Implications of Restrictive Legislation: Bullying and the Health of Sexually and Gender Diverse Youth

Since starting high school, Gary has been experiencing stress surrounding gender expression. Gary has always been considered “girly” by peers, wearing longer hair and traditionally feminine clothing. Now as a sophomore, Gary has been called names and assaulted by some of the boys at school who criticize Gary’s appearance and mannerisms. Having grown distant from friends and fearing a poor response from religious parents, Gary decides to confide in the homeroom teacher. “Mr. S, I’d like to start using she/her pronouns,” Gary starts to explain. Mr. S cuts the conversation short, apologizing that he needs to leave for a meeting. Later that evening, Gary’s parents angrily confront her, having received a call from Mr. S concerning their earlier conversation. Gary feels her world falling apart.This scenario communicates a reality that many sexually and gender diverse youth (SGDY), meaning youth who are not straight or cisgender, contend with. The experiences of concealing and disclosing one’s identity can be traumatic and have been linked to higher levels of depression and suicidal ideation.1 Gary faced relentless bullying, and her gender identity was revealed to her parents by a trusted mentor against her wishes, adding trauma to an already stressful circumstance. Here, we examine how recent restrictive legislation pertaining to student education defines the role of educators and how it may exacerbate bullying, and thus, mental health burdens for students like Gary. We propose several recommendations to protect SGDY against such harm.Previous research has consistently communicated an increased risk of psychopathology in SGDY.2,3 Among other factors, bullying is likely a significant mediator, presenting a persistent danger to physical and mental wellbeing that sexually and gender diverse students are particularly susceptible to.4 Students who experience bullying are more likely to report depressive and anxiety-related symptoms, decreased resilience, and suicidal ideation.5,6 Moreover, bullying based on discriminatory biases, such as homophobia and transphobia, is more strongly associated with health problems than general harassment.7 Many SGDY endure these struggles with little support. One recent Massachusetts study found that even after sexually and gender diverse students recounted several instances of bullying, school health professionals were largely unaware of these occurrences. Additionally, students approaching school health professionals for help believed that these interactions were dismissive and ineffectual.8 Calling attention to and promoting preventive action against these negative health sequelae for SGDY must become critical objectives within pediatrics and adolescent health.Despite the 2015 landmark decision by the Supreme Court in Obergefell v. Hodges upholding marriage equality, recent years have seen a significant rise in legislation against sexually and gender diverse people. These bills, currently numbering >520 nationally, can be grouped into 3 main categories, each potentiating bullying for SGDY in different ways.9,10 First are the laws that severely censor sex education curricular content and restrict the age at which these courses may begin. For instance, Florida’s SB1069 bans any instruction on sexual orientation and gender identity (SOGI) through the eighth grade. Furthermore, it mandates that all sex education curricula be taught in the context of female and male roles and that it be made clear that “these reproductive roles are binary, stable, and unchangeable.”11 This language, apart from conveying a false narrative that does not account for the science of human SOGI, also invalidates emerging sexually and gender diverse identities during a critical developmental period.12 Restrictions on learning about SOGI may contribute to feelings of fear and shame for SGDY.13 Failing to acknowledge the presence of identities other than the straight cisgender archetype lays a groundwork for further stigmatization. It may prove difficult for children to apply concepts that have been withheld from them, or for them to readily accept identities that never appear throughout their education.Second are the pieces of legislation that recruit school staff in performing harmful practices against sexually and gender diverse students. Indiana’s HB1608 requires school staff to divulge to parents if their students communicate an affirming name or pronouns. Revealing another person’s SOGI against their wishes is widely recognized by community advocates as detrimental.14 Rejection by family members after identity disclosure has been linked to long-term negative health outcomes, including higher rates of illicit drug use, depression, and suicide.15 Support from teachers and other school staff represents a critical protective factor in mitigating bullying of SGDY.16 Because of these laws, however, SGDY may elect to not seek out this support in instances of bullying because of fear of having their SOGI revealed against their will.8 Ostracism by peers, persecution by bullies, or rejection by family represent consistent stressors for many SGDY and important factors in deciding whether to publicly disclose one’s SOGI.A last set of laws either bans the use of students’ affirming names or pronouns by school staff or prevents “adverse employment action” against school staff who willfully refuse to use a student’s correct name or pronouns. These include Arkansas’s HB1468 and Florida’s HB1069. Teachers and other school staff are role models for students and have been shown to be a key mediating variable in reducing bullying behaviors.17 If teachers were to model practices such as intentional misgendering, it is probable that many students may mirror those actions. At a stage when affirmation of one’s identity is paramount to healthy psychological development, there is instead a legal coercion to produce an environment where students fear exploring their true selves for risk of persecution.We conclude with several recommendations for pediatricians. With so many barriers to sex education in place, it is imperative that pediatricians take a more proactive role in advocating for youth education. Some states, such as Kentucky and Florida, have afforded broad powers to parents in reviewing sex education curricula and the educational materials students may access. Pediatricians are uniquely positioned to encourage active parent participation in their children’s education. This participation may include advocacy to school boards for open and comprehensive sex education, benefitting all students within school systems. Increasing education can reduce instances of bullying and subsequent negative sequelae. Finally, pediatricians should consistently remind parents that validating a child’s identity can inoculate against many health risks among SGDY.1,18 Supporting open discussion of SOGI, and underscoring the critical importance of unconditional acceptance, should become systematic and routine.Pediatricians should continue to recognize that the role of the physician is ever-evolving. Though medical school curricula have increasingly integrated content on inclusive care, many physicians are often unfamiliar with these practices.19,20 It is crucial for clinicians to be well-versed in inclusive care to act as trusted confidantes for SGDY, emphasizing that any information discussed is protected under clinician–patient confidentiality. Pediatricians should also anticipate patients seeking resources and suggestions in the context of experiencing bullying. Having a well-researched list of recommendations facilitates this process. For example, current laws permit sponsoring clubs such as gender and sexuality alliances, which have been associated with decreased rates of bullying.21 These organizations provide a safe space for SGDY who have few other places to turn to. Pediatricians should be familiar with such resources and confident exploring these. Critically, any researched recommendations should be specific to the state in which a pediatrician practices. Some states have passed antibullying laws, associated with reduced bullying victimization and decreased suicide rates, whereas others have explicitly banned adding protections for SGDY and antibullying policies.22,23 Last, SGDY often report being unsupported in school amid peer bullying and harassment.24,25 Pediatricians should continue to fill this void as able and to educate all of their patients on the importance of antibullying options.Altogether, these recommendations are necessary to preserve the wellbeing of SGDY and must be implemented expeditiously. Though this article discussed the relationship between bullying and legislation directly affecting school curricula and educator roles, it did not examine many other restrictive laws that may similarly exacerbate bullying.10 Some examples include recent bans on transgender student participation in sports and on gender-affirming health care. The health consequences of these policies represent essential areas of future research.