The USICH intervention model for homeless youth identifies screening and assessment of youth as a first step toward targeting services appropriately. Assessments identify risk factors, which are “problematic symptoms, behaviors, and associations” that may contribute to poor outcomes, and protective factors, which are “positive skills, attitudes, behaviors, and associations” that counteract the effects of risk (U.S. Interagency Council on Homelessness 2012).9 According to the model, assessments should help providers determine how long a youth has been homeless (because a longer time on the streets is likely to put youth at higher risk), the risk factors that services should mitigate, and the protective factors that should be enhanced.
LGBTQ homeless youth may experience different patterns of risk from other homeless youth. One study of homeless youth in Seattle, for example, found that LGBT youth exhibit mental health or behavioral issues at higher rates than heterosexual youth, including such traits as delinquency, aggression, and withdrawn behavior (Cohran et al. 2002). Another survey found that lesbian, gay, and bisexual (LGB) youth in six states were more likely than non-LGB youth to engage in survival sex and substance abuse (Van Leuuwen et al. 2006). LGBTQ youth also may be more likely to experience rejection by parents, which contributes to youth homelessness (Quintana et al. 2010). According to existing research, transgender people, including youth, appear to face widespread discrimination in employment and housing, and tend to have difficulty accessing safe and appropriate shelter when homeless (Grant et al. 2011; Mottet and Ohle 2003).
LGBTQ youth may also benefit from protective factors in distinct ways. Support of friends and family may be especially important for youth who are sexual minorities. According to one study, this type of support positively affects measures of well-being among LGB youth, with family support, in particular, associated with reduced mental distress (Shilo and Savaya 2011). In another study, perceptions of social support, a sense of being connected to other people, and self-esteem in being part of a larger community (such as the LGBT community) were linked to psychological well-being among LGB youth (Detrie and Lease 2007). An emerging area of research focuses on the potential for resiliency—the ability to overcome challenges or trauma—to lessen the psychological harm that LGBT victims of harassment or violence may experience.
Our discussions with agency staff explored approaches to conducting assessments of homeless youth and addressing issues of sexual orientation and gender identity in this process. To better understand service provider perceptions, we also asked staff about the risks or needs exhibited among LGBTQ youth they serve, and how, in their experience, they compare between LGBTQ and non-LGBTQ youth. We found the following:
- Assessment tools may help staff explore risks or needs related to LGBTQ identity, but these issues are more often addressed during less structured discussions with youth.
- Many staff felt that homeless youth face similar types of risks, regardless of sexual orientation and gender identity. Nevertheless, some types of risks—emotional distress and poor mental health, substance abuse and sexual risk behavior, and problems with family and personal relationships—were perceived to be particularly salient or frequent among LGBTQ youth.
- According to staff reports, some LGBTQ youth encounter barriers to accessing services or resources that may enhance protective factors, including health and employment. These barriers may be especially high for transgender youth.
9 Risk factors specified in the USICH model include (1) trauma, (2) emotional distress, (3) sexual risk behavior, (4) family problems, (5) criminal or delinquent behavior, and (6) substance abuse. Protective factors specified include (1) family cohesion and support, (2) school engagement or employment, (3) survival skills, (4) positive connections, (5) positive future expectations, (6) decision-making skills, (7) self-esteem and self-efficacy, and (8) health.
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A. Addressing LGBTQ Identity in Assessments
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Agency staff conduct assessments during initial intake sessions and subsequent meetings with youth. These assessments focus on triaging to determine immediate needs, detailing personal circumstances, and identifying risk factors or barriers that may need to be addressed through longer-term services. Intake forms gather information on such topics as (1) living situation and reasons for homelessness; (2) physical and mental health status; (3) education history; (4) employment history and income; (5) involvement with other agencies (such as child welfare or juvenile justice); (6) experience with domestic violence; and (7) needs for food, shelter, and identification. Subsequent meetings, such as conversations between youth and licensed mental health staff, may address a broader range of issues and include more detailed assessments of risks and needs related to mental health status, experience with abuse or neglect, and substance abuse.
Some agencies’ assessment tools address sexual orientation and gender identity, but no agencies reported using tools that specifically target LGBTQ youth. Questions on life skills or health assessments can prompt discussion of issues related to LGBTQ identity. For example, according to staff at one agency, administration of the Casey Life Skills Assessment, which includes a question on comprehension of sexual orientation and gender identity concepts, sometimes leads to further conversations about these topics.10 Another agency’s health risk assessment form includes a question on sexual orientation and gender identity. This question helps staff put into context later items addressing safer sex practices and may also trigger discussions with youth about concerns related to sexual orientation or gender identity development.
Some staff reported that they assess needs or circumstances related to LGBTQ identity based on their own knowledge of these issues and techniques for exploring them with clients. For example, one staff member reported that she discusses sexual orientation and gender identity development milestones during individual meetings with youth, if these topics are of concern. With LGBTQ-identified youth, she inquires whether and to whom youth have disclosed their LGBTQ status, and, if so, the kinds of responses they have received.
10 The Casey Life Skills Assessment is a self-administered or interview-based questionnaire that assesses youths’ behaviors, knowledge, and awareness in eight life skill areas. Youth indicate whether statements presented in the tool “are like me” using a five-point scale. Under the Relationships and Communication area, the assessment presents the statement, “I can explain the difference between sexual orientation and gender identity.” For more information about this tool, see: http://www.casey.org/Resources/Tools/cls/default.htm.
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B. Perceptions of Needs, Risks, and Capacities of LGBTQ RHY
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In general, staff in case study agencies did not perceive major differences in the types of risks faced by LGBTQ and non-LGBTQ RHY. However, they did indicate that certain risks may be especially frequent among LGBTQ RHY or have distinctive contributing factors. For example, staff at one agency explained that they provide services using a trauma-informed perspective to understand how experiences of violence, abuse, and other adverse experiences shape all youths’ thoughts, feelings and behaviors. Although all RHY are likely to have experienced trauma, among LGBTQ RHY, these experiences may be connected with negative responses to the youths’ sexual orientation or gender identity from family, peers, and others.
Agency staff considered several risk factors to be salient for LGBTQ RHY. Although data are not available to confirm whether these risks affect LGBTQ youth disproportionately in case study agencies, staff perspectives concur with findings from existing research (summarized in the introduction to this chapter). Risk factors highlighted by staff include the following:
- Emotional distress, poor mental health, and substance abuse. Staff in all case study agencies perceived that LGBTQ RHY often contend with issues related to mental health. At two sites, staff reported that LGBTQ youth are more frequently referred than other youth for mental health treatment. Emotional distress among LGBTQ RHY may be a result of life trauma intensified by negative reactions from family and community to disclosure of sexual orientation, gender identity, or both. Staff noted that LGBTQ RHY appear to be likely to exhibit signs of depression, heightened anger and issues with conflict resolution, and uncertainty around identity development. Staff also reported that LGBTQ RHY frequently experience problems with drug or alcohol abuse, a perception consistent with findings from previous research.
- Sexual risk behavior and sexual exploitation. A few staff members noted a propensity among LGBTQ RHY to engage in risky sexual behavior and face exposure to sexually transmitted infections, a perception supported by analyses of data from the Centers for Disease Control and Prevention’s Youth Risk Behavior Surveillance System (Kann et al. 2011). This pattern may be linked to a general tendency among youth to take risks, but studies also have found an association between stressors related specifically to gay, lesbian, or bisexual sexual orientation (such as social isolation or victimization) and high-risk sexual behavior and other problem behaviors (Rotheram-Borus et al. 1995). Similar factors may contribute to problems LGBTQ RHY experience related to sexual exploitation, including human trafficking, which staff at one agency perceived to be more common among LGBTQ youth than other youth they serve.
- Family problems, relationship issues, and intimate partner violence (IPV). Staff in all agencies indicated that LGBTQ RHY are likely to have endured family and social rejection, sometimes directly linked to their sexual orientation or gender identity. However, a few expressed caution about assuming that family conflict is the primary driver of LGBTQ youth homelessness, which can also result from families’ difficult economic circumstances or parents’ personal issues. LGBTQ RHY may also have general difficulty forming trusting relationships, according to some staff, possibly because of experiencing IPV, an absence of adult role models, or efforts to avoid disclosing their sexual orientation or gender identity. Some staff members highlighted IPV, in particular, as a problem among LGBTQ RHY. Indeed, results of one study of violence and abuse within dating relationships among a sample of 5,647 middle- and high-school youth in three states confirms this impression. The study found that lesbian, gay, and bisexual youth were at elevated risk for dating violence victimization and perpetration, compared to their heterosexual peers, and that transgender youth were more likely than non-transgender male or female youth to be victimized and to perpetrate violence (except psychological abuse) (Dank et al. 2013).
Staff also mentioned risks relevant to subpopulations of LGBTQ youth, particularly transgender youth and youth of color. Staff in one agency felt that it was sometimes difficult when working with transgender youth to balance youths’ understandable focus on gender transition with the need to address other concerns, including housing and employment. Transgender youth also were perceived to be at particular risk of emotional distress resulting from discrimination or harassment, both by peers and within the larger community.
Staff in two agencies noted that LGBTQ youth of color face particular obstacles related to family and community acceptance. Staff shared the impression that minority racial and ethnic communities may be more likely to be connected to cultural or religious institutions that are not supportive of LGBTQ people and that LGBTQ youth in these communities may be likely to experience rejection by families and others as a result. These impressions echo findings in other research indicating that LGBTQ youth who are racial or ethnic minorities encounter challenges in family and community relationships. One study of Latino and non-Latino LGBT young adults, for example, found that Latino families, immigrant families, and families with high religious involvement were less likely to be accepting of LGBTQ youth (Ryan et al. 2010). In another study, representatives of schools and community organizations working with LGBT youth of color in Los Angeles indicated that gay, bisexual, and transgender male youth may have difficulty accessing services in racial or ethnic minority communities where religious organizations are prominent providers, due to stigma or prejudice (Durso et al. 2013).
According to agency staff, experiences among LGBTQ youth have the potential to support development of protective factors or personal capacities. In particular, resiliency among LGBTQ homeless youth may increase as they learn to contend with discrimination. Staff perceived LGBTQ youth to be “survivors” who develop self-protection skills after experiencing stigma and rejection. LGBTQ youth may also build resiliency by successfully connecting with other youth who share their sexual orientation or gender identity.
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C. Service and Resource Barriers Affecting LGBTQ Youth
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To enhance protective factors for RHY, agency staff attempt to provide or link youth with services that address identified needs and mitigate risks. Staff in case study agencies noted that some LGBTQ youth face barriers in accessing services or opportunities that may be important for achieving positive outcomes. Staff commonly mentioned barriers to two resources in particular:
- Health care. Staff noted that LGBTQ youth face challenges accessing care to address their unique health needs. Youth may find it difficult to locate health care providers who are knowledgeable about LGBTQ issues and prepared to discuss the particular risks LGBTQ youth face. Transgender RHY seeking assistance with gender transition may be unable to access this type of care. Staff in three of the four sites visited indicated that they face challenges trying to locate health care providers with expertise serving transgender people in their area.
- Employment. Staff also reported that LGBTQ RHY tend to encounter distinct obstacles to employment. Employers are not always accepting of LBGTQ youth, especially those whose gender expression does not conform to societal expectations. LGBTQ youth, and transgender youth in particular, may also experience harassment from fellow workers, decreasing their motivation to maintain employment.
Some agencies take steps to mitigate these barriers as they provide services to LGBTQ RHY. We describe these efforts in Chapter IV.
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