key: cord-0879646-9p1fu8ad
authors: Chan, Alex Siu Wing; Wu, Dan; Lo, Iris Po Yee; Ho, Jacqueline Mei Chi; Yan, Elsie
title: Diversity and Inclusion: Impacts on Psychological Wellbeing Among Lesbian, Gay, Bisexual, Transgender, and Queer Communities
date: 2022-04-29
journal: Front Psychol
DOI: 10.3389/fpsyg.2022.726343
sha: b8508fc3f4bcf4741c4faf31c3dd80145bb5574a
doc_id: 879646
cord_uid: 9p1fu8ad

For scholars, practitioners, and legislators concerned about sexual minority adolescents, one of the main goals is to create more positive and inclusive learning environments for this minority group. Numerous factors, such as repeated patterns of homophobic bullying by classmates and others in school, have been a significant barrier to achieving this goal. In addition, lesbian, gay, bisexual, transgender, and queer (LGBTQ) adolescents encounter substantial inequality across a broad spectrum of wellbeing and education consequences. Compared with their heterosexual counterparts, LGBTQ adolescents experience more anxiety, depression, suicidal thoughts, antisocial behavior, poorer academic performance, less school attachment and protection, and a weaker desire to finish their studies. Such discrepancies based on gender and sexuality were linked to more maltreatment encountered by LGBTQ adolescents. It is crucial to recognize the backgrounds and expectations of LGBTQ adolescents to offer them the best resources. To overcome the inequality and obstacles faced by these LGBTQ adolescents, it is essential to examine tools and techniques that can be utilized. This study examined the literature that explains why society fails to provide enough support to LGBTQ students. Specifically, mechanisms explaining how LGBTQ adolescents interact with others in the learning environment and how such discrepancies arise will be examined. Following that, violence and prejudice, which are fundamental causes of psychological problems among LGBTQ adolescents, will be explored. This review paper thus provides supportive strategies for schools to develop more inclusive learning environments for LGBTQ adolescents.

Globally, schools play an essential role in enabling students to acquire college credentials and knowledge, become familiar with the culture, learn about interpersonal relationships, ideals, and standards, and develop survival skills and expertise abilities (Skovdal and Campbell, 2015) . When individuals attend schools and colleges and receive a comprehensive education, their chances in life are improved. The community requires their expertise, and they are well equipped to serve it. Given the many roles and advantages of education, school environments need to be protective, stable, inclusive, and pleasant to all students to maximize learning opportunities for everyone to guarantee that school goals are met. Regrettably, colleges and universities worldwide may not be a safe environment for LGBTQ students, who face intimidation, maltreatment, rejection, and other types of discrimination and exploitation (Poynter and Washington, 2005; Fields and Wotipka, 2020; Kurian, 2020) . These experiences lead to agony, distress, and anxiety and could have a detrimental effect on LGBTQ students' physical, psychological and educational wellbeing (Mateo and Williams, 2020; Mallory et al., 2021) .

There are different forms of discrimination, including verbal abuse, physical aggression, burglaries, accommodation discrimination, and sexual assault (Flores A. R. et al., 2020) . Adolescents who identify as LGB experience more severe peer harassment and maltreatment than their straight counterparts (Kolbe, 2020) . In the United States, 34% of LGB adolescents experienced bullying at school in the surveyed year, compared to 19% of straight adolescents (Johns et al., 2020) . It has been reported that maltreatment of children based on their sexuality has occurred at an early age, as young as eight and nine years old (Evans-Polce et al., 2020) .

Proximal minority stressors may negatively affect the lives of LGBTQ individuals. They include internalized homonegativity, societal exclusion expectancies, and the concealment of one's sexual identity (Delozier et al., 2020) . Individuals who have a greater degree of internalized homonegativity express more unfavorable sentiments about themselves due to their sexual orientation (Ocasio et al., 2020) . Additionally, LGBTQ people may suffer stress or lack self-confidence due to their sexuality (Minturn et al., 2021) . Since sexuality can be concealed from others and that marginalization of LGBTQ people may not be immediately apparent throughout most human relationships (Kachanoff et al., 2020) , LGBTQ people need to determine whether, when, how, and to whom they disclose their sexuality (Alonzo and Buttitta, 2019; Lo, 2020) . Multiple declarations of their socially marginalized identities might be required, increasing their stress (Daniele et al., 2020) . Substantial evidence suggests that bisexual youngsters are at an even greater risk of developing psychological problems than gay/lesbian adolescents (Savin-Williams, 2020), given experiences of stressors associated with "double discrimination" (i.e., exclusion from both the heterosexual and LG populations) and dismissal of one's selfimage as "just a phase" (Ramasamy, 2020) .

It should also be noted that LGBTQ students who identify as members of other oppressed groups (for example, racial and cultural minorities, non-Christians, and members of the lower class) may face heightened instances of discrimination in educational institutions. According to The Trevor Project's 2019 national study on LGBTQ psychological wellness, 71% of LGBTQ youngsters encountered prejudice due to gender and/or sexuality. Additionally, two-thirds of the LGBTQ adolescent interviewees reported that they had been persuaded to alter their sexuality. A survey found that 78% of transgender and non-binary adolescents faced prejudice due to their gender and sexuality, while 70% of LGBTQ adolescents experienced discrimination against their gender expressions. Another study (Platero and López-Sáez, 2020) found that 58% of transgender and non-binary adolescents experienced being discouraged from using the restroom that matched their gender preference.

In addition, study findings indicate that LGBTQ individuals may have serious psychological issues due to their sexuality. A study showed that 39% of LGBTQ interviewees reported actively contemplating suicide in the surveyed year, a majority of them aged between 13 and 17 (Higbee et al., 2020) . An astounding 71% of LGBTQ adolescents reported experiencing despair or depression for no fewer than 14 days during the surveyed year (Higbee et al., 2020) . While significant progress has been achieved in terms of LGBTQ inclusion over the previous decade, this poll demonstrates that the LGBTQ community, especially younger members, continue to face challenges directed at their sexual identities (Standley, 2020) .

The effects of loneliness, marginalization, and inequality on psychological health and the assessment of health determinants have been examined in a number of quantitative studies conducted with LGBTQ adolescents ( Table 1) . The prevalence of suicidal ideation, depression, and drug abuse among LGBTQ adolescents is considerably higher than that of their heterosexual counterparts, highlighting the seriousness and frequency of LGBTQ adolescents' experiences of inequalities (Price-Feeney et al., 2020) . It has been found that LGBTQ adolescents have higher incidences of aggression and victimization as well as more despair and suicidal behavior. These adolescents are also more likely to develop psychosocial disorders, such as alcohol and drug problems and eating disorders (Lannoy et al., 2020) . Associations have been established between peer victimization and adverse psychological wellbeing indictors, such as depression, distress, and suicidal tendencies, along with liquor and drug misuse and compromised academic performance, including reduced school involvement and interruptions to academic paths (Brown et al., 2020) .

Quantitative analysis has also centered on defining vulnerability and preventive variables for the psychological wellbeing of LGBTQ adolescents, resulting in the establishment 

2020 United States Qualitative n = 20 Age: 18-25 Gender: Male (n = 7, 35%), Female (n = 11, 55%), Transgender female (n = 2, 10%) Sexual orientation: Bisexual (n = 5, 25%) Gay (n = 5, 25%) Lesbian (n = 3, 15%) Queer (n = 3, 15%) Asexual and bisexual (n = 1, 5%) Pansexual (n = 1, 5%) Homoflexible cupiosexual (n = 1, 5%) of mitigation, diagnosis, and recovery guidelines, as well as shaping legislation and policy (Lockett, 2020) . Family affirmation, for example, provides a protective factor against depression, drug misuse, and suicide among LGBTQ adolescents and young adults. It increases self-esteem, support networks, general wellness, and is a buffer against depression, drug misuse, and suicide (Reyes et al., 2020; Lampis et al., 2021) . Thus, household initiatives that inspire and support parents, care providers, and other close relatives have been identified as a beneficial paradigm for preventive strategies. This highlights the strengths and positive impact of constructive parent-child dynamics. Additionally, a recent comprehensive study (Flores A. R. et al., 2020; Flores D. D. et al., 2020) found that elevated degrees of community protection were correlated with a healthy ego while a shortage of community protection was linked with increased levels of stress, anxiety, guilt, alcohol and substance consumption, practices of unsafe sex, and lower levels of selfesteem. McDonald et al. (2021) emphasized the importance of acceptance by family and caregivers and a feeling of connection to a friend/community in LGBTQ youth's psychological wellbeing.

Mental health entails a positive relationship with people and the pursuit of a productive and fulfilling existence. It has been shown that those who have a high level of mental health tend to be more lighthearted and lead more energetic and pleasant lives (Chan et al., 2021) . Owing to their heightened likelihood of experiencing psychological challenges, LGBTQ adolescents are among the most disadvantaged populations in the community (Detrie and Lease, 2007; McGlashan and Fitzpatrick, 2017) . According to figures on the LGBTQ community, New Zealand has an estimated 8% of LGB adolescents, the United States has an estimated 7-8% of LGB adolescents (Wilson et al., 2014) . According to Aranmolate et al. (2017) , LGBTQ adolescents' psychological health difficulties are associated with a lack of familial recognition and experiences of harassment. They are more likely than their heterosexual counterparts to encounter violent conditions at home and in the larger community, and are exposed to overt and implicit discrimination, violence, vulnerability, and injustice, all of which have a negative effect on psychological wellbeing (Bertrand et al., 2005; Matebeni et al., 2018; Simons and Russell, 2021) . A recent study (Lucassen et al., 2017) found that LGBTQ adolescents were three times more likely than their heterosexual counterparts to exhibit depressive conditions and twice as likely to harm themselves. In the study, 20% of participants attempted suicide, and over half considered it. LGBTQ adolescents were more likely than their non-LGBTQ counterparts to seek therapy in the previous 12 months, at 41.0%. Additionally, the Youth 2000 Survey (Archer et al., 2021) indicates that LGBTQ youth face a higher risk of alcohol or substance usage. In Scotland over the given time, 40% of LGBT adolescents registered as having a psychological disorder, compared to 25% of non-sexual and gender marginalized adolescents and bullying was described as a significant source of anxiety among LGBT participants (Bradbury, 2020; Pachankis et al., 2020) .

LGBTQ adolescents, in general, have distinct risk factors, and when such specific threats are associated with common stressful events, this minority group tend to experience increased selfharm, suicidal tendencies, and emotional instability Hatchel et al., 2021) . These risk factors persist throughout adulthood, with Sexual/Gender Minority (SGM) person 400% more likely to commit suicide and both males and females 150% more likely to experience anxiety, depression, and drug abuse (King et al., 2008; Lothwell et al., 2020) . In a 2011 article (Chakraborty et al., 2011) , it was found that gay/lesbian individuals experience elevated degrees of psychological discomfort in comparison to straight people.

According to previous studies engaging with minority stress theory (Cyrus, 2017; Fulginiti et al., 2020;  Table 1 ), the rising likelihood of psychological health problems among LGBTQ adolescents is a result of increased social stress, which includes stigma, discrimination, bias, and victimization. Adolescence is a crucial period in cognitive growth, with elevated impact of pressure on psychological wellbeing and an increased susceptibility to substance use (Tavarez, 2020; Fulginiti et al., 2021) . At this critical juncture, experiencing discrimination at the hands of academic, clinical, or religious establishments, or internalizing victimization as a consequence of discrimination, transphobia, or biphobia, will create substantial mental difficulties for LGBTQ adolescents (Budge et al., 2020; Formby and Donovan, 2020) . Marginalization, loneliness, alienation, bullying, and a lack of supportive grown-ups and spaces all contribute to social tension among LGBTQ adolescents (Grossman et al., 2009; Hafeez et al., 2017) .

Stigma establishes individual obstacles for vulnerable adolescents, stopping them from seeking resources (Cortes, 2017) . According to Hackman et al. (2020) , humiliation, guilt, and apprehension of judgment are all factors explaining why LGBTQ adolescents stop accessing psychological health care.

LGBTQ adolescents who are homeless, remote, or drug addicts experience greater obstacles to obtaining assistance (Lucassen et al., 2011, Table 1 ). If parental or specialist assistance is unavailable, LGBTQ adolescents may seek assistance from peers and resources on online platforms (LaSala, 2015; Pullen Sansfaçon et al., 2020; Town et al., 2021) .

Recognition by family members has also been described as a significant factor influencing the psychological wellbeing of LGBTQ adolescents (Afdal and Ilyas, 2020; Buriae et al., 2020) . According to Strauss et al. (2020) , familial engagement is represented by openness and sensitivity to the demands of a child. As LGBTQ adolescents feel welcomed and respected, they are more likely to reveal their non-normative identities to family members (Hagai et al., 2020; Endo, 2021) . Nevertheless, a huge percentage of LGBTQ adolescents are homeless, indicating that family exclusion is a major risk factor for poor psychological wellbeing (Travers et al., 2020; MacMullin et al., 2021) . Durso and Gates (2012) released the findings of a nationwide internet study in the United States and discovered that nearly 68% of their LGBT homeless clients had encountered family abandonment and over 54% had encountered domestic violence.

Adolescence is a transitional stage during which adolescents discover their identity, and for LGBTQ adolescents, it is also the period during which they gain an awareness of their own gender identity and sexual preference (Prock and Kennedy, 2020) . Research has shown shifting relationships throughout adolescence and young adulthood, with a corresponding change in commitment to friends and social classes apart from the family, as well as to entities such as education, colleges, religious or political communities (Huang, 2020; Jordan, 2020) . Recognition by support communities is a powerful preventive mechanism for LGBTQ children and adolescents (Call et al., 2021) . A LGBTQfriendly climate has a profound impact on their psychological development and well-being. Perceptions of social integration with grown-ups help LGBTQ adolescents overcome challenges, especially during the precarious developmental phase when they are developing their sense of self (Proulx et al., 2019) .

The interaction between a person and his or her environment affects personal growth and development according to the social ecological model. The risk of suicidal behaviors among LGBTQ adolescents is influenced by a number of contextual factors including schools. Institute of Medicine asked for further research in 2011, focusing specifically on the impact of protective school policies and students' perceptions of their school environments on their health and well-being (Ancheta et al., 2021) . Much research pointed out that schools are wellpositioned to address health disparities by creating safe and supportive school climates for LGBTQ youth (Gower et al., 2018; Woodford et al., 2018 ; Table 2 ). Evidence shows that a safe and supportive climate is related to lower odds of student bullying involvement, some types of risky alcohol use and drug use, and victimization. A safe climate event may reduce LGBTQ adolescents' risk of suicidal thoughts (Konishi et al., 2013; Kosciw et al., 2013; Hatzenbuehler et al., 2014; Gower et al., 2018) . Having a supportive school environment and a sense of belonging to school were associated with lower levels of minority stress and better academic results, health, and wellbeing among LGBTQ students (Denny et al., 2016; Perales and Campbell, 2020) . Research has suggested multiple strategies for school-based support, including policies, supporting LGBTQ students organizations, educator intervention and LGBTQ related curriculum (Konishi et al., 2013; Kosciw et al., 2013) .

More inclusive policies could contribute to the school climate at the macro level. These policies include antidiscrimination policies (Woodford et al., 2018) and anti-homophobic bullying policies (Konishi et al., 2013) . Compared with students at schools with generic policies or no/unidentified policies, LGBTQ students in districts with sexual orientation, gender identity, and/or gender expression (SOGIE) protections in their policies reported greater school safety, less victimization based on their sexual orientation and gender expression, and less social aggression (Kull et al., 2016) . Moreover, a greater number of SOGIE-focused policies was associated with lower truancy for all students (Day et al., 2019) .

Furthermore, gay-straight alliance (GSAs) has been one of the major sources of support in high schools in the United States and Canada. GSAs are student-led, school-based clubs that aim to provide a safe environment in the school context for LGBTQ students, as well as their straight allies (Toomey et al., 2011. In recent decades, the number of GSAs in schools has increased dramatically, with over 4,000 GSAs registered in the United States (Toomey et al., 2011) . Research has suggested that a high school with a GSA can decrease LGBTQ students-risks for using illicit drugs and prescription drug misuse and reduce their burden of minority stressors (Heck et al., 2014) . GSAs foster inclusive school environments not only for LGBT + students but for all students, thereby contributing to lower levels of homonegative victimization, fear for safety, homophobic remarks and multiple forms of bias-based bullying (based on body weight, gender, religion, disability, gender typicality, sexuality) (Marx and Kettrey, 2016; Lessard et al., 2020) .

Educator intervention and LGBTQ related curriculum also constitute prevention strategies of inclusive schools. Teachers and school staff-in particular, the medical staff-could be provided with LGBTQ sensitive training and LGBTQ medical curricula, which are important for supportive climate building and LGBTQ students' wellbeing (Gower et al., 2018; Tollemache et al., 2021) . By strengthening teachers' analytical awareness of alienation experienced by children and adolescents, teachers may flourish in school, promoting equal opportunity principles and teaching students about love and consideration, justice and freedom . Willging et al. (2016) demonstrated that RLAS (Implementing School Nursing Strategies to Reduce LGBTQ Adolescent Suicide) is applicable to novel nurse-led intervention to address LGBTQ youth suicide and health-related concerns of other students. All these strategies have shown the importance of structural initiatives on campus in protecting LGBTQ students from discrimination (Woodford et al., 2018) .

Around the world, the importance of an inclusive school climate to LGBTQ student has been suggested and advocated for reducing the risk of violence and discrimination and enhancing their psychological wellbeing. However, most quantitative studies were concentrated in the Northern America, particularly the United States. There remains a lack of research about LGBTQ students' wellbeing in developing countries. Moreover, much research used the data from health or psychological surveys to state that policies, GSAs club, educator intervention, and LGBTQ related curriculum could improve the school climate; nevertheless, less experimental research could provide evidence and specific methods to guide schools. Further, due to the disparities among LGBTQ students, a 'one size fits all' approach to school policy might not fit all LGBTQ students. Day et al. (2019) have demonstrated that SOGIE-focused policy may support LGBTQ youth more than transgender youth. 

United States Student-focused (e.g., GSA), staff-focused (e.g., professional development), and a combination (e.g., point person for LGBT student issues). These programs include some elements of professional development, classroom activities, more formal curriculum, and school-wide communication of inclusive norms through stickers and posters.

Student-level data: 8th (n = 121), 9th (n = 121), or 11th (n = 119) grades (n = 176 schools in total) completing the 2013 Minnesota Student Survey (MSS). Assuming a 5% LGBQ rate. School-level data: N = 31,183 students in 103 schools.

This study provides promising evidence that school efforts to promote safe and supportive climates for LGBQ youth through multiple practices are associated with lower odds of student bullying involvement Findings support school-wide efforts to create supportive climates for LGBQ youth as part of a larger bullying prevention strategy Kosciw et al. (2013) United States Safe school policies, supportive school personnel, and gay-straight alliance (GSA) clubs N = 5,7630 lesbian, gay, bisexual, and transgender students between the ages of 13 and 21 (M = 16.3 years)

School-based supports contributed to lower victimization and better academic outcomes A hostile school climate has serious ramifications for LGBT students but institutional supports can play a significant role in making schools safer for these students Woodford et al. (2018) United States Using SEM, indicate that antidiscrimination policies that enumerate both sexual orientation and gender identity (vs. only sexual orientation), offering at least one for-credit course on LGBTQ topics, and the ratio of LGBTQ student organizations to the student body size N = 268, 58% undergraduates; 25% students of color; 62% gay/lesbian from 58 colleges completed an anonymous online survey addressing experiential heterosexism and psychological well-being

Colleges can work to decrease heterosexist discrimination on campus by utilizing multiple strategies: policies, formal educational resources, and by supporting LGBTQ student organizations

The results underscore the importance of particular structural initiatives on campus in protecting LGBQ+ collegians from discrimination and highlight the value of studying specific structural initiatives when investigating structural stigma and inclusion Willging et al. (2016) United States "RLAS" (Implementing School Nursing Strategies to Reduce LGBTQ Adolescent Suicide), builds on the Exploration, Preparation, Implementation, and Sustainment (EPIS) conceptual framework and the Dynamic Adaptation Process (DAP) to implement EB strategies in U.S. high schools Compared the LGBTQ students and their peers in RLAS intervention schools (n = 20) with those in usual care schools (n = 20)

The conceptual framework and methods for this novel nurse-led intervention are applicable to addressing LGBTQ youth suicide and the health-related concerns of other pediatric populations in schools as well Through its collaborative processes to refine, improve, and sustain EB strategies in these systems, the RLAS represents an innovative contribution to implementation science that also addresses a pressing public health challenge Konishi et al. (2013) Canada Gay-straight alliances and anti-homophobic bullying policies

A population-based sample of students in grades 8 through 12 from the British Columbia Adolescent Health Survey of 2008 (N = 21,708)

Gay-straight alliances and anti-homophobic bullying policies were linked to significantly lower odds of some but not all types of recent risky alcohol use and past-year harms from alcohol or drug use, but almost exclusively in schools where the policies or gay-straight alliances had been established for at least 3 years; and among lesbian, gay and bisexual adolescents, only for girls Our findings suggest that these school-based strategies (gay-straight alliances and anti-homophobia policies) to reduce homophobia and foster school inclusion may be beneficial in reducing problem alcohol use among all students, not just sexual minority students Heck et al. (2014) United States GSAs N = 475, LGBT high school students (Mage = 16.79) who completed an online survey

LGBT youth attending a high school without a GSA evidenced increased risk for using illicit drugs and prescription drug misuse. GSAs help foster school environments where the burden of minority stressors is reduced

The importance of providing LGBT youth with opportunities for socialization and support within the school setting

Frontiers in Psychology | www.frontiersin.org 

Canada

LGBTQ-inclusive education strategies They present quantitative and qualitative results of a national survey of more than 3,700 Canadian high school students undertaken in order to investigate what life is like at school for sexual and gender minority students

The findings show that even modest efforts to shift the balance of heteronormative discourse on behalf of LGBTQ students can have profound effects on the experiences and perceptions of sexual and gender minority youth, which we argue would go a long way in reducing incidents of suicidality among LGBTQ youth. In many jurisdictions across Canada, LGBTQ-inclusive policies have attempted to improve school climates and reduce the effects of homophobia and transphobia in schools These initiatives, along with the work done by Eagle Canada to create a National Youth Suicide Prevention Strategy, are important steps in addressing the needs of LGBTQ youth Kull et al. (2016) United States Antibullying policies that explicitly prohibit bullying based upon a student's sexual orientation, gender identity, and/or gender expression (SOGIE; i.e., SOGIE-inclusive policies)

Data from a national survey of LGBT students' school experiences (7,040 LGBT students from 2,952 unique school districts)

LGBT students in districts with SOGIE protections in their policies reported greater school safety, less victimization based on their sexual orientation and gender expression, and less social aggression than students with generic policies or no/unidentified policies Antibullying policies explicitly enumerating SOGIE protections can improve LGBT school experiences and that generic policies may not sufficiently protect LGBT students from bullying and harassment

Frontiers in Psychology | www.frontiersin.org 

United States Gay-straight alliances (GSAs) N = 62,923 participants in 15 primary studies GSA presence is associated with significantly lower levels of youth's self-reports of homophobic victimization, fear for safety, and hearing homophobic remarks

The findings of this meta-analysis provide evidence to support GSAs as a means of protecting LGTBQ+ youth from school-based victimization Lessard et al. (2020) United States Gay-straight alliances (GSAs, also referred to as gender-sexuality alliances)

A sample of diverse sexual and gender minority adolescents (N = 17,112; Mage = 15.57)

Lower levels of multiple forms of bias-based bullying (based on body weight, gender, religion, disability, gender typicality, and sexuality) at schools with versus without GSAs, and in turn higher perceived school safety, as well as higher grades and reduced school suspension (due to less weight-and sexuality-based bullying)

The findings shed light on the broad-reaching stigma-reduction potential of GSAs The support and belonging variables were responsible for 49-70% of the associations between sexual minority status and the health/well-being outcomes, with school belonging being the most important mediator These findings have important implications for health equity policy and practice Frontiers in Psychology | www.frontiersin.org Toomey et al. (2011) have pointed out that students perceived their schools as safer for gender nonconforming male peers when schools included LGBTQ issues in the curriculum and had GSAs. Given the growing significance of LGBTQ people as active, respected, and noticeable members of society (Chan, 2021b) , it is critical to promote LGBTQ acceptance within and beyond campus . LGBTQ students are more likely to report negative school performance when confronted with significant obstacles such as bullying, assault, and a lack of role models. Schools should uphold diversity, decency, compassion, and consideration (Chan, 2021c) . Additionally, deans of medical schools have suggested to increase teaching materials related to LGBTQ issues in order to improve medical services in schools (Van Bergen et al., 2013) .

This article has collected and analyzed the existing literature to indicate violence and prejudice as fundamental causes of psychological problems among LGBTQ adolescents and identify supportive strategies for schools to build a LGBTQfriendly environment. However, it is limited because previous studies still primarily focus on developed countries and offer limited insights into possible interventions in different contexts. This study has suggested how treatments should be further developed to guarantee lasting welfare and inclusion of LGBTQ adolescents.

As LGBTQ individuals are becoming a more dedicated, respected, and observable component of humanity (Chan, 2021a) , schools play a crucial part in ensuring that all children and adolescents realize that prejudice and discrimination are unacceptable. By teaching young people about all kinds of discrimination and their negative impact, critical pedagogy plays a crucial part in advancing human rights. It inspires optimism for the potential creation of a more just and fair society and empowers young people to be ethical new generations (Glazzard and Stones, 2021) . Mental health problems faced by LGBTQ youth are largely associated with discrimination, prejudice, and a lack of support from family, schools, and society at large. Increasing levels of support and acceptance for LGBTQ youth will most likely require political and social change in today's world, such as legalizing same-sex marriage and liberalizing cultural norms. Future research should continue to attend to LGBTQ students' health and educational needs and identify possible interventions in order to enhance their wellbeing.

AC and DW carried out the outline of this manuscript. AC wrote the manuscript with support from JH and IL. EY and IL gave valuable comments and suggestion. EY helped to supervise the whole manuscript. All authors contributed to the article and approved the submitted version.

The preparation of this manuscript was partially supported by funding from the Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China.

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LGBTQ youth activism and school: Challenging sexuality and gender norms

Early Intervention for LGBTQ Health: A 10-Hour Curriculum for Preclinical Health Professions Students

Internalizing symptoms and externalizing behaviors in Latinx adolescents with same sex behaviors in Miami

Sex, status, competition, and exclusion: Intraminority stress from within the gay community and gay and bisexual men's mental health

Health Disparities Between Sexual Minority and Different-Sex-Attracted Adolescents: Quantifying the Intervening Role of Social Support and School Belonging

Support, cohabitation and burden perception correlations among LGBTQA+ youth in Spain in times of COVID-19

Multiple identities: Creating community on campus for LGBT students

Understanding the mental health of transgender and nonbinary youth

Characteristics, experiences, and service utilization patterns of homeless youth in a transitional living program: Differences by LGBQ identity

Associations of lesbian, gay, bisexual, transgender, and questioning-inclusive sex education with mental health outcomes and school-based victimization in US high school students

Parents' journeys to acceptance and support of gender-diverse and trans children and youth

Young, disabled and LGBT+ identities

Perceived Parental Acceptance, Transgender Congruence, and Psychological Well-Being of

Coming out to parents and self-esteem among gay and lesbian youths

Educator interaction with sexual minority youth

Beyond education: What role can schools play in the support and protection of children in extreme settings?

Expanding our paradigms: Intersectional and socioecological approaches to suicide prevention

Tales From the Chalkface: Using Narratives to Explore Agency, Resilience, and Identity of Gay Teachers

Mental health issues and complex experiences of abuse among trans and gender diverse young people: findings from trans pathways

I can't quite be myself ": Bisexual-specific minority stress within LGBTQ campus spaces

Que (e) rying undergraduate medical curricula: a cross-sectional online survey of lesbian, gay, bisexual, transgender, and queer content inclusion in UK undergraduate medical education

High school gaystraight alliances (GSAs) and young adult well-being: An examination of GSA presence, participation, and perceived effectiveness

A qualitative investigation of LGBTQ+ young people's experiences and perceptions of self-managing their mental health

Lesbian, gay or bisexual identity as a risk factor for trauma and mental health problems in Northern Irish students and the protective role of social support

Victimization and suicidality among Dutch lesbian, gay, and bisexual youths

Gender Identity, Sexual Orientation, Mental Health, and Bullying as Predictors of Partner Violence in a Representative Sample of Youth

Implementing school nursing strategies to reduce LGBTQ adolescent suicide: a randomized cluster trial study protocol

Sexual and Gender Minority Youth in Foster Care: Assessing Disproportionality and Disparities in Los Angeles

LGBTQI+ youth and mental health: a systematic review of qualitative research

LGBTQ policies and resources on campus and the experiences and psychological well-being of sexual minority college students: Advancing research on structural inclusion

Understanding linkages between bullying and suicidal ideation in a national sample of LGB and heterosexual youth in the united states

AC and DW would like to express their gratitude to Dr. Ben Ku from the Department of Applied Social Sciences, Hong Kong Polytechnic University.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.