Supportive model for the improvement of mental health and prevention of suicide among LGBTQ+ youth

ABSTRACT Lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) youth experience a myriad of mental health disparities as well as a heightened risk of suicide compared to their non-LGBTQ+ counterparts. They are also more likely to experience a multitude of stressful experiences such as bullying, discrimination, rejection from family, prejudice, and even violence from peers, all of which contribute to suicidal proclivities. Therefore, it is important to comprehend triggers of the disparities faced by LGBTQ+ youth in mental health, hazardous sexual behaviours, and substance use and determine ways of solving them via a calibrated approach combining prevention strategies, appropriate policies, and community programs. In particular, this review focuses on actionable steps that can be taken within schools, families, communities, and healthcare settings, to bolster protective factors supporting LGBTQ+ youth in coping with these challenges. It particularly envisions prevention strategies and interventions that focus on creating spaces for LGBTQ+ youth, increasing a sense of support and acceptance within schools, families, and healthcare settings, and reducing experiences of victimization and stigmatization on the basis of gender identity and sexual orientation.


Introduction
The U.S. Census Bureau's Annual Estimates of the Resident Population 2017 population estimates the number of youth ages 13-18 to be 25,216,710 (U.S. Census Bureau, 2018). Based on the data from the Youth Risk Behaviour Surveillance (YRBS) Survey conducted in 2017, the Trevor Project estimated that 10.5% of youth aged 13-18 identified as LGBTQ+ (Green et al., 2019). From the data collected by the National Survey of Family and Growth (NSFG) from 10,416 women and men aged 15-44 in the United States, the Trevor Project observed that 9.6% of young individuals aged 18-24 were part of the LGBTQ+ community (Copen et al., 2016;Green et al., 2019). In addition, a 2017 Gallup Daily tracking survey found that 11.3% of youth aged 18-24 considered themselves LGBTQ+ (Green et al., 2019). These studies demonstrate that LGBTQ+ youth comprise a sizable portion of the young population. According to extant studies, unlike their cisgender-heterosexual counterparts, LGBTQ+ youth have a higher likelihood of facing challenges related to mental health, including suicidality, anxiety, depression, substance/alcohol abuse, social ostracization, and school avoidance (Williams et al., 2019).
While suicide is the second biggest cause of death among youth in general, LGBTQ+ youth are four times more likely to contemplate suicide compared to their non-LGBTQ+ counterparts (Hedegaard et al., November, 2018;Kann et al., 2018). According to the YRBS, about 1.2 million LGBTQ youth aged 13-18 living in the United States seriously contemplate suicide every year. This figure stands at 693,000 for LGBTQ individuals in the US who fall in the 19-24 age group (Baams et al., 2015;Green et al., 2019). LGBTQ+ youth are able to attain their full potential when they are respected, accepted, supported, and accorded a sense of value within their learning institutions and communities (National Association of School Psychologists, 2017). To attain this objective, it is important to focus advocacy and education on promulgating positive social and academic development for these youth while eradicating biases and discrimination on the basis of gender and sexuality. This study particularly envisions community support from schools, families, policy makers, and peers as potential protective factors that can offer support to LGBTQ+ youth coping with these challenges. Although previous studies have examined individual risk factors of LGBTQ+ youth suicide and mental health disparities (Di Giacomo et al., 2018;Gnan et al., 2019;Greydanus, 2017;Lucassen et al., 2018;Miranda-Mendizábal et al., 2017;Ream, 2019;Zimlich, 2019), no analyses have been conducted to integrate all potential risk factors and deliver recommendations to improve mental health and prevent suicide among LGBTQ+ youth. These recommendations involve a variety of stakeholders and policymakers, ranging from school personnel, families, and healthcare professionals.

Mental Health Disorders
There is compelling evidence that LGBTQ+ youth are at a higher risk of suffering mental illnesses, including post-traumatic stress disorders, depression, and anxiety, largely owing to homophobia, heterosexism, transphobia, and biphobia (J. E. Grant et al., 2014;Hatchel et al., 2019). In addition, weakened mental health has been identified as a forecaster for several behavioural health disparities observed among LGBTQ+ youth (Burk et al., 2018;Schulman & Erickson-Schroth, 2019). The Trevor Project's 2021 National Survey on LGBTQ Youth Mental Health, which consists of 34,759 LGBTQ youth between the ages of 13-24 residing in the United States found that 72% of LGBTQ youth reported symptoms of generalized anxiety disorder and 62% of LGBTQ youth reported symptoms of major depressive disorder in the past two weeks (Trevor Project, 2021). Several studies have also observed that there is a strong link between mental health disorders and attempts to die by suicide among LGB adolescents (Gnan et al., 2019;Lucassen et al., 2018;Miranda-Mendizábal et al., 2017). Furthermore, a meta-analysis of 25 studies involving nearly 12,000 LGB individuals observed that sexual minority youth are 1.5 times more likely to experience anxiety and depression and 2.5 times more likely to have attempted suicide than their heterosexual peers (Lucassen et al., 2018). In fact, many U.S. and international studies (Asia, Australia, Europe, North America, and South America) have consistently indicated that LGBT youth experience higher rates of suicidal ideation, emotional distress, anxiety/mood disorders, and other related symptoms compared to their non-LGBT counterparts (Feinstein et al., 2019;Mathy, 2002;King et al., 2008;McDonald, 2018).

Suicide
In addition to higher rates of mental illnesses, LGBTQ+ youth also report higher rates of suicidality (O'Brien et al., 2016;Ream, 2019). A new report indicates that LGBTQ youth are three times likelier to attempt suicide compared to other teenagers (Zimlich, 2019). The Trevor Project estimated that more than 1.8 million LGBTQ youth ages 13-24 in the U.S. have seriously considered suicide in the past year (Green et al., 2019). The Trevor Project's 2021 National Survey on LGBTQ Youth Mental Health with a sample size of 34,759 LGBTQ youth between the ages of 13-24 residing in the United States found that 42% of LGBTQ youth seriously considered attempting suicide in the past year (Trevor Project). Both ideation and actual rates of suicide are exceedingly high among the LGBTQ+ youth. This disparity is echoed in other studies as well. For example, di Giacomo et al. undertook a review of 35 studies that involved two million heterosexual youth and 113,468 sexual minority youth aged 12-20 (2018). The results revealed that sexual minority youth demonstrated a heightened risk of life-threatening behaviour (Di Giacomo et al., 2018). Other research similarly found that sexual minority youth were 3.5 times more likely to have had a suicide attempt compared to their heterosexual counterparts (Zimlich, 2019). Another study comprising 137 bisexual and gay males aged 14-21 also observed that almost 50% of this group had attempted suicide multiple times (Greydanus, 2017). This disturbing trend underscores the need to develop LGBTQ+-specific interventions for preventing suicide.

Risk Factors
Some of the most prominent risk factors that trigger depression include victimization, oppression related to sexual orientation, psychological distress caused by stigma and prejudice, rejection from parents and family, inability to cope socially, unpleasant interpersonal interactions, bullying at school, suicidality, homelessness, and violence within the community, among others (Gower et al., 2018;Hall, 2018). This conundrum is exacerbated by the fact that many peers and teachers are often not willing to extend their support to LGBTQ+ youth due to feelings of insecurity or fear (Page, 2017). In addition to hostile school environments, LGBTQ+ youth are frequently exposed to rejection at home due to the homophobic and transphobic attitudes of their families (Aranmolate et al., 2017;Toomey & Russell, 2016). Negative perceptions about LGBTQ+ individuals, coupled with gender bias, results in rejection from families, leading to a sense of isolation and a lack of access to support systems (Gibbs & Goldbach, 2015;Rodgers, 2017;Willging et al., 2016). As a result, this contributes to increased stress levels, substance abuse, and depression, which translates into an increased suicide risk among LGBTQ+ youth (Aranmolate et al., 2017;Kosciw et al., 2014). In the wake of such alarming realities, it is important to gain a better understanding of the drivers of such disparities, so they are able to formulate feasible strategies to counteract them and improve prospects for this community.

Victimization and Bullying
Victimization and discrimination based on sexual orientation and gender identity is common among LGBTQ + populations (Brandelli Costa et al., 2017;Williams et al., 2019). As per the Trevor Project's 2021 National Survey on LGBTQ Youth Mental Health with a sample size of 34,759 LGBTQ youth between the ages of 13-24 residing in the United States, 75% of LGBTQ youth had experienced discrimination based on their sexual orientation or gender identity at least once in their lifetime (Trevor Project). Bullying of LGBTQ+ youth is a widespread phenomenon within educational institutions, manifesting itself through verbal and physical harassment, which harms the mental health of these students (Day et al., 2018;Earnshaw et al., 2016). According to findings from the 2019 National School Climate Survey consists of 16,713 students between the ages of 13 and 21 from all over U.S., 68.7% of LGBTQ students had experienced verbal harassment and 25.7% of LGBTQ students had experienced physical harassment in school over the past 12 months (Baams et al., 2015;Kosciw et al., 2020). Such victimization can easily lead to, among others, sleep challenges, posttraumatic stress disorder, somatization, depression, nightmares, suicide attempts, property damage, and illegal consumption of drugs (Taylor, 2019). In addition, victimization related to bullying is linked to truancy, reduced educational aspirations, and poor academic performance (Aragon et al., 2014;Birkett et al., 2014). Not surprisingly, LGBTQ+ youth who are subjected to bullying feel unsafe at school, which, in turn, affects their ability to enjoy learning and maximize their educational outcomes and experiences (Greydanus, 2017). LGBTQ+ adolescents suffering from prolonged and intense levels of victimization are reported to make more attempts to die by suicide compared to their heterosexual counterparts exposed to the same victimization levels because of the unique nature of their stressors (Taliaferro & Muehlenkamp, 2017;Taylor, 2019;Williams et al., 2019). National estimates show that LGBTQ+ individuals who have experienced bullying or harassment are 5-6 times more likely to attempt suicide compared to LGBTQ+ youth who have not experienced victimization (Gower et al., 2018;Marshall, 2016). Therefore, it is safe to conclude that lowering the victimization of LGBTQ+ youth is likely to yield long-term gains in their physical and mental health and reduce existing disparities.

Identity/Sexuality Issues
Disclosing one's sexual orientation is linked to many health benefits such as better relationships, lower stress levels, and improved well-being (Charbonnier et al., 2018), while the compulsion to conceal one's sexual orientation and/or gender identity can cause immense damage to psychological health (Frost et al., 2015). According to the Gay, Lesbian, and Straight Education Network (GLSEN) survey conducted in 2019 consisted of a total of 16,713 LGBTQ students between the ages of 13 and 21 from all 50 states, 68.7% the surveyed sexual minority youth reported verbal harassment based on sexual orientation, 56.9% based on gender expression, and 53.7% based on gender (Kosciw et al., 2020). As a result, nearly 59.1% of LGBTQ students felt unsafe at school because of their sexual orientation, 42.5% because of their gender expression, and 37.4% because of their gender (Kosciw et al., 2020). Fear of disclosure is also prevalent within other contexts. This was revealed in another survey of approximately 28,000 transgender people conducted by the National Center for Transgender Equality in 2015, which found that close to 33% of respondents felt disrespected by their healthcare providers due to their identity and 23% of respondents did not seek care they needed because they feared facing hostility and rejection in the year preceding the survey (James et al., 2016). Overall, there is clear evidence suggesting that disclosure of one's identity is a stressful experience that exacerbates the risk for mental health challenges and suicidality among LGBTQ+ youth.

Psychological Distress
Psychological distress is a state of an unpleasant emotional experience of a psychological (cognitive, behavioural, emotional) and emotional suffering that may interfere with the ability to cope with in daily life (Arvidsdotter et al., 2016;Holland & Gooen-Piels, 2003). LGBTQ+ youth also experience high rates of psychological distress (Gower et al., 2018). When dealing with stressors such as victimization, perceived discrimination, or even family rejection, LGBTQ+ youth are likely to develop harmful coping strategies that further intensify their psychological distress (Russell & Fish, 2016;Taylor, 2019). Stigmatization, rejection, and victimization in particular have been identified as some of the common stressors that lead to higher psychological distress among LGBTQ+ youth (Puckett et al., 2017). Existing evidence shows that LGBTQ+ individuals experience greater risk associated with various types of psychological distress than do their cisgender-heterosexual counterparts (Hackimer & Proctor, 2015;Mustanski et al., 2016).

Stigma
Stigma can be defined as marginalizing, labelling, and stereotyping a particular social group, and it plays an important role in triggering the health disparities that LGBTQ+ individuals face (Bucchianeri et al., 2016;Hadland et al., 2016). LGBTQ+ youth experience far more stigma than their non-LGBTQ+ counterparts as a result of their marginalized identity (Bucchianeri et al., 2016). For such youth, stigmatization on the grounds of gender identity, gender expression, or sexual orientation is a significant source of stress rooted in societal homophobia and transphobia (Gower et al., 2021). Stigma is recognized as a primary cause of mental and physical health disparities and is one of the most frequently discussed risk factors in elucidating mental health inequalities (Hatzenbuehler, 2017). Stigmatization, such as family rejection, exposes LGBTQ+ youth to the risk of negative mental health outcomes that lead to morbidity and mortality among this community (Adelson et al., 2019).

Healthcare Disparities
LGBTQ+ youth experience inequalities in accessing healthcare services compared to their cisgenderheterosexual counterparts (E. Eisenberg et al., 2017;McCann & Brown, 2018). Healthcare disparities for LGBTQ+ youth also manifest as low utilization of services (Macapaga et al., 2016). As per the Trevor Project's 2021 National Survey on LGBTQ Youth Mental Health with a sample size of 34,759 LGBTQ youth between the ages of 13-24 residing in the United States, 48% of LGBTQ youth reported they wanted counselling from a mental health professional but were unable to receive it in the past year (Trevor Project). LGBTQ+ youth experience trouble sharing their sexual orientation or gender identity with clinicians, who are generally inept at understanding the experiences and challenges of this community (Hafeez et al., 2017). For example, according to a Washington-based study of paediatricians and adolescent medicine specialists, 68% of sexual minority youth avoided revealing their sexual orientation, while 90% said that they were reluctant to share their identities with clinicians (Hafeez et al., 2017). In addition, various studies indicate that sexual minorities are more dissatisfied with the quality of mental health services offered to them (17.6%) than their heterosexual counterparts (8%), and this is attributed to discrimination within these settings (Avery et al., 2001;Zeeman et al., 2019). Moreover, transgender individuals also face their own unique struggles. A study involving 6,540 transgender participants from all over the U.S. demonstrated that 28% of these individuals reported experiencing verbal harassment from their practitioners, while 19% reported that they had been denied healthcare altogether because of their identity (J. M. Grant et al., 2011). In addition, transgender youth also experience various challenges when it comes to gaining access to proper hormone therapies (Nahata et al., 2017).

Family Rejection
Family is one of the strongest socioecological support systems that shape the health of an individual (Hall, 2018). As per the Trevor Project's 2021 National Survey on LGBTQ Youth Mental Health with a sample size of 34,759 LGBTQ youth between the ages of 13-24 residing in the United States, only 1 in 3 LGBTQ youth found their home to be LGBTQ-affirming (Trevor Project). LGBTQ+ youth often experience rejection from family after coming out, and this is strongly linked to negative mental and physical health outcomes (Doyle, 2018;Hall, 2018;Russell & Fish, 2016). Therefore, rejection from the family is linked to sexual risk, substance abuse, depression, and suicidal tendencies (Newcomb et al., 2019;Puckett et al., 2017). A study assessing 224 LGB young individuals found a significant relation between high levels of family rejection and poor health outcomes (Ryan et al., 2009). LGBTQ+ youth who faced high parental rejection were found to be almost 8.5 times likelier to attempt suicide, 6 times likelier to experience heightened depression levels, and 3.5 times likelier to engage in risky sexual behaviours or illegal drugs compared to their peers who were facing lower parental rejection (Ryan et al., 2009).

Protective Factors
Due to the negative mental health outcomes that are common among LGBTQ+ youth, it is important to promote protective factors that can disrupt the stigma related to sexual orientation and gender identity and harness support and resilience (Johns et al., 2019). Various studies suggest that developing a sense of belonging can help prevent depression and suicidal ideation among LGBTQ+ youth (Aranmolate et al., 2017;Gower et al., 2018;Hall, 2018). Some protective factors that contribute to developing a sense of belonging include supportive healthcare practitioners, families, schools, and communities (Center for Disease Control and Prevention, 2016). To establish positive changes towards better LGBTQ+ youth mental health, it is necessary to support programs, policies, and resources that focus on their well-being. The Trevor Project's 2021 National Survey on LGBTQ Youth Mental Health with a sample size of 34,759 LGBTQ youth between the ages of 13-24 residing in the United States found that LGBTQ youth who had access to spaces that affirmed their sexual orientation and gender identity reported lower rates of attempting suicide than those who did not (Trevor Project).

Recommendations for Preventing Bullying
Anti-bullying policies have been shown to have a protective effect on LGBTQ+ youth's mental health, thus lowering the risk of suicidality (Marshall, 2016;Seelman & Walker, 2018). LGBTQ+ youth residing in states with stringent anti-bullying laws concerning sexual orientation and gender identity experience fewer instances of harassment, stigma, and victimization Russell & Fish, 2016;Taylor, 2019). For instance, a survey conducted between 2005 and 2015 across 22 states observed that LGBQ youth experienced fewer cases of bullying in states with anti-bullying laws on sexual orientation (Seelman & Walker, 2018). In states without such policies, there was evidence of male students missing school due to fear, thus underscoring the need for enumerated anti-bullying guidelines to help the community at large (Seelman & Walker, 2018). Table 1 illustrates recommendations for LGBTQ+ advocates, public policy makers, and school administration/principal on anti-bullying interventions aimed at lowering negative mental health outcomes caused by victimization and stigma associated with LGBTQ+ identities.

Recommendations for Suicide Prevention
Pushing for protective steps and non-discrimination of the LGBTQ+ community works in tandem with efforts to reduce the risk of suicide by addressing causes of mental health challenges (Haas et al., 2011). Studies have consistently described connectedness as a protective measure against suicidality among LGBTQ+ youth (DiFulvio, 2011;Teasdale & Bradley-Engen, 2010). For instance, a qualitative study found that a sense of belonging with peers and families helped prevent suicidal tendencies among sexual minorities between the ages of 14 and 22 (DiFulvio, 2011). Three distinct studies across a nationwide representative survey of youth in high school also observed that teacher or parent support was negatively correlated to suicidality among LGBTQ+ youth (Teasdale & Bradley-Engen, 2010). Another study similarly found that a mere perception of school staff support for LGBTQ+ youth acted as a deterrent against multiple suicide attempts, regardless of individual and school characteristics (Stone et al., 2015). Drawing from this research, recommendations for LGBTQ+ advocates to prevent suicide among LGBTQ+ youth are presented in Table 1.

Recommendations for Better Schools
Schools remain the centre of life and culture for most students, yet in many cases, they continue to be some of the most homophobic and transphobic institutions in society. Considering that many LGBTQ+ youth decide to come out during their high school years, it is important for schools to be cognizant of the fact that LGBTQ+ youth often experience disproportionate levels of bullying and victimization. Therefore, they should be well-equipped to address such inequalities through cultivating non-judgemental, safe, and supportive environments, which can improve the academic outcomes of LGBTQ+ students (Gower et al., 2018). Schools should take concrete measures to ensure a healthy environment for all youth, especially LGBTQ+ youth who are often the most vulnerable, by implementing a variety of evidence-based policies, activities, and procedures.

Counsellors
Many LGBTQ+ students have reported that school counsellors were the staff members that they would be most comfortable speaking to about the challenges they face in relation to their gender identity or sexual orientation (Abreu et al., 2018). However, a countrywide GLSEN study consisting of a total of 7,261 LGBTQ+ students between the ages of 13 and 21 in 2010 established that only 58% of LGBTQ+ students felt comfortable discussing their issues with school mental health professionals and under 41% of them had actually conversed with these staff members on at least one occasion about challenges associated with their LGBTQ+ identity (Gay & Education Network, 2010). On the other hand, about 66% of the participants reported that they had conversed with their teachers about these matters, further demonstrating that counsellors must evolve to more effectively create comfortable spaces for such conversations and acceptance (Luke & Goodrich, 2012). Supportive school counsellors can have a significant impact on LGBTQ+ youth's success, thus counterbalancing the potentially harsh and negative experiences of these youth within school settings (Abreu et al., 2016;Kull et al., 2015). In addition, school counsellors should foster an open environment for conversation by encouraging LGBTQ+ students to freely share their experiences with bullying and harassment with school staff (Abreu et al., 2018;Johns et al., 2019). Doing so would make it easier for school staff to establish a rapport with LGBTQ+ students and enable them to become more aware of the mental and physical ramifications of bullying.

Spaces and Groups
Developing youth-driven Gender and Sexuality Alliance (GSAs) are a promising intervention to reduce prejudice, stigmatization, and bullying within schools Estrada et al., 2017;Russell & Fish, 2016). Research shows that LGBTQ+ students in schools with GSAs experience a higher sense of belonging and lower victimization, as well as lower risks of negative mental health outcomes associated

Recommendations for LGBTQ+ Advocates & Public Policy Makers:
1. Advocate for anti-bullying legislation and for the integration of gender identity and sexual orientation in protective laws concerning safety within schools.
2. Push for changes across all state and federal laws creating inequities on the basis of gender identity, as these legislations have been shown to have a negative impact on LGBTQ+ youth's mental health, including increasing the risk of suicide. 3. Call for better access to mental healthcare via non-discrimination policies and advocate the extension of health insurance to same-gender partners. 4. Push for legislation requiring the integration of sexual orientation and gender identity in federally-funded benchmark surveys and other databases concerning general and mental health to fully identify the ramifications of disparities that affect the LGBTQ+ community

Recommendations for School District Administrators/School Administration/Principal related to school policy:
1. Advocate for the eradication of bullying in schools. To bolster this effort, schools should teach students how to become allies for their LGBTQ+ peers, speak out, and identify bullying. 2. Ensure anti-bullying efforts include educating people that it is unacceptable to bully anyone on the basis of gender expression or sexual orientation.
3. Seriously consider and investigate all reports pertaining to bullying and follow through on these complaints. 4. Identify adults on campus who can spearhead anti-bullying efforts and investigate bullying reports. 5. Converse with students to identify hotspots on campus or times during which bullying occurs and incorporate supervision within these times and places.
6. Conduct yearly trainings for both staff and students on bullying. Ensure that trainees recognize what bullying entails and the steps they can take to make their campuses safer. 7. Build a positive environment in schools by cultivating pro-social skills. If schools are able to foster a supportive and empathetic community, then bullying will be eliminated.

Sources
Recommendations for LGBTQ+ Advocates: 1. Address the LGBTQ+ youth suicide risk as well as potential interventions that can lower the risk of suicide through prevention plans/strategies 2. Provide resources and educational materials on LGBTQ+ youth suicide risk to LGBTQ+ organizations and foster an examination of opportunities to integrate LGBTQ+-specific suicide prevention strategies within the context of the organizations' objectives.
3. Integrate examinations of outcomes into all interventions that aim to lower the risk of suicide among LGBTQ+ youth. 4. When developing suicide prevention programs for the general population, emphasize LGBTQ+ suicide risk and support strategies.
6. Develop/enforce strategies to increase competency in LGBTQ+ suicide prevention across general suicide prevention organizations as well as among community gatekeepers such as teachers and staff who work with at-risk youth.
7. Focus on improving the quality of training in LGBTQ+ suicide risk for law enforcement, crisis line workers, and emergency care professionals, among others who are involved in suicide prevention or intervention. 8. Develop programs utilizing media as a platform for education on suicide prevention and discourage the use of media that glamorizes suicide. 9. Launch educational programs and awareness campaigns for primary care physicians, organizational gatekeepers, and the general public.

Sources
Recommendations for School Administration/Principal/Counsellors:

Establish a point person (teacher/counsellor) who is in charge of handling issues facing LGBTQ+ students and share
LGBTQ+-affirmative content in spaces commonly occupied by students.
2. Encourage students to create LGBTQ+-inclusive settings such as GSAs and other safe spaces on campus.
3. Provide inclusive health curricula containing information relevant to LGBTQ+ youth, such as HIV. 4. Devise clear policies to deter and forbid bullying or victimization, particularly on the grounds of sexual orientation or gender identity.
5. Pay attention to issues affecting LGBTQ+ students and provide extensive training to staff on cultivating supportive ecosystems within schools. They should also include information on the LGBTQ+ youth suicide risk in staff education.

Sources
Recommendations for Families/Parents: 1. Use respectful language when speaking to their LGBTQ+ children, ensure their safety, and encourage other family members to show them respect as well.
2. Have open conversations with their LGBTQ+ children. Such conversations will enable them to listen to their children's experiences and help nurture a loving and supportive relationship.
3. Support their children's journey with their LGBTQ+ identity, including helping them access inclusive mental health services, medical care, and education.
4. Know their children's friends and what they are doing. Such involvement will make their LGBTQ+ children feel cared for. 5. Include LGBTQ+ youth in family events and activities to counter feelings of exclusion. 6. Assist their youth in creating a plan on how to overcome challenges, maintain safety, and reduce the risk of negative experiences.
7. Initiate conversations with their children about the ramifications associated with bullying. 8. Report cases of abuse to teachers and school administrators if their children experience any victimization in school. 9. Support their youth in discovering organizations and communities that support LGBTQ+ youth as well as accompanying their children to LGBTQ+ events.

Recommendations for Policy Makers:
1. Work with key stakeholders to develop campaigns on both mainstream and social media with the aim of tackling the social and healthcare disparities that LGBTQ+ youth face.

Recommendations for Community Leaders:
1. Emphasize providing victimized LGBTQ+ youth with the resources and support that they need to overcome the negative impacts of such victimization. Such initiatives can also help these youth deal with the pervasive feeling that they are a burden to others when they are looking for help after victimization. 2. Develop LGBTQ+-specific campaigns that are focused on alleviating the stigma associated with mental disorders while educating the community about the link between anxiety, mental health ailments, and substance abuse and suicide.

Recommendations for LGBTQ+ Youth Space Organizers:
1. Engage LGBTQ+ youth in efforts of seeking positive change and responding to negative environmental factors by driving societal transformation.
Recommendations for Healthcare Providers: 1. Create safe spaces for LGBTQ+ youth, strengthen protective factors, and provide support for healthy development.
2. Demonstrate cultural sensitivity while addressing the unique challenges facing LGBTQ+ youth. 3. Provide training to develop open communication and empathetic care with these youth in a respectful and nonjudgemental manner.

School/ School District Policies
Unsurprisingly, school/school district policies also play a key role in determining the mental health of LGBTQ+ youth (Haas et al., 2011;Lucassen et al., 2018). LGBTQ+ students are less likely to be harassed and more likely to feel safer in schools that have anti-harassment policies in place (Kull et al., 2015). A 2015 countrywide YRBSS study involving private and public high school students found that anti-bullying legislation encompassing sexual orientation was linked to fewer suicide attempts (Meyer et al., 2019). In addition, this legislation was also linked to youth feeling safer not only within school, but also on the way from and to school. Overall, LGBTQ+ youth attending school in districts with anti-bullying legislation including sexual orientation and gender identity are at a lower risk of experiencing negative mental health outcomes such as suicidality (Hatzenbuehler & Keyes, 2013;Willging et al., 2016).

Curriculum
Despite increasing attempts to address issues related to LGBTQ+ students in schools, LGBTQ+ themes continue to be neglected and underrepresented in curricula (Batchelor et al., 2018;Snapp, McGuire et al., 2015). Schools should adopt inclusive curricula that cut across all subjects and include LGBTQ+ history, as well as relevant information about the LGBTQ+ community (Snapp, McGuire et al., 2015). Such curricula would have immense potential in improving students' perceived acceptance and safety while reducing levels of victimization. Furthermore, administrators, teachers, and staff must be provided with LGBTQ+specific training to develop a deeper understanding of LGBTQ+ students and encourage anti-bullying intervention (Gay & Education Network, 2011;. In a data analysis of the 2014 School Health Profiles and the 2015 YRBS, researchers found that students are less likely to suffer from adverse mental health outcomes and school victimization in states that provide sex education covering the LGBTQ+ community (Proulx et al., 2019). It is possible to use these findings for guiding interventions across schools and even states. Furthermore, a nationwide GLSEN study in 2015 consisting of 10,528 LGBTQ+ students between the ages of 13 and 21 found that 75.2% of LGBTQ+ students in schools with an LGBTQ+-inclusive curriculum reported peer acceptance as opposed to 39.6% of those in schools without such inclusive curricula . Table 1 lists research-based interventions that schools can initiate to support LGBTQ+ students and improve their well-being.

Recommendations for Social Support
Social connectedness, particularly within the LGBTQ+ community, is another significant protective factor for LGBTQ+ youth (Ceatha et al., 2019;Painter et al., 2018). In fact, a study conducted in Israel involving 461 LGB respondents aged 18-23 found that social support had a direct, positive effect on the participants' mental health (Edidin et al., 2012). Support emerging from all members of society (i.e. from family, medical staff, school staff, and peers) is crucial in minimizing the inequalities facing LGBTQ+ youth (M. E. Eisenberg et al., 2020;Hafeez et al., 2017;Snapp, Watson et al., 2015). In particular, support from fellow youth can help LGBTQ+ youth cope with their challenges in positive ways (McDonald, 2018;Taylor, 2019). As a result, LGBTQ+ youth with supportive friendships have reported lower levels of depression and suicidal thoughts, as well as higher self-esteem, compared to LGBTQ+ youth who are deserted by friends once they come out (Russell & Fish, 2016).
In addition, youth can find both peer support and empowerment by getting involved in LGBTQ+ organizations which can allow them to expand their connection with LGBTQ+ communities while advocating for the change they hope to see (Baams et al., 2015;Gamarel et al., 2014). According to a study involving 72 young individuals aged 14-23, critical consciousness and community engagement have a strong correlation with the empowerment of LGBTQ+ youth (Wagaman, 2016). Another analysis involving 2,678 sexual minority youth also observed that access to LGBTQ+ community events and organizations can serve as a protective factor against negative coping mechanisms such as substance use . This link between LGBTQ+-supportive community factors and lower substance use holds significant implications. Therefore, more investments must be made in community programs, organizations, and legislations that further visibility and equity for LGBTQ+ youth . The context of the community in which LGBTQ+ youth reside is also significant because neighbourhoods with higher anti-LGBTQ+ hate crimes are linked to greater disparities in suicidality (Duncan & Hatzenbuehler, 2014). This underscores the need for community-level suicide-prevention programs specific to LGBTQ+ youth. A study involving 1,292 racially diverse high school students in Boston similarly found that LGBTQ+ youth living in neighbourhoods with high rates of homophobic or transphobic hate crimes were more likely to experience suicidal ideation than those living in more queer-friendly neighbourhoods (Duncan & Hatzenbuehler, 2014).
Familial support is a significant protective factor that contributes to the resilience and wellbeing of LGBTQ+ youth (Mills-Koonce et al., 2018;Stone et al., 2015;Watson et al., 2016). Familial support, which entails having open discussions on gender identity/sexual orientation and acknowledging diverse expressions of gender, has been linked to better self-esteem and lower risks of negative mental health outcomes such as suicidality (Mills-Koonce et al., 2018;National Association of School Psychologists, 2018;Newcomb et al., 2019). Therefore, it would be beneficial to offer family therapy that would enable parents to process their children's coming out in a positive and supportive way, allow youth to cope with negative responses from family, and foster communication within the family to solidify it as a support system (Hall, 2018). Involvement of family both in and out of school is crucial in fostering a sense of safety and self-esteem for their children (Schmitz & Tyler, 2018). Families must engage school administration to ensure that an LGBTQ +-inclusive learning environment is established, share the negative experiences facing their children, and advocate for more inclusive policies (Kosciw et al., 2012;Lawrenz & Habigzang, 2019). Engaging with local Parents, Families and Friends of Lesbians and Gays (PFLAG) chapters is one of the ways family members can participate in advocacy and support LGBTQ+ youth. Table 1 illustrates research-based interventions that families, community leaders, and youth space organizers to lessen LGBTQ+ youth suicidality and ensure better health outcomes.

Recommendations for Healthcare
Health disparities can only be remedied when best practice guidelines are complied with and when key stakeholders start making conscious efforts to support the well-being of LGBTQ+ youth (Rodgers, 2017). To augment the quality of and access to mental healthcare for the LGBTQ+ community, clinicians must be encouraged to be more empathetic to their needs (Veltman & La Rose, 2019). Establishing empathy would lead to reduced discrimination, prejudice, and stigmatization, which is crucial in decreasing the mental health burden of LGBTQ+ populations (Veltman & La Rose, 2019).
One of the most important elements of paediatric primary care includes assessing and supporting youth's mental health (Adelson et al., 2016;Hafeez et al., 2017). This is particularly significant for LGBTQ+ youth, who are prone to experiencing unique stressors associated with family rejection, disclosure, victimization, self-nonacceptance, and stigmatization (Samaroo, 2017). Therefore, paediatricians must be aware of how to apply principles of mental health practice to LGBTQ+ youth as well as resources that are available locally in the continuum of mental healthcare (Bonvicini, 2017;E. Eisenberg et al., 2017). Table 1 provides an overview of research-based interventions that should be enacted by healthcare providers to improve the wellbeing of their LGBTQ+ youth.

Conclusions
Overall, it is evident that LGBTQ+ youth experience severe mental health disparities compared to their cisgender-heterosexual counterparts and as a result, they are more likely to experience suicidality, depression, substance abuse, and other mental health challenges. Bullying is a particularly pervasive and brutal phenomenon within school settings, with many studies revealing that LGBTQ+ students are subjected to physical and verbal abuse, leading to school avoidance and worse academic outcomes. In addition to a lack of school support, LGBTQ+ youth frequently face rejection from their own families, despite the fact that family support is a major protective factor for LGBTQ+ youth's mental health. Many LGBTQ+ youth are not comfortable revealing their sexual orientation or gender identity to their mental healthcare providers because many healthcare professionals maintain biases against them and fail to create inclusive and accommodating spaces. Given that most of these risk factors are deeply rooted in our social systems, it is important to tackle these inequalities by developing and supporting programs and policies that facilitate societal change. In addition, parental involvement within and outside of schools is crucial in ensuring the safety of LGBTQ+ youth. Schools must also take an active role in supporting LGBTQ+ youth by developing LGBTQ+-specific training for counsellors and staff, enacting and enforcing stringent anti-bullying policies, developing safe spaces such as GSAs, and implementing LGBTQ+-inclusive curricula. In addition, healthcare systems must also evolve to become safer and more inclusive for LGBTQ+ youth. Health practitioners should develop LGBTQ+-specific training highlighting the specific struggles and risk factors experienced by LGBTQ+ youth to reduce mental health disparities. Overall, this model emphasizes creating safe spaces for LGBTQ+ youth, protecting them from victimization, and developing accessible support systems to support more positive mental health outcomes.

Disclosure statement
No potential conflict of interest was reported by the author(s).