Homelessness Among Sexual Minority Youth

This study used data from the 2017 and 2019 Youth Risk Behavior Surveys (YRBS).¹⁸  This survey, conducted every 2 years, is a nationally representative health survey of public and private high school students in grades 9 through 12 in nearly all states and the District of Columbia.¹⁹  High schools in each state are selected with a probability proportional to the size of student enrollment. Then, classes of students are randomly selected to participate in the YRBS. Students are asked a core of demographic and health questions, but states have the option to add additional questions. We restricted our sample to the 21 states (presented in Table 1) that ascertained information on sexual orientation, same-sex or different-sex sexual behaviors, and experiences of homelessness.

Sampled students were asked which of the following categories best represents how they identify themselves: heterosexual (straight), gay or lesbian, bisexual, or not sure. Additionally, students were asked to describe the sex of their sexual contacts. They could choose the following options: never had sex, opposite sex only, same sex only, or both sexes. We restricted our analysis to high school students who answered questions about their sexual minority status and their homelessness status. The final analytic sample included sexual minority respondents (n = 28 405) who indicated their sexual orientation as (1) gay, (2) lesbian, (3) bisexual, (4) not sure, and (5) respondents identifying as heterosexual and reporting sexual contact with partners of the same sex or both sexes. The inclusion of respondents who identified as heterosexual and reported sexual contact with members of the same sex or both sexes (n = 2353) was motivated in part by the disparities experienced by this group on the dimension of interest (homelessness). However, it also points to the complex nature of defining sexual orientation through attraction, behavior, and identity.²⁰  The comparison group included participants who reported their sexual orientation as heterosexual and did not report sexual contact with partners of the same sex or both sexes (n = 136 232). Additionally, we do not consider gender identity in this analysis because only a fraction of the states in our sample simultaneously ascertained it and recent research has focused on the unique homelessness experiences for gender minority youth.²¹  However, in the 11 states that simultaneously record gender identity, we find that approximately 80% of gender minority respondents are also categorized as sexual minorities, suggesting our comparison group is not composed of a large group of gender minority youth.

Students were identified as homeless if the respondent reported that during the past 30 days, they usually slept (1) in the home of a friend, family member, or other person because they had to leave their home or their parent or guardian could not afford housing; (2) in a shelter or emergency housing; (3) in a motel or hotel; (4) in a car, park, campground, or other public place (which we collectively refer as the colloquial term, “the streets”); (5) they did not have a usual place to sleep; or (6) somewhere else. Respondents who indicated that during the past 30 days, they usually slept in a parental or guardian home were classified as not homeless.

The state-level policy environment toward sexual minority populations was calculated using the index scores developed by the Movement Advancement Project (MAP), an independent think tank that provides research on LGBTQ+ issues.²²  The major categories covered by the policy tally included relationship and parental recognition, nondiscrimination protections, religious exemptions, and issues affecting LGBTQ+ youth (eg, LGBTQ+ inclusive curriculum). Public policy scores are reported in the Appendix. Stigma surrounding sexual minority populations at the state-level was calculated using the Pew Research Center’s 2014 Religious Landscape Study. Pew Research Center is a nonpartisan think tank that conducts public opinion polling and demographic research.²³  The Religious Landscape Study is conducted every 7 years and is based on telephone interviews with more than 35 000 Americans from all 50 states.²⁴  Respondents were asked whether homosexuality (1) should be accepted, (2) should be discouraged, (3) neither accepted nor discouraged or both equally, or (4) don’t know. We used the state-level percentages of respondents agreeing that homosexuality should be accepted and assigned it to the corresponding state in the YRBS (values are available in Appendix). Although there was substantial variation in public opinion across states, we note that except for Arkansas and Kentucky, self-reported acceptance of homosexuality was greater than 50%. Another limitation of this measure is that the Pew Center’s Religious Landscape Study was conducted in 2014 and there have been substantial improvements in attitudes toward the LGBTQ+ population over the past 10 years, so their estimates may not correspond to stigma in 2017 and 2019. Although state-level public opinion is difficult to estimate for those exact years, we conducted a similar analysis using data from the 2020 Nationscape Study and reached very similar results (available upon request).²⁵ 

We assessed health outcomes and risk behaviors that are frequently used to monitor adolescent health with data from the YRBS.²⁶  We prioritized 3 broadly defined categories: mental health, sexual risk behaviors, and substance use. Mental health measures included feeling sad or hopeless, considering suicide, planning suicide, attempting suicide, and requiring medical treatment of a suicide attempt.²⁷  Sexual risk behavior measures included any sexual intercourse, sex with 4 or more people, the combination of substance use and sex, and unprotected sex.²⁸  Substance use measures included any tobacco use, alcohol use, binge drinking, and marijuana use in the previous 30 days.³  We compared the prevalence of each health outcome by sexual minority status and homelessness status.

We used descriptive statistics and Pearson χ-square tests to define the sample by sexual minority and homelessness status. Next, we calculated the prevalence of homelessness and types of homelessness by sexual minority status. Then, we used multivariable logistic regression models to estimate the associations between public policies, stigma, and homelessness. All estimates are reported as marginal effects and considered statistically significant when P < .05. Finally, we compared health risk behaviors between homeless and nonhomeless youth, separately for sexual minority and heterosexual youth. Fully adjusted regression models controlled for similar variables to those used by Corliss et al (2011) in their analysis of the Massachusetts YRBS, including age, race and ethnicity, sex, survey year, and state of residence.¹⁰  We consider race and ethnicity as social rather than biologic constructs in this analysis and use it as a covariate because race and ethnicity are measurable proxies for the effects of structural racism associated with disparities in homelessness risk and health outcomes. Furthermore, the racial and ethnic composition of sexual minorities in our sample differs from that of heterosexuals. All analyses were conducted using survey weights and the subpop and svy commands in Stata (version 16) to adjust standard errors and to generate representative estimates.²⁹  This study was deemed exempt from the Institutional Review Board because it used deidentified data from secondary and publicly available sources.

Table 1 presents sociodemographic characteristics by sexual minority and homeless status. Of the high school student participants in our sample of 21 states, 17.4% identified as sexual minority and 82.6% identified as heterosexual. Approximately 12% of sexual minority youth and 4.1% of heterosexual youth experienced homelessness in the past 30 days.

Figure 1 presents the types of homelessness by sexual minority status. Living in a nonparental home was the most common form of homelessness for heterosexual youth (49.4%) and sexual minority youth (40.5%), followed by living on the streets (18.2% and 20.4%), living in a shelter (14.6% and 19.4%), living in a hotel (8.6% and 11.8%), and other forms of homelessness (9.2% and 7.9%) (parenthetic estimates are for heterosexual and then sexual minority youth, respectively).

Table 2 presents the marginal effects predicting homelessness by sexual minority status for various sociodemographic characteristics, LGBTQ+ public policy index scores, and attitudes toward homosexuality and sexual diversity. Sexual minority youth of color and male sexual minorities were more likely to experience homelessness compared with white sexual minority youth and female sexual minorities, respectively. Similar patterns were observed among heterosexual youth. There was no association between LGBTQ+ policy index scores and homelessness among sexual minority and heterosexual youth. Sexual minority and heterosexual youth in states with greater acceptance of sexual diversity were significantly less likely to experience homelessness. A 20-percentage-point increase in the state’s acceptance of homosexuality was associated with a 6.8 (95% CI = −11.5 to −2.2) percentage point decrease in homelessness for sexual minority youth and a 2.6 (95% CI = −4.1 to −1.0) percentage point decrease in homelessness for heterosexual youth.

Finally, Table 3 presents the prevalence of a variety of health risk factors stratified by sexual minority status and homelessness status. Compared with nonhomeless sexual minority youth, homeless sexual minority youth were more likely to report suicidal ideation (49.8% vs 39.1%), suicidal plans (45.5% vs 32.0%), suicidal attempts (47.8% vs 18.1%), and receiving medical treatment of a suicidal attempt (26.8% vs 6.0%). Homeless sexual minority youth were also more likely to engage in risky health behaviors, including sex with 4 or more partners (38.7% vs 8.8%), unprotected sex (31.0% vs 9.8%), use of substances before sex (53.3% vs 21.1%), alcohol use (52.0% vs 29.5%), tobacco use (71.2% vs 27.2%), cocaine use (42.2% vs 6.7%), and marijuana use (39.0% vs 24.2%) compared with nonhomeless sexual minority youth. Homeless heterosexual youth reported similar patterns that included elevated levels of suicidality, sexual risk behaviors, and substance use compared with nonhomeless heterosexual youth. Homeless sexual minority youth were significantly more likely to report worse health outcomes compared with heterosexual youth across all 3 domains of mental health, sexual risk behaviors, and substance use.

We estimated that 12% of sexual minority youth experienced homelessness in the past month, whereas in comparison, 4.1% of heterosexual youth experienced homelessness. The disparities observed in homelessness for sexual minority youth suggest that interventions should expand school- and/or community-based programs for sexual minority high school students experiencing housing insecurity and homelessness. Additionally, the disparities in types of homelessness experienced by sexual minority youth as compared with heterosexual youth suggest that emergency shelters and LGBTQ+ community centers should tailor programs that are safe for sexual minority youth to fill in the gaps in family and nonfamily support structures.

We also found that homeless sexual minority youth report substantial disparities in behavioral health and sexual risk behaviors. Health care and social service providers who work with youth should be trained and aware of the health risks experienced by homeless youth, and particularly sexual minority homeless youth. Emergency shelters and independent living programs should work collaboratively with local mental health and substance use resources to ensure that sexual minority youth receive treatment and affirming care when needed. Meanwhile, housing providers serving sexual minority youth should continue to work with public health agencies and sexual health clinics to educate, prevent, and treat sexually transmitted infections, including HIV. Given elevated sexual risk behaviors among homeless youth, routine sexually transmitted infection testing and methods to prevent HIV transmission (eg, condoms and pre-exposure prophylaxis) should be offered to homeless youth by health care professionals. Additionally, one example of an effective intervention is the Family Acceptance Project, which has been shown to improve family dynamics and reduce the risk of health risk behaviors and homelessness for sexual minority youth.^30,31  Future research should include more qualitative methods to assess the mechanisms that link sexual minority and homeless status to adverse health outcomes. Meanwhile, the health risks we find are intersectional and complex—although we reaffirm previous studies that find that sexual minority status and homelessness status are associated with adverse health outcomes, we record that youth at the intersection of these identities experience worse health than either nonhomeless sexual minority youth or homeless heterosexual youth.

One of the goals of this study was to examine the associations between state policy environments and cultural stigma (via state-level data on attitudes on sexual diversity) and the risks for homelessness among sexual minority youth. We found that greater acceptance of homosexuality and sexual diversity was associated with lower risk of homelessness among sexual minority and heterosexual youth. This may be because of a variety of reasons, such as decreased structural stigma lessening the risk for homelessness, shelter systems that are more supportive of LGBTQ+ youth, or greater parental acceptance of sexual diversity lessening the amount of sexual minority youth who become homeless.^6,32  However, we did not find a significant association between state-level policy environments and homelessness risk among sexual minority youth, suggesting that attempts to reduce stigma may be more valuable policy strategies to address the high risk of homelessness among sexual minority youth. It is also possible that changes in public policy lag public opinion shifts and thus, the policy environment had not yet responded to large public opinion shifts in favor of LGBTQ communities.

There were several limitations to using the YRBS for this analysis. First, recall and social desirability biases could lead to inaccurate answers on homelessness status, many of the health risk behaviors, and accurate sexual orientation identities. Additionally, only 21 states were included in the sample, as they were the only sites that collected data on both homelessness status and sexual orientation. Though this is far from complete data for the United States, there was wide geographic and political diversity among the sampled states. Another limitation of this study is that it represents a point-in-time count of youth homelessness for the 30 days before the administration of the survey, which does not capture the extent of youth homelessness over longer periods. Finally, some homeless youth may not have been enrolled or attending school when the YRBS was administered, meaning that the actual prevalence of homelessness is likely higher than reported here. Although it is difficult to assess the magnitude of this difference because reliable homelessness data for youth are not collected, some estimates indicate that approximately 700 000 youth aged 13 to 17 experience homelessness each year, and that there are approximately 400 000 homeless enrolled students in that age range, suggesting that our coverage of the homeless population may be around 60%.^33,34  Additionally, a major limitation of our analysis is that there may be unmeasured confounding—ie, the states that have more friendly LGBTQ+ policy environments may also have other unobserved characteristics that are related to youth homelessness rates (eg, diversity training requirements for shelters receiving state funds, varying public opinions about the appropriate level of government assistance to the poor, etc.). Although we are unable to overcome this weakness in the data used here, there have been an increasing number of studies examining state-level changes in LGBTQ+ policies and their effects on wellbeing.^15–17  To identify best practices to prevent LGBTQ+ youth homelessness, additional qualitative research and primary data collection may be needed to inform statewide interventions. However, in the coming years, as more YRBS data available, researchers should examine the effects of state policy changes on LGBTQ+ youth health and wellbeing more broadly.

Using a multistate and population-based sample, we estimated that 12% of sexual minority youth experienced homelessness, which was significantly higher compared with their heterosexual peers (4.1%). We also found a significant association between state-level acceptance of sexual diversity and sexual minority youth homelessness rates. Finally, we reported the existence of large disparities in mental health outcomes and health risk behaviors at the intersection of sexual minority status and homelessness status. Practitioners should be aware of the health risks experienced by sexual minority homeless youth. More research, educational campaigns, and collaborative solutions are needed to prevent homelessness among sexual minority youth.

LGBTQ+

lesbian, gay, bisexual, transgender, and queer

YRBS

Youth Risk Behavior Survey