression–based stigma. When prevention efforts are only located in schools, important community contexts in which LGBTQ youth are exposed to enacted stigma are neglected.
Furthermore, the experiences shared by youth echo and amplify calls for creating safe and supportive school environments. These efforts should include systems-level assessment, examining what practices and policies are currently in place and what changes are necessary. At the school level, professional development and school practice review aimed at supporting teachers and staff in recognizing enacted stigma, acting consistently and swiftly when they observe it, and providing support, particularly for targets of stigma, is warranted (Earnshaw et al., 2018; Goodenow, Szalacha, & Westheimer, 2006; Kosciw et al., 2018; Russell et al., 2011; Southern Poverty Law Center, 2017). While some youth noted that some teachers responded appropriately or recalled cases where conditions were getting better, on the whole, youth found much room for improvement in this area. Supportive school staff, in conjunction with whole school efforts to promote safe and supportive school climates, can reduce experiences of enacted stigma for LGBTQ youth in schools (Earnshaw et al., 2018; Gower, Forster, et al., 2018; Southern Poverty Law Center, 2017).
In multiple areas, including schools, after-school activities, and businesses, youth described choosing not to go somewhere because of their own or others’ experiences of enacted stigma in that location. This not only limited youth’s movements, but it also limited opportunities for positive youth development (PYD) activities. The PYD perspective views providing adolescents support, meaningful opportunities to engage, and key relationships with adults as a universal prevention strategy (Bernat & Resnick, 2006). This type of capacity building for all youth is intended to be protective, but it requires youth to feel safe enough to be present and participate. For LGBTQ youth to engage in these activities, efforts should be taken to ensure the spaces are safe/safer and supportive. LGBTQ youth-serving organizations in the locations in which we conducted these interviews are beginning to use the term “safer spaces” rather than “safe spaces” to acknowledge that although intensive efforts are made to ensure all people feel safe, no space can be guaranteed safe to all people. These safety improvement efforts should be clearly communicated to LGBTQ young people. Organizations wishing to support LGBTQ youth may need to describe new practices frequently in channels where youth will hear them (e.g., social media) in order to build trust and overcome second-hand stories of enacted stigma, which youth used in decision-making around whether activities were safe.
Findings from this investigation can be viewed in the context of the minority stress model (Hendricks & Testa, 2012; Meyer, 2003). Youth’s anticipation of enacted stigma such as rejection, harassment, and victimization, based on their own and/or others’ actual experiences, led to changes in their decisions or limited their participation in activities. For example, some youth moved from public schools to homeschooling or alternative schools after experiences of enacted stigma that were not properly addressed by school administrators. Homeschooling and some alternative schools may provide fewer PYD opportunities but improve feelings of safety. Others purposefully avoided social settings or group activities. Vigilance in settings where youth have heard of enacted stigma happening can also take a psychological toll on youth, with this defensive coping mechanism being associated with mental distress (Lick, Durso, & Johnson, 2013; Meyer, 2003; Mustanski et al., 2016). Future empirical research is needed to understand how experiences of enacted stigma in multiple contexts influence health and well-being for youth. Additionally, school- and organization-based research is needed to identify processes by which these environments can be improved to reduce enacted stigma. Once these spaces are deemed safer for LGBTQ youth, qualitative research may be useful to identify the best methods and channels to communicate to LGBTQ youth the improved safety of these spaces.
This study has some key strengths: (1) we accessed a diverse sample of LGBTQ youth in three locations in two countries to understand youth’s experiences with harassment; (2) the go-along method allowed for rich, contextual information on enacted stigma in the environments in which youth typically interact, rather than focusing specifically on the school context or harassment in general. Because youth and interviewers were moving around in spaces youth frequent, we were able to hear about enacted stigma in contexts where youth typically spend (or spent) time. We were thereby able to discern adaptive differentiation in the appraisal of the relative safety of different settings. In addition, (3) the diversity of perspectives on the research team strengthened qualitative analysis.
However, several limitations must also be noted. The interview guide did not specifically ask about or probe for experiences of enacted stigma; as a result, the quotes analyzed here were spontaneously given by youth, for whom these experiences may have been particularly salient. Given that interviews were focused on LGBTQ safe spaces, it is not surprising that the majority of participants discussed victimization based on sexual orientation, gender identity, or gender expression, but participants may have been less likely to share harassment experiences related to other topics. Youth who did not experience enacted stigma may also have been less likely to mention such events.
In light of these findings, researchers, developers of prevention programs, and those who work with youth should acknowledge and investigate the multiple contexts in which LGBTQ youth face enacted stigma in order to reduce it and mitigate risks. Youth not only experience the negative repercussions of being the targets of stigma, but they also miss out on opportunities for PYD activities that are important to the success and well-being of all youth. School nurses are uniquely poised to hear about enacted stigma, as students who are the targets of this stigma also report increased physical health, somatic problems, and visits to the school nurse (e.g., Reynolds, 2011; Rider, McMorris, Gower, Coleman, & Eisenberg, 2018). As a result, school-based efforts to reduce enacted stigma and improve school climate should include school nurses. Further, collaboration between schools, school nurses, and community efforts, such as anti-bullying campaigns that explicitly discuss bias-based bullying and harassment, would strengthen these efforts and address the multiple contexts in which LGBTQ youth experience enacted stigma. For those working with youth in schools, clinics, and community settings, evaluating the LGBTQ inclusiveness of all people working with youth (e.g., receptionist, cafeteria worker, security personnel) is critical to ensure that LGBTQ youth feel safe and supported in each setting, rather than just with certain individuals within those settings (e.g., youth worker, nurses). Furthermore, when efforts have been undertaken to improve in this area, communications through trusted sources might help youth overcome the legacy of secondhand accounts of enacted stigma and encourage them to reengage in that setting.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Amy L. Gower, Cheryl Ann B. Valdez, Marla E. Eisenberg, Christopher J. Mehus, Elizabeth M. Saewyc, Heather L. Corliss, Richard Sullivan, and Carolyn M. Porta contributed to the conceptualization of the manuscript. Data were analyzed and interpreted by Amy L. Gower, Cheryl Ann B. Valdez, Ryan J. Watson, Marla E. Eisenberg, Christopher J. Mehus, Elizabeth M. Saewyc, and Carolyn M. Porta. Amy L. Gower, Cheryl Ann B. Valdez, and Ryan J. Watson drafted the manuscript while the rest were involved in the critical revision of the manuscript. All authors gave final approval of the manuscript and agreed to be accountable for all aspects of work, ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number R01HD078470. Watson acknowledges support from the National Institutes of Drug Abuse Award Number K01DA047918.
Amy L. Gower, PhD https://orcid.org/0000-0001-9852-9196
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Amy L. Gower, PhD, is a research associate at the University of Minnesota.
Cheryl Ann B. Valdez, MPH, BSN, RN, was a graduate student at the time of the work, but she is now a public health nurse at the County of San Diego Health and Human Services Agency.
Ryan J. Watson is an assistant professor at the University of Connecticut.
Marla E. Eisenberg, ScD, MPH, is a professor at the University of Minnesota.
Christopher J. Mehus, PhD, is a research associate at the University of Minnesota.
Elizabeth M. Saewyc, PhD, RN, FSAHM, FCAHS, FAAN, is a professor at the University of British Columbia.
Heather L. Corliss, MPH, PhD, is a professor at San Diego State University.
Richard Sullivan, PhD, RSW, is an associate professor emeritus at the University of British Columbia.
Carolyn M. Porta, PhD, MPH, RN, FAAN, is a professor at the University of Minnesota.
1 Division of General Pediatrics and Adolescent Health, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
2 Graduate School of Public Health and Institute of Behavioral and Community Health, San Diego State University, San Diego, CA, USA
3 Department of Human Development and Family Sciences, University of Connecticut, Storrs, CT, USA
4 Stigma and Resilience Among Vulnerable Youth Centre, School of Nursing, University of British Columbia, Vancouver, BC, Canada
5 School of Nursing, University of Minnesota, Minneapolis, MN, USA
Corresponding Author:Amy L. Gower, PhD, Division of General Pediatrics and Adolescent Health, Department of Pediatrics, University of Minnesota, 717 Delaware St SE, Minneapolis, MN 55455, USA.Email: gowe0009@umn.edu
