Moderation Effects of State LGBTQ+ Policy Environments on Mental Health Disparities between Youth with and without a Sexual Minority Identity: Evidence from National Data

Background and Purpose:

Sexual minority youth (SMY), including those who identify as lesbian, gay, or bisexual (LGB), face elevated mental health risks compared to their heterosexual peers. Rates of depression and suicidality among U.S. adolescents have risen in recent years, and structural stigma and unsupportive environments remain key contributors to these disparities. Given the variation in state-level LGBTQ+ policies across the U.S., this study examines whether more inclusive state policies are associated with lower mental health risks and reduced disparities between LGB and non-LGB youth.

Methods

Data were pooled from the 2021 and 2023 Youth Risk Behavior Surveillance System (YRBSS), including 215,395 high school students. States were grouped into four levels of LGBTQ+ policy inclusiveness based on the Human Rights Campaign’s (HRC) annual policy classification report. Outcomes included self-reported depression, suicidal ideation, suicide planning, and suicide attempts in the past 12 months. The primary independent variable was LGB identity (vs. non-LGB). Covariates included sex, race/ethnicity, grade, socioeconomic status (proxied by fruit consumption), experience of being bullied, and survey year. Survey-weighted logistic regression models were estimated in Stata (v18), and average marginal effects (AMEs) and predicted probabilities were calculated to assess disparities across policy categories.

Results

Of the total sample, 25.2% identified as LGB. Most LGB youth (77.5%) resided in the most inclusive states. Among LGB youth, the predicted probability of feeling depressed ranged from 54.4% in states with the most inclusive policies to 60.3% in those with moderately inclusive policies. Within the same group, the predicted probabilities of suicidal ideation, suicide planning, and suicide attempts ranged from 33.1% to 40.3%, 25.9% to 33.0%, and 14.5% to 19.1%, respectively. Across these three outcomes, the highest probabilities were consistently observed in the most exclusionary policy environments and the lowest in the most inclusive ones.

Across all outcomes, LGB youth had significantly higher predicted probabilities of adverse outcomes compared to non-LGB peers. The largest disparities were consistently observed in most exclusionary states, and gaps narrowed in more inclusive environments. The predicted probability gap in suicidal ideation declined from 24.4 percentage points to 19.0 percentage points between least and most inclusive states. Similar reductions were observed for suicide planning and suicide attempts. The confidence intervals for disparities in suicidality outcomes between LGB and non-LGB youth did not overlap between the least and most inclusive policy environments. This indicates statistically significant moderation effects of policy environments on severe mental health risks.

Conclusions and Implications

Inclusive state-level LGBTQ+ policies moderate the association between LGB identity and poor mental health, particularly for suicidal ideation, planning, and attempts. While disparities persist, more inclusive policy environments are linked to lower mental health risks among LGB youth and reduced disparities between LGB and non-LGB youth. These findings underscore the role of structural protections in mitigating mental health inequities and suggest that expanding inclusive policies may serve as an important public health strategy to support sexual minority youth.