The Role of Stigma in LGBTQIA+ Youth in Rural and Urban Areas

Abstract

The stigma experienced by LGBTQIA+ youth in middle school and high school is commonly linked to poor mental health and academic success, but little is known about its potential long-term impact. It was hypothesized that stigma levels would differ based on geographical location, with rural youth experiencing higher stigma levels compared to urban youth. This IRB-approved exempt research design collected anonymous survey data from college students at a mid-south public university. The sample included a total of 94 respondents, with 63 from rural areas and 31 from urban areas. Experiences of internalized, enacted, and perceived stigma were assessed with rating scales. No statistically significant differences were found between rural and urban youth, with both groups reporting high levels of internalized, enacted, and perceived stigma. Rural youth reported experiencing more discrimination or attacks at school and fewer LGBTQIA+ school resources but slightly higher family support. Urban youth were more likely to be out to family members and felt safer at school. Comparatively, more rural youth reported experiencing anxiety, depression, and suicidal thoughts in the past 30 days than urban youth. A moderate correlation was found between perceived and internalized stigma. This study provides insight into the pervasive nature of LGBTQIA+ stigma, regardless of geographical location.

1. Introduction

Schooling is considered an essential element in the academic and social development of children. The experiences that children have while in elementary and secondary school can both positively and negatively impact their future academic success and wellbeing [1,2]. For children who identify as a part of the Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual+ (LGBTQIA+) community, social stigma may be a barrier to learning and making positive social connections while in school. Research examining the impact that social stigma has on LGBTQIA+ youth has repeatedly linked it with higher rates of depression, anxiety, suicidality, and substance abuse [2,3,4,5] but is limited in the exploration as to how this stigma may continue to affect them as they mature into young adults.

1.1. Literature Review

As of 2021, one in five Gen Z young adults identified as lesbian, gay, bisexual, or transgender [6]. According to the American Psychological Association, children become aware of gender between three and five years old [7]. An individual’s gender identity is their personal sense of being male, female, transgender, non-binary, or other identities, and it may differ from their sex assigned at birth, which is based on external genital anatomy. We use pronouns, names, dress, mannerisms, and other means to communicate our gender identity to the world. It is important to note that gender identity is separate from sexual orientation, which addresses the types of individuals to whom we are physically, emotionally, and/or romantically attracted [7].

LGBTQIA+ is an umbrella acronym representing lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all other gender and sexual identities not covered in the acronym. In general, children whose gender identity is part of the LGBTQIA+ community often feel alone and experience harassment and discrimination related to how they express their gender [1,2]. These experiences are linked to academic struggles that include school avoidance or self-exclusion from school activities because of feeling unsafe. The experience of being stigmatized based on one’s identity often leads to internalized stigma that is carried into adulthood [8]. In this study, we examine three dimensions of social stigma that LGBTQIA+ youth may experience in middle school and high school—perceived, enacted, and internalized stigma.

1.1.1. Types of Stigma

Stigma is a socially constructed concept in our society. The effects of stigma on LGBTQIA+ youth are deleterious and multifaceted. One effect of stigma on mental health is a decrease in help-seeking behavior as youth may fear discrimination from providers [9]. This fear-related stress and unwillingness to seek intervention or support compounds the mental distress from the original stigmatizing experience [9,10,11]. More specifically, this additive effect causes increased susceptibility to mood disorders, eating disorders, non-suicidal injury, suicidal ideation, and suicide attempts [10]. The following is a review of the more specific types of stigma explored in this study.

1.1.2. Perceived Stigma

Perceived stigma refers to an individual’s awareness of others’ bias or discriminatory beliefs toward a group with whom they affiliate [12]. It occurs at a distance from the individual but still carries with it a heavy burden of distress upon the individual [13]. Concerning LGBTQIA+ youth, perceived stigma may be experienced from many sources, including family members, school personnel, and health and mental healthcare workers [13] which can exacerbate mental health issues. A more specific example would be awareness of an individual’s belief of an LGBTQ+ identity being immoral or unhealthy due to their religious beliefs. Additionally, the perception of stigma may again reduce youths’ help-seeking behaviors and willingness to engage with family or providers [10].

1.1.3. Enacted Stigma

Enacted stigma refers to the experience of actual violence perpetrated on an individual because of their identity as part of a particular group [12]. This violence encompasses physical, verbal, and sexual violence as well as microaggressions [14]. This type of stigma is also inclusive of subtle acts of exclusion perpetrated by teachers, counselors, or other adult support figures in classrooms and youth-focused groups or activities [15].

1.1.4. Internalized Stigma

Internalized stigma refers to one’s acceptance or support of society’s negative views toward them and the use of this in constructing their self-concept and esteem, leading to increased mental health concerns, including anxiety, depression, suicidality, and substance abuse [8,14]. It can also increase the belief in the need to hide one’s identity, which then leads to an increased risk of depression [16].

1.1.5. Rural Youth and Stigma

Research has shown a greater rate of harassment and bullying among queer youth living in rural communities [17]. They may face discrimination at home, at school, and in their communities as they try to embody their non-heteronormative identity and express their authentic selves. A 2019 school climate survey found that these youths in rural schools may experience more harassment by peers and staff and more discriminatory policies [18].

In 2022, Rand and Paceley conducted a qualitative study with rural LGBTQIA+ high school youth [19]. Themes from the interviews with the sample included challenges at school with harassment and exclusion. They also noted challenges within their larger community in terms of feeling unsafe to reveal their identity as part of the LGBTQIA+ community, which then led to increased isolation. Youth identified the importance of having a safe place to be themselves, which, for some, was at school or in a gay/straight alliance club. And, in alignment with this study’s comparison of rural and urban LGBTQIA+ youth, Kosciw et al. (2015) found that rural youth who were “out” reported increased occurrences of victimization compared to their suburban and urban queer peers [20].

Compounding the effects of stigma in the United States is the recent spate of anti-LGBTQIA+ laws that have been enacted in many states [21,22]. These laws are aimed at banning gender-affirming care for youth, restricting access to restrooms that match the student’s gender identity, and banning participation in school athletics [23,24]. These laws may increase the stigma and related effects that members of the LGBTQIA+ community already experience, such as anxiety, depression, non-suicidal self-injury, and suicidality [10,25,26]. Awareness and advocacy by those who work with the LGBTQIA+ community are essential to expand resources and address the impact of stigma on youth.

1.1.6. Research Question and Hypothesis

This descriptive study seeks to characterize the experiences of stigma among LGBTQIA+ youth, focusing on differences between rural and urban settings. It does not test specific hypotheses but aims to describe the levels and types of stigma experienced by these individuals.

2. Materials and Methods

This IRB-approved exempt research study (protocol #5085) examined LGBTQIA+ young adults’ perceptions of stigma in their lives using a retrospective framework, looking back at their middle school and high school experiences. The participants were college students during the spring 2023 semester at a mid-south public four-year university. Data were electronically collected using a survey built with Qualtrics software. The responses were anonymous, with no IP address or other identifiers captured, and they were cleaned and analyzed using the free open-source software Jamovi v2.3 [27]. Of the original 119 respondents, 22 cases with less than 95% survey completion were deleted. Three participants who did not answer the rural/urban school question were also deleted. The final sample comprised 94 completed surveys, with 63 rural and 31 urban participants.

2.1. Participant Recruitment

This study was advertised across the university campus using fliers posted on public bulletin boards that included a QR code for students to access the survey. The flier was also specifically emailed to an LGBTQIA+ support group on campus. The inclusion criteria were that the individuals be aged 18 to 25, enrolled in courses at the university either full or part-time, and identify as LGBTQIA+.

2.2. Measures

The survey was developed by the researchers using existing stigma measurement scales for the top three types of stigma—internalized, enacted, and perceived—to increase the validity of the results. The internalized and perceived stigma measures were adapted from scales used in Puckett et al.’s study of homophobic stigma [5]. Internalized stigma refers to the extent to which an individual has absorbed negative social messages about being LGBTQIA+, while perceived stigma relates to the extent to which queer individuals believe people around them to hold negative attitudes towards them because of their identity. Enacted stigma was measured using questions adapted from Gower et al.’s study of youth perception of enacted stigma [14]. The participants were asked to rate their level of agreement with statements using Strongly Agree, Agree, Disagree, or Strongly Disagree. Enacted stigma relates to discrimination experienced in daily life due to being LGBTQIA+.

The behavioral health questions were adapted from the Monitoring the Future survey to examine substance use and mental health related to stigma as an LGBTQIA+ individual [28]. General quantifiers were reframed within the context of the past 30 days, since we were interested in measuring the perception of frequency rather than the actual frequency. The participants rated how often they had experienced substance use and mental health concerns in the past 30 days due to LGBTQIA+ stigma using a scale, with the following options: Not at all, Some days, Most days, or Every day. A full list of the questions is provided in Appendix A.

3. Results

3.1. Demographic Characteristics

The participants’ demographic characteristics are displayed in

Table 1. Demographic characteristics of participants.

Characteristics	Total (n = 94)	Rural (n = 63)	Urban (n = 31)
Age	%	%	%
18–20	58.1	38.7	19.4
21–25	42.1	60.3	78.6
Gender Identity
Man	11.7	8.5	3.2
Non-binary, gender fluid, genderqueer	27.7	20.2	7.4
Transgender	12.8	8.5	4.3
Woman	40.4	24.5	16.0
Not sure, questioning, decline	7.5	5.3	2.2
Sexual Orientation
Asexual	7.4	5.3	2.1
Bisexual	30.9	18.1	12.8
Gay	14.9	11.7	2.1
Lesbian	13.8	10.6	4.3
Pansexual	18.1	12.8	5.3
Queer/Questioning	8.5	6.4	2.1
Other entries: Asexual/Panromantic; Biromantic/Asexual; Demisexual; Heterosexual (FTM, Attracted to women)	6.4	2.1	4.3
Race/Ethnicity
White/Caucasian	94.7	93.7	96.8

. The participants’ ages ranged from 18 to 25, with more than half being 18 to 20 years old. The participants’ gender identity was diverse with 40.4% of the sample identifying as women, 27.7% as non-binary/gender fluid/genderqueer, 12.8% as transgender, and 11.7% as men. The sample’s majority identified as white (94.7%). Sexual orientation was varied in this sample, with 30.9% of participants identifying as bisexual, 18.1% as pansexual, 14.9% as gay, and 13.8% as lesbian. Two-thirds (67.0%) of the participants were from rural communities, and one-third (33.0%) were from urban ones.

3.2. Stigma Ratings

The researchers examined possible trends or patterns in the data to better understand how stigma is impacting LGBTQIA+ youth. The frequencies for responses to internalized, enacted, and perceived stigma rating scales among the rural and urban respondents are compared in this section.

3.2.1. Internalized Stigma Ratings

The comparison of rural and urban participants agreeing with statements on the internalized stigma rating scale is displayed in Figure 1. The participants’ responses were comparable regarding their believed choice in their gender and sexual identities: Thirty percent of rural and 29.0% of urban participants believed that they had a choice about their gender identity, and 27.4% of rural and 29.5% of urban participants believed that they had a choice about their sexual orientation. Approximately 65% of both groups had tried to change their sexual orientation at one time. A total of 18% of rural and 19.3% of urban participants believed that being LGBTQIA+ was a shortcoming for them. And yet, 87.3% of rural and 83.9% of urban participants reported feeling glad to be LGBTQIA+.

3.2.2. Enacted Stigma Ratings

The comparison of rural and urban participants agreeing with statements on the enacted stigma rating scale is displayed in Figure 2. Approximately 72% of rural and 74% of urban participants had at least one caring adult at school who they felt supported them. More rural (58.7%) than urban (43.3%) participants reported being discriminated against at school, and more rural (57.1%) than urban (32.23%) participants reported being physically or verbally attacked at school for being LGBTQIA+. Slightly more rural (77.8%) than urban (71.0%) participants were out as LGBTQIA+ to close friends. Only 26.9% of rural and 19.4% of urban participants were out to everyone at school. Slightly more urban (28.5%) than rural (29.1%) participants were out to their family members. Slightly more family support was reported by rural (42.8%) than urban (33.3%) participants, but fewer rural (27.0%) than urban (50.0%) participants believed that school was a safe place for them. Similarly, LGBTQIA+-supportive school programs or resources were fewer among rural (20.7%) than urban (45.2%) participants.

3.2.3. Perceived Stigma Ratings

The comparison of rural and urban participants agreeing with statements on the perceived stigma rating scale is displayed in Figure 3. Perceived stigma was high among both rural and urban participants. The majority of both groups—88.9% of rural and 86.7% of urban participants—believed others to maintain that LGBTQIA+ individuals have psychological or mental health issues. More rural (85.7%) than urban (70.0%) participants believed that families would be disappointed to have an LGBTQIA+ child, and more rural (87.3%) than urban (55.5%) participants believed that LGBTQIA+ individuals should not raise children. Ninety percent of both groups perceived others to believe that LGBTQIA+ individuals should not show affection in public. Slightly more rural (87.3%) than urban (74.2%) participants felt that healthcare providers were not educated about LGBTQIA+ health needs.

Figure 2. Enacted stigma ratings.

Figure 2. Enacted stigma ratings.

3.3. Behavioral Health

Research shows that experiencing stigma can increase behavioral health problems for many people. The researchers compared participant ratings of the past 30-day depression, anxiety, and suicidality by average stigma types.

The participants were asked about behavioral health issues experienced in the past 30 days due to being LGBTQIA+, and these results are displayed in Figure 4. Most participants did not report the use of drugs, alcohol, marijuana, or nicotine but did report several mental health concerns. More rural than urban participants reported experiencing mental health issues in the past 30 days due to stigma: 54.2% of rural compared to 24.5% of urban participants reported experiencing anxiety, 41.5% of rural compared to 16.0% of urban participants reported experiencing depression, and 13.8% of rural compared to 4.3% of urban participants reported experiencing suicidal thoughts.

4. Discussion

LGBTQIA+ youth ratings of stigma and its impact were measured using scales for perceived, internalized, and enacted stigma. The parallel trends between perceived and enacted stigma may indicate that experiencing stigma leads to a greater perception of stigma in the surrounding environment. Youth who perceive stigma from outside sources may also assume that stigma is factual or warranted and proceed to internalize it, thus negatively impacting their mental health [29].

Despite increased visibility, social acceptance, and support of the LGBTQIA+ community in the United States, members of this community who also belong to Gen Z continue to encounter high levels of stigma. While both rural and urban youth in this sample reported high levels of internalized, enacted, and perceived stigma, there were noticeable, elevated trends for rural youth. Though both groups reported relatively high levels of all three stigma types, there were notable trends regarding rural youth. First, more rural than urban youth reported experiencing discrimination or attacks at school. Second, urban youth were slightly more likely to be out to family members and felt slightly safer at school. Rural youth, on the other hand, reported slightly higher family support but fewer LGBTQIA+-supportive resources at school. Finally, considerably more rural youth experienced anxiety and depression in the past 30 days due to being LGBTQIA+ than their urban peers. Furthermore, almost 14% of rural youth reported thoughts of suicide, which is very concerning and supports past findings regarding the high rates of suicide among LGBTQIA+ youth [30].

Acknowledging the impact of stigma on youth mental health is essential to making changes that can protect and support LGBTQIA+ young people. Based on this research study’s findings, we suggest several areas of focus in future practice, advocacy, and research.

4.1. Family Support and Resources

Familial acceptance and support of LGBTIA+ youth have repeatedly been linked to positive outcomes, especially concerning their health and wellbeing, and the lack thereof has been linked to poorer outcomes [31]. The low rates of family support among LGBTQIA+ youth in this sample point to an area of need. Interventions for youth dealing with family-based stigma are limited, yet this is where youth spend a large part of their lives until age 18 or later [32]. In rural areas, the discrimination and stigma experienced at home by young people can often be related to more conservative and religious values that focus on traditional heteronormative gender and sexual roles or practices [2]. Families would benefit from more education about the LGBTQIA+ community as well as its impact and their role in protecting and supporting their youth. Schools and community providers can partner on both school-based curriculum and community-based events or information dissemination toward this goal. It would also be beneficial for them to collaborate on responsive family interventions, such as joint meetings with families to discuss their youth’s wellbeing and needs and plan the implementation of home supports.

4.2. School Support and Resources

School-based peer and teacher intervention or support have been correlated with greater levels of perceived safety among LGBTQIA+ youth [33]. School-based support and advocacy groups provide LGBTQIA+ youth and their allies a safe space to connect and positively engage (e.g., Gender and Sexuality Alliances; Gay, Lesbian, Straight Education Network). More specifically, these groups provide a sense of belonging and protected spaces where youth can truly be themselves without fear of judgment or discrimination [34]. Youth in rural school communities have a harder time finding and accessing these supports [19]. School personnel should help by both informing their students of these groups and organizing them in collaboration with their students, particularly in rural communities. If policy or sentiment limits these individuals’ ability to accomplish so, then they may look at partnering with community providers to organize and facilitate these groups outside of school.

Additional school responses and supports include the provision of mental health services and other accommodations to support LGBTQIA+ students. School counselors or other school-based mental health providers may be able to offer therapeutic services to these students or might need to assist them in receiving these services from community-based providers. These school personnel can also explore the creation of school-based support groups for these students, which vary from the social and advocacy groups mentioned earlier in that they focus on the social–emotional impact of these students’ experiences. Examples of accommodations include access to gender-neutral bathrooms, which contributes toward stigma reduction [35], and classroom-based strategies or work adjustments to academically support students.

4.3. Promoting Inclusive Language and Affirming Spaces

Promoting the use of self-identified pronouns and names for LGBTQIA+ youth can significantly reduce symptoms of depression and suicidal ideation [36], especially as it demonstrates acknowledgment and acceptance for youth [15]. Schools can provide personnel training on the use of inclusive language and develop safe and welcoming spaces in their classrooms.

Ensuring the presence of anti-bullying and zero-tolerance policies in schools is essential to protect young people. Jana and Baran identified subtle acts of exclusion or microaggression occurring in schools as a form of harassment that is allowed to go unchecked [15]. Training on how to identify and address these acts can help empower teachers, academic leaders, and young people too. This type of training goes a long way toward reducing bullying and harassment and helping LGBTQIA+ youth feel safe and supported. School personnel must also monitor their colleagues and intervene if or when they notice them being even implicitly biased or discriminatory toward LGBTQIA+ youth.

4.4. Legislative Advocacy

Promoting policies that protect gender identity and sexual orientation from discrimination or harassment can be important for making schools a safe place for LGBTQIA+ youth [32]. One of the more challenging issues facing LGBTQIA+ youth is the waxing and waning of support for this vulnerable population based on who is in power politically at any given moment [37]. It would seem that, in order to counter this movement from opposing LGBTQIA+ individuals and their rights to a position of support, education must be constantly provided. Recent laws in the US have indicated a move away from supporting LGBTQIA+ individuals and toward opposing them [23,24]. For example, in southern states, there are unequal interpretations of policies across regions or counties. This means that some areas restrict resources and support for LGBTQIA+ youth more than others based on local jurisdictions, most notably in rural communities where social sentiment may lean more conservative. However, legislation can also be a powerful deterrent to crimes committed against the LGBTQIA+ community [38].

4.5. Conclusions

Again, despite increased visibility, acceptance of, and support for the LGBTQIA+ community, even its youngest members in Gen Z continue to encounter generally high levels of stigma. Stigma—whether perceived, enacted, or internalized—causes those who experience it to suffer across numerous dimensions (i.e., physically, mentally, emotionally, and socially) [9,10,11]. By providing relief from the various forms of stigma which LGBTQIA+ youth can experience, adults can help decrease anxiety, depression, non-suicidal injury, and suicidal ideation, as well as suicidal attempts and completions, within this vulnerable population. Rural and urban schools can be leaders in this effort by providing safe spaces for youth, especially through educating their families and communities about the topic, ensuring that inclusive and affirming language is used [in reference to LGBTQIA+ youth], and challenging policies and practices which are limiting or discriminatory to LGBTQIA+ youth. Furthermore, advocacy at local, state, and federal levels for laws that protect all persons is imperative for LGBTQIA+ youth protection and ending stigma.

5. Limitations

It is impossible to conduct research without errors or limitations that impact the data and their interpretation. Two primary and related limitations of this study are the following: it assessed a small sample within the same geographical region of a southern state; and it failed to assess and include in its analyses contributing factors, such as culture, family, local policies, and resource access. It could very well be the case that individuals within the geographic region of the sample have unique cultural features that affect individuals’ perspectives and subsequent behaviors or responses toward the LGBTQIA+ community, limiting the generalizability of the findings and their interpretation. Another limitation of this study is that it failed to, at least more specifically, assess contributing resiliency factors that could account for internalized stigma rates. Although this study explored supportive individuals and resources, especially through school, which could account for some resiliency to counteract the internalized stigma rates, it did not assess additional contributing resiliency factors, such as intelligence, personality, and scope of social connectedness, which could also account for it and its impact on internalized stigma. A final limitation of this study is that it did not explore how perceived, enacted, and internalized stigma impacted the sample’s experiences and functioning within the university setting. More specifically, it did not explore how past experiences and current states of being may have affected these individuals’ academic performance and social engagement within the university. It could be helpful, if not important, to measure these relationships to further emphasize the need for prevention or early intervention for this vulnerable population and identify additional interventions, supports, etc., at the university level to support their transition and success therein.

6. Implications for Future Research

The limitations of this study noted in the previous section give way to important implications and suggestions for future research regarding this population and/or topic. Future research on LGBTQIA+ youths’ experiences with stigma should include participants from a wider geographic range and/or include measurement of cultural factors that could positively impact the findings and improve the accuracy of their interpretation. A follow-up qualitative study with participants from the same geographical region as those from this study could help illuminate some of the cultural factors affecting experiences. Future research should also explore additional resiliency factors [beyond family- or school-based supports] to identify the range of those potentially available to LGBTQIA+ youth. Future research should again explore how youths’ experiences and their impacts during the secondary schooling years affected their behaviors and experiences as they transitioned to and navigated the higher education environment. This research could again underscore the importance of prevention or early intervention with this student population as well as identify additional interventions, resources, supports, etc., that higher education institutions could provide to address secondary schooling’s impact and aid these students’ transition and success in their higher education pursuits.