TRANSLATIONS

Health Justice for LGBT Youths: Combining Public

Health and Human Rights
Stewart L. Adelson, MD, Graeme Reid, PhD, Alice M. Miller, JD, Theo G.M. Sandfort, PhD

s a socially marginalized group, LGBT youths LGBT youths provide an example of a group experi-
A experience elevated rates of physical and mental
health problems that are leading causes of mor-
tality due to a variety of factors. Minority stress theory links
encing health risk disparities. Suicide is the second leading
cause of mortality from age 15 to 24 years in the United
States, and psychiatric and behavioral problems including
exposure to stigma with health outcome disparities. Struc- suicide, homicide, and accidents—frequently involving
tural stigma including biased laws, policies, and societal substance use—are the leading causes of youth and young
norms predicts approximately 20% of elevated suicidality adult mortality in the general population.1 Although the
among LGBT youths. Comprehensive public health efforts majority of LGBT youths are healthy, in comparison with
to reduce mental health disparities among LGBT youths the general population they are at increased risk for physical
need to address structural stigma. An interdisciplinary and mental health problems. LGBT youths are at approx-
Health Justice approach is described, in which public health imately 2- to 4-fold greater risk for suicidality compared to
evidence is integrated with human rights principles in the general population, as well as increased risk for
keeping with the bioethical Justice Imperative. In this depression, anxiety, substance abuse, disordered eating, to-
approach, epidemiological research is used to inform public bacco use, and HIV/AIDS.2 These are significant morbid-
health efforts to address health disparities in LGBT youths ities and causes of increased mortality.
due to structural stigma in a way that is (1) empirical; (2) In addition to addressing health problems at the indi-
aimed at basic goals of reducing morbidity and mortality; vidual level, epidemiology and public health provide
(3) applicable to diverse cultural contexts; (4) capable of powerful tools to understand and to address societal patterns
amending stigma-related power and associated health in- and causes of health disparities through advocacy at com-
equities; and (5) guided by human rights principles. By munity and societal levels. Such advocacy requires appro-
applying human rights principles to public health needs, priate concepts, skills, and tools to respond to structural
this approach will help to achieve health equity for LGBT influences on epidemics. It may entail collaboration with
youths. colleagues possessing expertise to translate public health
Social inequities contribute to disparities in physical knowledge into policies, programs, and practices that
and mental health. Some health disparities are a result of address structural determinants of health. We describe a
factors directly affecting health care delivery, such as framework derived from both human rights and bioethics
policy inequities or implicit bias. In addition, there are a principles through which such collaboration can address an
number of indirect mechanisms that link social inequality important cause of mental health disparities in LGBT
to poor health, such as maldistribution of economic re- youths: minority stress due to stigma. We describe an
sources and societal power associated with disparities in interdisciplinary approach to reducing minority stress due to
nutrition, education, employment opportunities, family stigma as an example to illustrate the collaboration that is
stability and support of families, community safety, needed to address other structural influences on mental
transportation, encounters with the criminal legal system, health risk as well.
and housing. Medical paradigms that focus solely on
individual determinants of health to the exclusion of STRUCTURAL PREJUDICE, MENTAL HEALTH,
societal determinants risk overlooking important modifi- AND HEALTH JUSTICE
able health risk factors and colluding with their Stigma involves negative stereotyping of marginalized
perpetuation. groups. Anti-LGBT stigma is an important specific risk

804 www.jaacap.org Journal of the American Academy of Child & Adolescent Psychiatry
Volume 60 / Number 7 / July 2021
 TRANSLATIONS

factor for LGBT adults and youths, and can occur at several entail using legislative and jurisprudential tools capable of
levels.3 Components of stigma include being given a dis- achieving health equity.9 We conceive of Health Justice for
tinguishing label; having negative attributes ascribed; being LGBT youths as involving the application of human rights
seen as different from others; loss of status; discrimination, principles to public health needs. From a Health Justice
that is, being treated unfavorably; and experiencing loss of perspective, understanding and intervening in health dis-
resources and/or power.4 Minority Stress Theory relates parities’ relation to social inequity is necessary to ameliorate
exposure to stigma to health outcome disparities in disad- social and health inequities.
vantaged groups through a variety of direct and indirect Historically, civil rights progress in the United States
social influences over time, including epigenetic, allostatic, has involved collaboration with mental health science
hypothalamic pituitary, traumatic learning, and other applied for justice. In its landmark Brown v Board of Ed-
mechanisms.5 ucation (1954) decision overturning “separate but equal”
At an individual level, examples of LGBT stigma education systems, the US Supreme Court established a
include identity concealment and rejection anticipation. At precedent by which the court considered evidence of psy-
an interpersonal level, examples of LGBT stigma include chological harm to youths. In the majority opinion’s
family nonacceptance and peer bullying, both of which are important “Footnote 11,” the court considered social sci-
associated with suicidality. Homophobic bullying is associ- ence evidence of the deleterious mental health effect on
ated with risk for chronic depression, anxiety, and substance minority youths of exposure to segregated schools as part of
abuse.6 A third level is structural stigma involving norms, legal evidence bearing upon the right to educational
policies, and laws. Examples include laws or policies that equality. Under 14th Amendment constitutional rights to
confer unequal status, such as inequities in school anti- equal protection and due process, along with other evi-
bullying programs excluding LGBT youths from protected dence, the psychological harm of this structural stigma to
groups. Other examples include marriage inequality, youths supported the court’s conclusion that the prevailing
employment nondiscrimination laws, and high community “separate but equal” system was unjustified.
rates of anti-gay bias crime. The Supreme Court’s 2015 Obergefell v Hodges mar-
LGBT stigma may be exacerbated by other intersecting riage equality decision applied this jurisprudential precedent
stigma, such as sexism and racial/ethnic or other biases. in considering youth mental health evidence related to 14th
Intersectional theory posits that a comprehensive under- Amendment equal rights protections. It considered scien-
standing of health must also consider factors such as race/ tific findings that same-sex families promote the mental
ethnicity, gender, socioeconomic status, and other possible health and well-being of youths as well as heterosexual
markers of marginalization. These factors may interact to families. This research followed changes in medical
mediate or modify the impact of stigma on health status nomenclature that had historically reflected and reinforced
across and differentially within the populations constituting cultural stigma against gay and lesbian people.10 The court
LGBT youths.7 recognized other historical changes in marriage such as the
Controlling for other personal and interpersonal stigma demise of coverture, by which a woman’s rights were sub-
and other risk factors such as being depressed, living in sumed under her husband’s; of anti-miscegenation laws; and
stigmatizing social environments is associated with approx- marriages arranged without the consent of both parties.
imately 20% more suicide attempts in LGBT youths.8 Simultaneously, it recognized marriage’s importance to
Exposure to structural stigma such as community laws children’s well-being, and therefore a compelling govern-
and policies that reflect prejudiced societal norms is thus a ment interest in regulating it. The court concluded that
unique risk factor for poor health outcomes among disad- there was no rational constitutional basis for denying chil-
vantaged minorities. Therefore, any comprehensive public dren the benefits of same-sex families. Research on LGBT
health effort to reduce LGBT youth suicide must consider youth suicide following Obergefell v Hodges found that
the role of structural stigma. establishing marriage equality was followed by decreased
suicidality among LGBT youths.11 This provides evidence
PROMOTING HEALTH EQUITY: that eliminating stigmatizing laws and policies and other
INTERDISCIPLINARY COLLABORATION TO structural stigma can be an important public health measure
ADDRESS STRUCTURAL RISK FACTORS to reduce youth mental illness burden and mortality.
A critical strategy to improve health outcome disparities in Building on this model, health, legal, and policy ex-
socially disadvantaged groups involves collaboration among perts can assemble and disseminate epidemiological and
fields such as pediatric mental health, human rights law, and other health research knowledge about youth mental
public health to achieve Health Justice. Health Justice may health disparities to help ground law and policy in
Journal of the American Academy of Child & Adolescent Psychiatry www.jaacap.org 805
Volume 60 / Number 7 / July 2021
ADELSON et al.

scientific evidence. Examples pertaining to LGBT youths questions about how to achieve public health goals in the
in the United States include laws and policies that increase face of political hostility. These include how to translate
risk for adverse interpersonal experiences such as bullying and interpret public health goals in a culturally meaningful
through school climate and anti-bullying program ineq- way; the role of health science research in informing legal
uity, family nonacceptance in child welfare and adoption, and human rights affecting LGBT people; the appropriate
lack of protection from hate crimes, community harass- relationship between public health aims and rights advo-
ment and inequitable policing, and exposure to structural cacy; and how to reconcile public health goals when these
inequality due to discriminatory laws in employment, are seen to be in conflict with cultural values, without
housing, and public accommodation.12 Policy areas in sacrificing rights. This is all the more so in settings in
which health outcome research could address areas of which culture and tradition become highly politicized, and
recent controversy related to transgender youths in LGBT youths are caught in the middle of geo-political
particular include nondiscrimination and public accom- conflicts that have little to do with their daily lived realities.
modation, access to care, and health research enumeration In many countries, constitutional jurisprudence often
such as inclusion in public health population surveil- entails balancing competing interests and rights. Collabo-
lance.13,14 Internationally, advocacy areas include rights ration with legal and human rights experts in a Health
abuses such as curtailment of speech promoting family and Justice model provides a mechanism for translating health
societal acceptance, conversion therapies, so called science knowledge into programs, policies, and practices
“corrective rape,” imprisonment, forced marriage, torture, that can support favorable youth mental health outcomes
and capital punishment. An international example is against competing factors put into play in jurisprudence and
Russia’s so-called “anti-propaganda” laws that limit free policy formulation.
speech in support of LGBT people in the presence of a Bioethical and human rights traditions are foundational
minor.15 Such draconian laws endanger youths byout- frameworks within which Health Justice can be pursued.
lawing speech including support for family acceptance, Following the World War II, the Universal Declaration of
anti-bullying protection, or affirmative mental health care. Human Rights established a global human rights framework
Collaborating with public health, human rights, and reflecting principles of human equality and common hu-
policy experts, mental health experts can clarify research ev- manity. Contemporaneous bioethics codes include the
idence relevant to policy, mechanisms of change, appropriate Nuremberg Code (1947), the Belmont Report (1979), the
methods of data collection, and evaluation of effective stra- World Medical Association Declarations of Helsinki (1964–
tegies to decrease structural LGBT and intersectional stigma 2008), and various foundational codes of research ethics.
and support mental health in LGBT youths. Human rights These bioethical frameworks codify widely recognized
experts can, in turn, evaluate opportunities to advocate for bioethics principles reflecting both secular humanist and
policies, laws, and programs that support youth equity and religious tradition. They recognize a bioethical Justice
mental health. Strategies to facilitate such collaboration Imperative that includes a principle of Distributive Justice
include meetings, information exchange in academic and that requires equitable distribution of health resources
public service channels, and promotion of data sharing. within populations.
Along with constitutional and human rights frameworks,
PUBLIC HEALTH, CULTURAL SPECIFICITY, AND the Justice Imperative provides a basis for harmonizing
THE HUMAN RIGHTS AND BIOETHICAL legal, human rights, and bioethical foundations of Health
FRAMEWORKS FOR HEALTH JUSTICE Justice. Recent developments in human rights advocacy
Health justice efforts may involve advocating for change in seek to build accountability for recognition and distribution
stigmatizing policies and laws associated with morbidity and regimes of governments, markets and other institutions. In
mortality. To be effective, public health efforts to reduce addressing structural determinants of health, including
stigma need to be framed in a culturally intelligible register. stigma, a Health Justice framework is a strategy for achieving
This is particularly true in relation to divergent, culturally distributive justice in pursuit of the Justice Imperative.
inflected understandings of sexuality. However, in a plural-
istic and changing world, LGBT identities are often seen as CONCLUSION
markers of modernity, cast as a threat to culture and tradition A Health Justice approach provides a heuristic by which
or a foreign import threatening national sovereignty. epidemiological research can inform public health efforts to
As a result, questions of culture and tradition can address health disparities due to structural stigma in a way
become highly fraught and politically contested, raising that is (1) empirical; (2) aimed at basic goals of reducing

806 www.jaacap.org Journal of the American Academy of Child & Adolescent Psychiatry
Volume 60 / Number 7 / July 2021
 TRANSLATIONS

morbidity and mortality; (3) informed by cultural and Author Contributions

historical perspectives; (4) capable of amending stigma- Writing e original draft: Adelson
Writing e review and editing: Reid, Miller, Sandfort
related power and associated health inequities; and (5)
ORCID
guided by human rights principles. This approach can help Stewart L. Adelson, MD: https://orcid.org/0000-0002-6069-3174
to achieve public health goals of health equity for LGBT Graeme Reid, PhD: https://orcid.org/0000-0002-6404-2459
Alice M. Miller, JD: https://orcid.org/0000-0001-8527-1595
youths and other stigmatized groups, rooted in public Theo G.M. Sandfort, PhD: https://orcid.org/0000-0002-4986-1739
health and human rights principles that are effective and The authors gratefully acknowledge the support of the Tides Foundation and
intelligible within diverse cultural settings. Broadway Cares/Equity Fights AIDS who supported this project through the
Youth Equity Science Project of the Yale Law and Public Health Schools’ Global
Health Justice Partnership.
Disclosure: Drs. Adelson, Reid, Sandfort, and Ms. Miller have reported no
Accepted March 3, 2021.
biomedical financial interests or potential conflicts of interest.
Dr. Adelson is with Weill Cornell Medical College, Yale Law School, and
Correspondence to Stewart L. Adelson, MD, Columbia University Vagelos
Columbia University Vagelos College of Physicians and Surgeons, New York.
College of Physicians and Surgeons, Weill Cornell Medical College and Yale
Dr. Reid is with Human Rights Watch, Yale University, New Haven, Connecticut.
Law School Global Health Justice Partnership, 117 West 17th Street, Suite 2B,
Dr. Miller is with Yale Law School and Yale School of Public Health, New Haven,
New York, NY 10011; e-mail: [email protected]
Connecticut. Dr. Sandfort is with the Division of Gender Sexuality and Health,
Columbia University and New York State Psychiatric Institute, New York. 0890-8567/$36.00/ª2021 American Academy of Child and Adolescent
Psychiatry
Dr. Sandfort’s contribution was supported by a grant from the National Institute
of Mental Health (NIMH; P30 - MH43520; PI: Remien). https://doi.org/10.1016/j.jaac.2021.02.021

REFERENCES
1. Centers for Disease Control and Prevention. 10 Leading causes of death by age group, 11. Raifman J, Moscoe E, Austin SB, McConnell M. Difference-in-differences analysis of the
United Statese2018. Accessed November 6, 2020; https://www.cdc.gov/injury/images/ association between state same-sex marriage policies and adolescent suicide attempts.
lc-charts/leading_causes_of_death_by_age_group_2018_1100w850h.jpg. JAMA Pediatr. 2017;171:350-356.
2. Adelson SL, Schuster MA. Gay, lesbian & bisexual adolescents. In: Kliegman RM, 12. “Like Walking Through a Hailstorm:” Discrimination Against LGBT Youth in US
Stanton BF, St. Geme J, chor N, eds. Nelson Textbook of Pediatrics. 21st Edition. Schools. Human Rights Watch. 2016. Accessed October 25, 2020; https://www.hrw.
Philadelphia: Elsevier; 2020. org/report/2016/12/08/walking-through-hailstorm/discrimination-against-lgbt-youth-us-
3. Hatzenbuehler ML, Pachankis JE. Stigma and minority stress as social determinants of schools.
health among lesbian, gay, bisexual, and transgender youth: research evidence and clinical 13. Cahill S. “The best of times.the worst of times": What Bostock v. Clayton County,
implications. Pediatr Clin North Am. 2016;63:985-997. Georgia and the repeal of federal nondiscrimination rules mean for LGBT health. LGBT
4. Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27:363-385. Health. 2020;7:345-348.
5. Meyer IH, Frost DM. Minority stress and the health of sexual minorities. In: 14. Thoreson R. Lawmakers in the US unleash barrage of anti-transgender bills; proposed
Patterson CJ, D’Augelli AR, eds. Handbook of Psychology and Sexual Orientation. New laws threaten health, rights of trans kids. Human Rights Watch, January 20, 2020.
York: Oxford University Press; 2013:252-266. Accessed January 15, 2021; https://www.hrw.org/news/2020/01/20/lawmakers-us-
6. Roberts AL, Rosario M, Slopen N, Calzo JP, Austin SB. Childhood gender nonconformity, unleash-barrage-anti-transgender-bills.
bullying victimization, and depressive symptoms across adolescence and early adulthood: an 15. Hylton E, Wirtz AL, Zelaya CE, et al. Sexual identity, stigma, and depression: the role of
11-year longitudinal study. J Am Acad Child Adolesc Psychiatry. 2013;52:143-152. the “anti-gay propaganda law” in mental health among men who have sex with men in
7. Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Moscow, Russia. J Urban Health. 2017;94:319-329.
Health. 2000;90:1212-1215.
8. Hatzenbuehler ML. The social environment and suicide attempts in lesbian, gay, and
bisexual youth. Pediatrics. 2011;127:896-903.
All statements expressed in this column are those of the authors and do not
9. Benfer EA. Health justice: a framework (and call to action) for the elimination of health
reflect the opinions of the Journal of the American Academy of Child and
inequity and social justice. Am Univ Law Rev. 2015;65:275. Adolescent Psychiatry. See the Guide for Authors for information about the
10. Bayer R. Homosexuality and American Psychiatry: The Politics of Diagnosis. New York: preparation and submission of Translations.
Basic Books; 1981.

Journal of the American Academy of Child & Adolescent Psychiatry www.jaacap.org 807
Volume 60 / Number 7 / July 2021