Reduction of Bullying to Address Health Disparities Among LGBT Youth

  • Date: Nov 18 2014
  • Policy Number: 20142

Key Words: Gay Lesbian Bisexual Transgender, Adolescent Health, Violence

Bullying of young people in schools has become a major concern in America. Its prevalence is pervasive (for example, up to 32% of all youth between 12 and 18 years of age report having been victimized), and it has a strong impact on a student’s well-being, social functioning, and academic achievement. Bullying contributes to increased risks for suicide, depression, high-risk sexual behavior, and substance use, among other negative health outcomes. Sexual minority youth, or those youth who are perceived as such, are disproportionately subjected to bullying relative to their heterosexual counterparts. Over the past 20 years, progress has been made through state laws prohibiting bullying and implementation of innovative programs within schools and classrooms to reduce harassment and improve the safety of LGBT (lesbian/gay/bisexual/transgender) youth. However, to accelerate the decline of this problem and its resulting disparities, additional comprehensive efforts must be made. APHA sets forth a series of recommendations that can be used to advance policies promoting safety and providing sufficient recourse for victims. Most important, these recommendations advocate for comprehensive health education, sex education, and sexual health programs that will address the problem upstream by influencing children’s beliefs and behaviors at a very early age.

Relationship to Existing APHA Policy Statements  
•    APHA Policy Statement 2004-09: Promoting Public Health and Education Goals through Coordinated School Health Programs

Problem Statement
LGBT (lesbian/gay/bisexual/transgender) youth (or those perceived as such) are disproportionately subjected to harassment and bullying relative to their heterosexual counterparts.[1] (The terms “LGBT” and “sexual minority,” as used here, encompass those whose identities are more accurately described as lesbian, gay, bisexual, transgender, gender variant, gender neutral, questioning, queer, two-spirit, or intersex. The defined terms are used for brevity and not for exclusionary purposes.) Bullying has a strong impact on students’ well-being (regardless of their sexual orientation or gender identity), social functioning, and academic achievement. Bullying places young people at increased risk of suicide, depression, high-risk sexual behaviors, and substance use, among other negative health outcomes.[2] Those who engage in bullying also suffer ill effects throughout their lives, such as escalating use of bullying or violence and psychiatric disorders.[2]

US-based research on the prevalence of bullying is limited, and estimates vary; however, all findings show bullying to be a pervasive problem. For example, 2007 data from the US Department of Education showed that 32% of students 12 to 18 years of age reported having been bullied during the school year.[3] According to the National Institutes of Health (NIH), the prevalence of bullying among students in grades 6 through 10 (in public schools) is 23.6% (including students identified as both victims and perpetrators).[4] A widely accepted definition of bullying is that it is a specific type of aggression in which (1) the behavior is intended to harm or disturb, (2) the behavior occurs repeatedly over time, and (3) there is an imbalance of power, with a more powerful person or group attacking a less powerful one.[4]

Data specifically focused on the LGBT population, including LGBT youth and those who are perceived as such, are highly limited, with few high-quality data sets and a lack of sufficient sample sizes. A 2011 Institute of Medicine report recommended, as a minimum for further research, that “[d]ata on sexual orientation and gender identity…be collected in federally funded surveys…which could provide valuable information on the context for health disparities experienced by LGBT people. Similarly, surveys on crime and victimization…would be aided by the development of standardized measures.”[5] Such gaps in the data have forced those studying disparities among LGBT populations to rely on data sets that are not as current as would be desired or to use combinations of different data sets through statistical manipulation. For example, the biennial Youth Risk Behavior Survey (YRBS), conducted by the Centers for Disease Control and Prevention (CDC), does not include any questions on sexual orientation or gender identity, instead encouraging states and cities to add their own questions. This practice has resulted in wide variance in what is asked, how it is asked, and, ultimately, the reliability of the resulting data (the CDC has conducted a meta-analysis of the jurisdictions with the most similar questions over the period 2001–2009; that analysis and its findings are discussed below).[6]

In April 2013, the Journal of Adolescent Health issued an editorial statement recognizing that one of the difficulties in data collection is a lack of understanding by researchers during survey instrument design. Sexual orientation involves constructs of attraction, behavior, and identity. Within each construct, a wide spectrum exists that evolves throughout adolescence and adulthood. The recognition of this complex requirement for thorough data yielded an editorial position according to which providers, clinicians, and researchers must exercise caution in assigning any labels to an adolescent.[7] Large-scale cross-sectional and longitudinal studies that incorporate standardized language to assess sexual orientation and gender identity are necessary to capture the complexities of these constructs. Such improvements will enhance the value of future survey data so that disparities can best be addressed through directed programs and interventions suited to specific subpopulations.

Beyond the issues noted in that editorial statement, many data sets are small and cross sectional and rely on self-reported information. Youth may not respond to any nonconforming classification. The language used to ask about sexual orientation or gender identity is inconsistent in contemporary research. Perhaps most important, researchers have had difficulty adequately teasing apart the experiences of the different populations within the broad LGBT umbrella because of small sample sizes. Data have shown strong evidence suggesting that youth who have participated in same-sex behavior or who are questioning their sexuality represent a very significant portion of the population most bullied.[8] Yet, it is this very group that is least likely to be addressed through interventions because they are not captured in surveys that do not allow for a spectrum of orientations and identities.[8]

Fortunately, sufficient data are available to allow the conclusion that LGBT youth (or those who are perceived as such) are disproportionately subjected to harassment and bullying.[1] Prominent among the major relevant studies is the above-mentioned Youth Risk Behavior Survey. Although this survey does not include questions about sexual orientation or gender,[9] states and other jurisdictions, as noted, are free to add such questions. In 2011, for example, 21 jurisdictions asked some form of question (or questions) related to sexual contacts and self-reported identity. After assessing the various survey instruments adapted by local jurisdictions (and using data from its 2009 survey of 7,000 LGBT youth 13 to 21 years of age), the CDC reported that 80% of LGBT youth had been verbally harassed, 40% had been physically harassed, 60% felt unsafe, and 20% had been the victim of a physical assault, all at school and in the previous 12 months.[6] In the 2003 Massachusetts Youth Risk Behavior Survey, 42% of sexual minority youth reported being bullied in the preceding 12 months, as compared with 21% of heterosexual youth.[10]

Researchers in Washington State have developed a far-reaching quality of life scale in which bullying is a component. Their findings among students in grades 8 through 12 showed that 9% to 14% reported having been bullied because of their perceived sexual orientation. These percentages were found to be significantly different from those among students who self-identified as heterosexual. The authors added that being bullied as a result of perceived sexual orientation led to lower quality of life scores not only because of the bullying itself but because of its related consequences of depression and suicidal ideation.[11] It should be noted that Washington State has several anti-bullying laws in place,[12] some of which (along with those of New Jersey) are considered to be among the toughest in the nation.[13]

The Gay, Lesbian & Straight Education Network (GLSEN) is a recognized leader in anti-LGBT bullying interventions built around data-driven considerations. This organization receives funding from the CDC to support schools and community-based groups in addressing the physical and mental health of LGBT youth.[6] In addition, its National School Climate Survey (NSCS) is widely accepted by researchers and the CDC as an example of a methodologically solid, comprehensive survey with a significant sample size. In the 2011 NSCS, data were collected from a sample of 8,584 students between the ages of 13 and 20 who resided in all 50 states and 3,224 unique school districts. The findings showed that there had been a decline in anti-LGBT language over the previous 10 years and, for the first time, a decrease in victimization based on sexual orientation (relative to the results of the 2009 survey). While these results demonstrate positive progress, GLSEN reports that overall levels of harassment and assault remain disproportionately high.[9] GLSEN’s survey instrument is considered an important source of data for researchers because it is comprehensive and national in scope and has served to confirm much of the information found in CDC’s above-noted analysis.[14]

Another source of data is the Growing Up Today Survey, a joint effort of researchers from Brigham and Women’s Hospital and the Harvard School of Public Health. This survey, although focused on health indicators, does disaggregate bisexual-identified youth from lesbians and gay youth. It also includes two questions on bullying, one asking respondents whether they have been bullied in the past year and another asking whether they have participated as a perpetrator.[15]      

In addition to the previously mentioned disparities involving feelings of safety, harassment, and assault, LGBT youth may face issues related to academic performance and mental health. Increased absenteeism to avoid facing hostility at school is common and leads to lower academic achievement and, ultimately, to the multitude of poor health indicators found among adults in lower socioeconomic strata. According to the 2011 NSCS, students who experienced higher levels of victimization as a result of their perceived sexual orientation or gender identity were two to three times more likely than other students to have missed school in the preceding month. Grade point averages were significantly different between youth who were frequently and infrequently harassed, and students who experienced higher levels of victimization in school were twice as likely to report that they did not plan to pursue a postsecondary education.[9,14] A retrospective study of LGBT adults showed that 72% of those who reported that they had been bullied reported having made efforts to play sick or simply be truant, confirming the findings of the NSCS.[16]

It is well established that LGBT youth experience great disparities with respect to mental health. One early 1990s study, highly regarded for its methodology and large sample size, showed that 41% of males and 28% of females (under the LGBT umbrella) were either very troubled or extremely troubled by depression (as compared with a national average of 8% among all individuals over 12 years of age). These numbers have been confirmed more recently by the CDC, indicating little progress over 20 years.[17,18] Suicide, suicidal ideation, and substance use also occur among LGBT youth at rates much higher than those among their heterosexual counterparts.[8] A 2013 study incorporating pooled 2005 and 2007 YRBS data from 14 jurisdictions revealed stark differences between sexual minority students and sexual majority students in these areas. For example, 32.2% of sexual minority students (versus 11.7% of nonminority students) reported suicidal ideation, and 22.8% (versus 6.6% of nonminority students) reported actual suicide attempts.[19]

Homophobic, bullying, and unsafe or unwelcoming school climates have been firmly established as factors that contribute to these disparate conditions.[20,21] In one study, pooled data from the 2005 and 2007 YRBS and the 2010 CDC School Health Profile Survey were used to examine whether sexual minority students living in states and cities with protective school climates were at lower risk of suicidal thoughts, plans, and attempts. The results strongly underscored that homophobic schools and unwelcoming conditions play a significant role in health outcomes among these students.[19] In another large-scale study, conducted in Oregon in 2012, students who lived in districts without inclusive anti-bullying policies and curricula were more than twice as likely as those living in districts with inclusive and safe policies to have attempted suicide.[22] The 2011 NSCS produced compelling evidence that a person who is “out” at school is more likely be bullied. Ordinarily, being bullied leads to lowered self-esteem. Yet in that survey, students who were “out” had higher self-esteem despite increased victimization.[9] It would thus be a natural inference that the coming-out process can serve as a protective factor. It is also worth noting that students report significantly less difficulty with mental health issues when their school environment is positive and safe and they are not experiencing homophobic harassment.[8]

The need to reduce and eliminate bullying against LGBT youth is imperative if these young people are to succeed in school, be mentally healthy, avoid substance use, and achieve the highest possible level of overall health. Several frameworks and theories support this assertion. The minority stress model is a widely used framework to understand the relationships between stressors and associated health outcomes (both positive and negative).[23] This framework has been adapted to specifically address the stressors found in the lives of LGBT populations.[24] According to the model, experiencing both distal (e.g., bullying) and proximal (e.g., fear of being bullied) stressors will advance a person’s movement toward negative health outcomes such as those discussed above. These frameworks allow for the creation of interventions that target one or more areas of minority stress. Such interventions can be structured to help eliminate the stress (e.g., legal approaches to distal problems) or to create protective factors so that an individual can build the resiliency needed to withstand both the distal and proximal effects of stress.[25]

Consistent with minority stress frameworks, efforts to stop bullying to date have taken two approaches. The first has been legalistic in nature: creating laws and/or rules to prohibit bullying and giving all students a right to a safe environment. These legislative efforts have occurred at the state and local levels with widely varying protections and requirements. All states have related laws or policies in effect, with Montana being the only state without a specific law.[26] These laws and policies range from weak, with limited protections and enforcement mechanisms, to strong and progressive. California prohibits discrimination against students whose identity differs from the gender appearing on official records. It specifically grants access to gender-specific facilities such as bathrooms to students according to their identity as opposed to their biological assignment. In addition, the state mandates that all students receive education regarding the historical contributions of gay Americans. Washington and New Jersey have been credited with enacting arguably the most comprehensive anti-bullying bills in the country, bills with far-reaching mechanisms for enforcement and reporting of events both in and out of school. These laws were passed on the heels of the tragic suicide of a gay Rutgers University student who had been victimized by his roommate. At present, however, no federal law specifically addresses bullying, and laws that address harassment and civil rights violations are often not effective in protecting victims (e.g., the LGBT population is not a protected class under existing federal laws).

Having laws on the books or enforceable regulations is an important element in any effort that attempts to create social change. Yet, as can be seen with the Civil Rights Act, the Americans with Disabilities Act, and Title IX, simply having the law or rule in place is not sufficient to sway the attitudes of everyone. Therefore, a second approach to the problem has been programmatic or curriculum based. GLSEN has pioneered numerous programs including Gay-Straight Alliances (GSAs) in schools, Safe Spaces, and ThinkB4YouSpeak. There is a growing body of literature that demonstrates the positive effects of these programs on the lives of students, including reduced absenteeism, a higher sense of safety at school, higher grade point averages, and the presence of faculty allies who will provide a comfortable and accepting environment for discussions.[9,27,28] In 2011, according to GLSEN, LGBT students who attended a school with a GSA were significantly less likely than students attending a school without a GSA to feel unsafe (54.9% versus 70.6%). LGBT students were also less likely to have been absent owing to perceptions that they were unsafe (24.4% versus 38.8%).[9] Moreover, LGBT students in schools that worked toward eliminating institutional homophobia were more likely to plan for college and had higher grades. For example, 14.9% of LGBT students in schools without supportive staff indicated that they were not planning to pursue a postsecondary education, as compared with only 5.1% of LGBT students who had six or more supportive educators. Curricula designed to train teachers, administrators, and staff on how to properly intervene in a bullying situation are becoming more common. These types of solutions go hand and hand with the laws and policies being created.

Another programmatic approach, and one that can begin to shape a new generation, is age-appropriate inclusion of comprehensive health education topics such as sexual behavior, sexual health, and sexual identities. Such programs must be delivered year after year, be adapted for different age groups, and build upon themselves. While many schools offer some form of health education, few offer this type of coordinated curriculum.[29] According to a 2004 report from the Institute of Medicine, only 27% of schools nationwide require health education in grade 6, and only 2% require such instruction education in grade 12.[29] More recently, the CDC reported that the percentage of schools requiring health education for students in any grade from 6 to 12 ranged from 36% to 98% across the US states.[30] Although these data seemingly represent an improvement over the 2004 data, it is important to realize that health education has to be offered only once between those grade levels. Furthermore, bullying as a topic is lumped together with violence prevention, fighting, and dating violence in the CDC curricula.[30] One barrier to the establishment of comprehensive health education offered on a regular basis is not having the topic considered among the core curricula under the Elementary and Secondary Education Act (also known as No Child Left Behind). As such, school districts do not have an option to use Title I or Title II funds for health education programs.[31] Without that reimbursement, it is a natural inference that schools, especially those facing tight municipal budgets, will default away from the expense.

The use of comprehensive health education has been accepted and studied for some time. School promotion and prevention programs that address youth development constructs have demonstrated improved relationships among students and faculty as well as reductions in problem behaviors, including bullying.[32,33]The CDC, in its report on health risks among sexual minority youth, recommended the development and use of policies addressing topics such as social stigma, discrimination, family disapproval, and social rejection.[34] These are all topics that would be addressed in a comprehensive health education curriculum. Seattle and King County, Washington, have implemented a novel health education program known as FLASH (Family Life and Sexual Health). Although this comprehensive sexuality education curriculum, developed for grades 5–12, has not yet undergone a rigorous evaluation, the county’s department of public health has viewed it as highly promising and worthy of continued funding.[35]

Opposing Arguments
The statistical evidence regarding the issues discussed above, while demonstrating a range owing to differing methodologies, is not in dispute. Data are consistent across governmental and private entities. There will be opposition from those who do not believe that sex education in any form belongs in a school. There are also those who believe that homosexuality or gender nonconformity is an illness and do not want their children exposed to the topic. Others will claim that it is contrary to their religion. Mechanisms are in place for all legitimate claims of exemption due to religious beliefs. Yet there is no scientific evidence to support those feelings. It is beyond the scope of this policy to examine the ill effects of isolating children from those who are perceived as different, whether racially or because of their orientation or identity. Some may argue that existing laws are sufficient and allow for punishing perpetrators of bullying. State laws, although common, still do not exist in all states and vary widely with respect to protections afforded and level of enforcement. Many states have implemented only policies and have not passed legislation. Such opposing arguments also do not address the potential for upstream approaches that help stop bullying and lead to the eventual eradication of the issue. Relying strictly on legal or administrative rules will not create the protective factors that are necessary for a person to withstand minority stress. This policy seeks to put forth both legalistic and programmatic recommendations through a public health lens to combat bullying in the short term and lay the groundwork for the next generation of youth to live free from the threat of such behavior and the outcomes that result.  

There could also be an argument that the situation is improving without further interventions. There certainly is evidence (some of which was presented above) of improvements, particularly in schools that have implemented “safe” programs such as GSAs or supportive staff efforts. As noted above, in 2011 GLSEN reported a continued decline in anti-LGBT language and a decrease in victimization based on sexual orientation.[36] However, it also concluded that LGBT harassment in schools remains pervasive.

Action Steps
This policy statement demonstrates APHA’s firm support for reduction and ultimate elimination of LGBT bullying; this serious public health issue must addressed so that LGBT youth can live healthier lives on par with their heterosexual counterparts. APHA calls for all appropriate parties, including but not limited to the US Congress, the US Department of Education, the US Department of Justice, state legislatures and education departments, local school districts, CDC, NIH, the Health Resources and Services Administration, and advocacy organizations, to participate in promulgating and implementing the recommendations below consistent with their ability and authority to do so. While some of the recommendations are specific to the federal government, the principles and goals can be implemented at every level of government with the help of local advocates.

Namely, APHA:
•    Urges Congress to enact laws prohibiting discrimination specifically on the basis of actual or perceived sexual orientation or gender identity.
•    Urges Congress to encourage alliances among local and national organizations already working with LGBT youth and localities or states to best leverage work that has been done and could be disseminated more widely.
•    Urges Congress to enact legislation that will provide comprehensive, age-appropriate health and sex education that is based on science for all students throughout their years in school. This education must include:
o    Information and skills young people need to become healthy adults and develop healthy relationships with all people, regardless of differences.
o    Information about all aspects of sex (as appropriate for the age group) including gender, gender identity, and sexual orientation or fluidity across sexual or gender spectrums. Information on anatomy, growth, and development should be included as well.
o    Information on gender and gender identity sensitivity and instruction regarding the importance of equality and the social environment in helping students achieve overall well-being.
o    Skill building to protect students from dating violence, sexual assault, bullying, and harassment.
o    Promotion of educational achievement, self-esteem, and self-efficacy.
Schools should incur loss of funds if the curriculum deliberately withholds life-saving information about HIV, contains medically inaccurate information, and is unresponsive to the needs of sexually active adolescents of all gender identities and orientations.
•    Urges Congress to elevate health education to core curriculum status, thereby allowing local jurisdictions the discretion to access federal Title I and II funds to provide this type of education.
•    Urges all appropriate federal agencies, including the National Institutes of Health, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the Department of Education, to create a research agenda with broad community input. This research should be focused on filling in gaps and evaluating new and existing programs over time. An implementation science framework should be considered to help prioritize issues, programs, and interventions for research on comparative effectiveness across multiple populations under the LGBT umbrella.
•    Encourages all appropriate agencies and legislative bodies with jurisdiction to expand training programs for teachers to increase their understanding of the concepts of attraction, identity, and behavior so that they can be effective in communicating a sensitive curriculum.
•    Encourages state and local school boards and education departments to implement innovations and programs that will effectively address the safety and well-being of LGBT students.
•    Urges state and local education agencies to adapt curricula in history and other social sciences to highlight positive and respectful representations of LGBT individuals, events, and contributions.

1. Berlan ED, Corliss HL, Field AE, Goodman E, Austin SB. Sexual orientation and bullying among adolescents in the Growing Up Today Study. J Adolesc Health. 2010;46:366–371.
2. Sournader A, Helestela L, Helenius H, et al. What is the early adulthood outcome of boys who bully or are bullied in childhood? The Finnish “From a Boy to a Man” study. Pediatrics. 2007;120:397–404.
3. Robers S, Zhang J, Truman J. Indicators of school crime and safety, 2010. Available at: Accessed January 12, 2015.
4. Nansel TR, Overpeck M, Pilla RS, Ruan J, Simons-Morton B, Scheidt P. Bullying behaviors among US youth: prevalence and association with psychosocial adjustment. JAMA. 2001;285:2094–2100.
5. Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press; 2011.
6. Centers for Disease Control and Prevention. Lesbian, gay, bisexual, and transgender health. Available at: Accessed January 12, 2015.
7. Society for Adolescent Health and Medicine. Recommendations for promoting the health and well-being of lesbian, gay, bisexual, and transgender adolescents. J Adolesc Health;2013;52:506–510.
8. Birkett M, Espelage DL, Koenig B. LGB and questioning students in schools: the moderating effects of homophobic bullying and school climate on negative outcomes. J Youth Adolesc. 2009;38:989–1000.
9. Kosciw JG, Greytak EA, Bartkiewicz MJ, Palmer NA. 2011 National School Climate Survey: the experiences of lesbian, gay, bisexual, and trangender youth in our nation’s schools. Available at: Accessed January 12, 2015.
10. Hanlon BM. 2003 Massachusetts Youth Risk Behavior Survey Results. Boston, MA: Department of Education; 2004.
11. Patrick DL, Bell JF, Huang JY, Lazarakis NC, Edwards TC. Bullying and quality of life in youths perceived as gay, lesbian, or bisexual in Washington State, 2010. Am J Public Health. 2013;103:1255–1261.
12. Washington State Legislature. House bill report 2SHB 1163. Available at: Accessed January 12, 2015.
13. Hu W. Bullying law puts New Jersey schools on spot. Available at: Accessed January 12, 2015.
14. Centers for Disease Control and Prevention. Sexual identity, sex of sexual contacts, and health-risk behaviors among students in grades 9–12. Available at: Accessed January 12, 2015.
15. Brigham & Women’s Hospital, Harvard School of Public Health. Growing Up Today Study 2. Available at: Accessed January 12, 2015.
16. Rivers I. Social exclusion, absenteeism and sexual minority youth. Support Learning. 2000;15: –3–18.
17. D’Augelli AR, Hershberger SL. Lesbian, gay and bisexual youth in community settings: personal challenges and mental health problems. Am J Community Psychol. 1993;22:421–488.
18. Centers for Disease Control and Prevention. Prevalence of current depression among persons ≥ 12 years, by age group and sex—United States, National Health and Nutrition Examination Survey. Available at: Accessed January 12, 2015.
19. Mustanski B, Van Wagenen A, Birkett M, Eyster S, Corliss HL. Identifying sexual orientation health disparities in adolescents: analysis of pooled data from the Youth Risk Behavior Survey, 2005 and 2007. Am J Public Health. 2014;104:211–217.
20. Morrison LL, L’Heureux JE. Suicide and gay/lesbian/bisexual youth: implications for clinicians. J Adolesc. 2001;24:39–41.
21. Friedman MS, Koeske GF, Silvestre AJ, Korr WS, Sites EW. The impact of gender-role nonconforming behavior, bullying, and social support on suicidality among gay male youth. J Adolesc Health. 2006;38:621–623.
22. Hatzenbuehler ML, Keyes KM. Inclusive anti-bullying policies and reduced risk of suicide attempts in lesbian and gay youth. J Adolesc Health. 2013;53:S21–S26.
23. Dohrenwend BP. The role of adversity and stress in psychopathology: some evidence and its implications for theory and research. J Health Soc Behav. 2000;41:1–19.
24. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129:674–697.
25. Meyer IH, Frost DM. Minority stress and the health of sexual minorities. In: Patterson CJ, D’Augelli AR, eds. Handbook of Psychology and Sexual Orientation. New York, NY: Oxford University Press; 2013:252–266.
26. US Department of Health and Human Services. Policies and laws. Available at: Accessed January 12, 2015.
27. Lee C. The impact of belonging to a high school gay/straight alliance. High School J. 2002;85:13–26.
28. Walls NE, Kane SB, Wisneski H. Gay-straight alliances and school experiences of sexual minority youth. Youth Soc. 2010;41:307–332.
29. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004.
30. Demissie Z, Brener ND, McManus T, Shanklin SL, Hawkins J, Kann L. School Health Profiles 2012: Characteristics of Health Programs Among Secondary Schools. Atlanta, GA: Centers for Disease Control and Prevention; 2013.
31. Society for Public Health Education. Physical activity fact sheet. Available at: Accessed January 12, 2015.  
32. Catalano RF, Berglund ML, Ryan JAM, Lonczak HS, Hawkins JD. Positive youth development in the United States: research findings on evaluations of positive youth development programs. Available at: Accessed January 12, 2015.
33. Greenberg MT, Weissberg RP, O’Brien MU, et al. Enhancing school-based prevention and youth development through coordinated social, emotional, and academic learning. Am Psychol. 2003;58:466–474.
34. Centers for Disease Control and Prevention. Health risk among sexual minority youth. Available at: Accessed January 12, 2015.
35. Public Health–Seattle and King County. Health education and outreach. Available at: Accessed January 12, 2015.
36. Gay, Lesbian & Straight Education Network. LGBT students experience pervasive harassment, but school-based resources and supports are making a difference. Available at: Accessed January 12, 2015.