A mentor told me during my pediatrics residency that going to school is “the main job of a teenager.” This is because at school, teenagers will be spending the majority of their time and energy learning and growing to become a thriving adult. However, the school environment matters. We are familiar with how excellent teachers, the availability of tutoring, and an administration dedicated to academic achievement play a big role. We also should be aware that if teenagers feel unsafe going to school – especially if they are victims of bullying – they are unable to take advantage of these resources.

Bullying is a repetitive, unwanted, and aggressive behavior among children and adolescents that involves a real or perceived power imbalance.1 Despite the increasing visibility of lesbian, gay, bisexual, and transgender (LGBT) individuals, bullying remains a serious problem for this population. Although between one in four and one in three of all youth experience bullying,2 according to the Youth Risk Behavior Survey, LGBT students are two to four times as likely to be threatened or injured with a weapon on school property, two to three times as likely not to go to school because they feel unsafe, and about two times as likely to be bullied at school, compared with their heterosexual peers.3 Alarmingly, more than half of transgender students experience bullying and harassment at school.4

A key component of bullying is the power imbalance. Bullying perpetrators feel that they have more power physically (e.g., in size) or socially (e.g., in social status).5 LGBT youth are often the victims of bullying because of the societal stigma against same-sex attraction or gender nonconformity. As a result, they tend to have a lower social status, putting them at risk for bullying. Remember, however, that this power imbalance is perceived. Even straight teenagers can be victims of antigay and antitrans bullying because they don’t conform to gender norms (e.g., a straight boy interested in theater instead of sports).6 Therefore, any teenager can be a victim of antigay and antitrans bullying.

Although many believe that experiencing bullying is a “rite of passage,” a look at the research on bullying contradicts this. Youth who experience bullying have higher rates of depression, loneliness, and, most worrisome of all, suicide.7,8 One study showed that LGBT youth who experience bullying are almost six times as likely to consider suicide.9 Such sobering statistics prove that bullying is harmful. Furthermore, the effects of bullying can last into adulthood. One study showed that LGBT youth who experienced bullying during high school are more likely to have depressive symptoms and to be dissatisfied with life as a young adult.10 If rites of passage are designed to make a teenager into a well-adjusted young adult, then bullying does a poor job.

Although antigay bullying and harassment occur outside the clinic, providers can encounter both the perpetrator and the victim as patients and not realize it. Providers who have patients at risk for bullying – such as LGBT or gender-nonconforming youth – should routinely ask them about bullying through such questions as:

• “How many good friends do you have in school?”

• “Do you ever feel afraid to go to school? Why?”

• “Do other kids ever bully you at school, in your neighborhood, or online? Who bullies you?

• When and where does it happen? What do they say or do?”11

Asking these questions is especially important if you or your patient’s caregivers notice school phobia, attention problems, or psychosomatic complaints.11 Once you identify a victim, refer the patient to a mental health provider to develop skills to cope with the stress of bullying. Such skills include how to make friends. Emphasize that it is not the victim’s fault that they are experiencing bullying. Avoid telling victims to fight back or “suck it up.” In addition, work with parents and school authorities to intervene on behalf of the child to stop the bullying behavior.

At the same time, it is especially important to identify perpetrators. Perpetrators tend to have conduct problems, increased depressive symptoms, and poor school adjustment.12 They may have been bullied themselves. Also refer perpetrators to a mental health provider and other resources to address these problems.

However, with your limited time to screen for bullying or to create an individualized plan to protect bullying victims, approaches to reducing bullying and their adverse effects require a community effort. Use your expertise and access to the latest scientific research to advocate and help create policies schools can use to address antigay bullying. Clark and Tilly recommend a three-tier approach in addressing antigay bullying. In the first tier, schools should create a safe and affirmative environment for all students. An example of such an approach is to have a speaker – such as a physician from the community – talking to students about bullying and encouraging bystanders to speak up (i.e., be an ally) for bullying victims. Although some schools may be hesitant to implement a schoolwide intervention, they may implement a second-tier approach, such as classroom curricula on how to be an ally or incentive programs for helping vulnerable students (e.g., tutoring). Finally, the third tier requires intensive individualized interventions for bullying victims. Schools should have a step-by-step plan involving school authorities that students and their parents can use if students are experiencing bullying.13 Implementation of this plan requires timely follow-up from school officials to ensure cessation of the bullying behavior.10

Another way you can advocate for your LGBT patients is to be knowledgeable about the laws surrounding bullying. Bullying laws vary according to state. This is especially true if such laws specifically prohibit bullying based on sexual orientation or gender identity. This is known as “enumeration.” Enumerated laws grant school authorities the power to prevent and to correct any bullying based on sexual orientation and gender identity. Currently, 18 states and the District of Columbia have enumerated antibullying laws.14 If you live in a state that does not have an enumerated antibullying law, you can contact your state government officials to urge them to pass such a law.

Bullying has a powerful impact on the health and well-being of LGBT youth. Screen for bullying in your LGBT patients and work with schools and parents to protect them from such behaviors. Most importantly, advocate for creating a safe school environment for LGBT youth so that they can focus on their main job of learning and becoming a thriving adult.

Resources

• The website www.stopbullying.gov is a comprehensive resource for bullying and how to address it.

•  Society of Adolescent Health & Medicine (SAHM) position statement on bullying (J Adolesc Health. 2005 Jan;36[1]:88-91).

•  American Academy of Pediatrics (AAP) position statement on bullying (Pediatrics. 2009 July. doi: 10.1542/peds.2009-0943).

•  Gay, Lesbian & Straight Education Network (GLSEN) information on enumerated antibullying laws by state (www.glsen.org/article/state-maps).

References

1. Bullying definition at www.stopbullying.gov.

2. Student Reports of Bullying and Cyber-Bullying: Results From the 2011 School Crime Supplement to the National Crime Victimization Survey.

3. J Adolesc Health. 2014 Sep;55(3):432-8.

4. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.

5. Can Fam Physician. 2009 Apr;55(4):356-60.

6. J Adolesc Health. 2016 Feb;58(2):S1-S2.

7. Pediatrics. 2003;111(6 Pt 1):1312-7.

8. Journal of Educational Psychology. 2000 Jun;92(2):349-59.

9. Prev Sci. 2015 Apr;16(3):451-62.

10. Dev Psychol. 2010 Nov;46(6):1580-9.

11. Roles for pediatricians in bullying prevention and intervention (www.stopbullying.gov/resources-files/roles-for-pediatricians-tipsheet.pdf).

12. J Adolesc Health. 2005 Jan;36(1):88-91.

13. Clark JP, Tilly, WD. The evolution of response to intervention. In: Clark JP, Alvarez, Michelle, ed. Response to intervention: A guide for school social worker. (New York: Oxford University Press; 2010:3-18).

14. Enumerated antibullying laws by state (www.glsen.org/article/state-maps).

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh.

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