Contents

Summary

Despite the fact that life conditions of LGBTI persons^{[1]LGBTI is an acronym for Lesbian, Gay, Bisexual, Transgender and Intersex. This term is used in the Nordic context as well as many other, international ones.}  in the Nordic countries have changed in the last seventy years, major public health surveys indicate that this group suffers from an increased amount of mental and physical health issues compared to the rest of the population. Younger generations of LGBTI persons see their lives affected, too, by having a sexuality or gender identity that falls outside heteronormativity. Among other factors, this is due to the exposure to stress that LGBTI persons experience in daily life, so-called minority stress. This includes the risk of or actual harassment, vulnerability, and violence. Further, it includes facing prejudice and discrimination in everyday life, having to sometimes conceal your identity, and dealing with internalized homo- and transphobia, which in turn have detrimental effects on health.

The Nordic Council of Ministers, therefore, has initiated a project that aims to shed light on the well-being of young LGBTI persons. The purpose of the project is to promote knowledge and experiences in the region, in order to contribute to improved life conditions for young LGBTI persons in the Nordic countries. Nordic Information on Gender, NIKK, has carried out the project, which has resulted in the report at hand. The report consists of two parts:

• A literature review describing the current state of research regarding the well-being of young LGBTI persons in the Nordic countries, and
• A survey, presenting a selection of efforts aimed to improve the well-being of young LGBTI persons in the Nordic countries.

Literature review

The literature review is based on a systematic literature search, with a main focus on empirical studies involving young LGBTI persons in the Nordic countries, published between 2015 and 2020. All in all, the review draws upon 38 publications, quantitative as well as qualitative studies among them. The research review has them structured in two groups with overarching themes; health and norms and life conditions respectively, both with a number of subthemes. 

​Health

Studies that focus on mental health and experiences of, among other things, depression, anxiety, and stress, indicate that having a sexuality or gender identity which falls outside the norm seems to have a major impact on mental health. Trans persons in particular are reporting mental health issues exceeding the average. As a group, young LGBTI persons also display an above-average ocurrence of self-harm, as well as disproportionate figures regarding suicidal thoughts and suicide attempts. Again, trans persons feature prominently among these cases, as do people who have had sex with another person of the same sex, but do not identify as homo- or bisexual.

The LGBTI group also reports below-average physical health, in particular among trans persons. Health issues may include various kinds of pain, stress, sleep disturbance, chronic physical conditions, and self-estimated physical health. Multiple studies also indicate above-average drug and alcohol abuse in the LGBTI group. Norms prevalent in sports contexts may affect which adolescents feel welcome there. For example, young trans people may avoid going to gyms, due to fear of transphobia.

An early sexual debut is considered a common risk factor within sexual and reproductive health. Many of the studies included in this literature review indicate that an early sexual debut is more common among bisexuals, and among those who report being uncertain about their sexuality – compared to young heterosexuals. Young homo- and bisexuals report a higher occurrence of sexual risk-taking compared to heterosexuals.

Norms and life conditions

Studies included in this review show that many young LGBTI persons are unable to be as candid as they would like, regarding their sexuality or gender identity. Sexual harassment and vulnerability to violence appear to be common among young LGBTI persons. Trans persons in particular are subjected to offensive treatment, or to harassment. Such violence is rarely reported to the police.

The studies that focus on schools show that students from the LGBTI group experience more difficulties in the school environment compared to other students. The group describes the environment as heteronormative, which might cause increased absence, school fatigue, and feelings of unsafety in school. Regarding bullying, several studies indicate that young LGBTI persons run a higher risk of being bullied. A couple of the studies included suggest that smaller schools and rural schools may also be environments that increase the vulnerability of LGBTI students. School nurses may be a vital asset in the school environment, and potentially provide a measure of counselling, but in this profession it is important to have sufficient competence regarding LGBTI issues.

When it comes to studies focused on working life, these indicate that young LGBTI persons experience more long-term unemployment than other young people. Looking at perceived comfort; compared to heterosexuals, a much larger percentage of non-heterosexuals are unhappy with their situation at work or in school, and report that they have been subjected to bullying, or frozen out.

The studies also show that it is more common for trans identifying young people to rate their relationships with parents as average or poor, compared to other young people. Proportionally, more youths in the LGBTI group report unwanted loneliness or lack of practical support from those around them. This is particularly reported by trans and nonbinary persons.

Some of the qualitative studies included also show how different experiences and contexts affect life conditions for young LGBTI persons. Growing up in a rural setting might, for example, involve particular experiences. Locations that offer a limited number of social contexts may create anxiety in parents, regarding what other people in the area might say about their kids. Geography also matters, where a geographic location may imply various cultural expectations, and provide proximity or distance to other LGBTI persons, places, and contexts. Locations where religious and conservative norms have a firm hold may also present obstructions to openness. One study shows how Sami roots are highlighted both as something positive and as a problem. Another study sheds light on the experiences of young, asylum-seeking LGBTI persons, whose LGBTI identity might expose them to bullying and harassment in asylum reception centres or asylum housing facilities.

Among the identities included in the LGBTI acronym, it is mainly intersex experience that is absent from current research. The qualitative studies that have been carried out demonstrate the difficulties in being open regarding your condition, for fear of not being perceived as the gender with which you identify, of being considered strange or deviant, or to become your condition only. Young people with intersex experience further perceive that general knowledge about intersex is severely lacking throughout society.

Factors creating differences within the LGBTI group

The studies included show that young trans persons report more issues regarding both mental and physical health, compared to other categories of the LGBTI group. Young bisexuals also display somewhat less well-being compared to young homosexuals. Differences between homo- and bisexual girls and boys can be observed across multiple studies. Girls are more frequently represented than boys in the group reporting mental health issues. Suicidal thoughts or a limited number of suicide attempts are common among the girls. The boys represented in the group reporting mental health issues are fewer in number, but a proportionally larger amount of them carry out a number of suicide attempts. Among boys, there is a stronger link between homosexuality and vulnerability to sexual harassment, and they are at greater risk of being bullied.

Bisexuals often report greater vulnerability than homosexuals, for example when it comes to mental health issues, suicide attempts, and physical health issues. Compared to homosexuals, a greater percentage of bisexuals avoid being open about their sexual orientation. In addition, they report few or no contacts with friends, and access to few or no persons to talk to. A study including people who report having sex with other people of the same sex, but do not identify as homo- or bisexual, reveals that they suffer from more mental health issues, and have carried out suicide attempts to a greater extent, compared to both bi- and homosexuals.

Apart from the abovementioned, other factors are also affecting life conditions among young LGBTI persons. In some population studies, health issues are found particularly within these younger groups. This can be understood through theories about age-specific minority stress, where people currently in the youth category will be exposed to multiple stressors during the course of their life, but where these stressors gradually drop with age. Socioeconomy is another factor which might impact the life conditions of young LGBTI persons.

Needs and measures

A recurring model of explanation in the studies reviewed is that the difficulties experienced by young LGBTI persons in daily life revolve around minority stress. With this in mind, awareness-raising efforts are in focus when the studies propose any recommendations.

Several of the studies agree that there is need for change in societal attitudes, and for increased knowledge concerning sexual minorities, trans persons and intersex. Many of these studies provide more detailed recommendations for various kinds of improvement measures. Additional knowledge about sexualities and gender identities that fall outside the norm is required: within training programmes, in schools, within sex education, families, healthcare, and asylum reception centres. Some studies have drawn attention to the fact that young people who identify with less normative identities (beyond the hetero, homo, and bi categories) such as queer, nonbinary, or asexual should be given particular attention.

Efforts in the Nordic countries 

In order to address the exposure of LGBTI persons, several Nordic countries are currently making efforts meant to improve health, life conditions and well-being in this group. The efforts are targeting young people directly, as well as a number of professions with which they interact, such as school and healthcare staff. Other efforts may involve raising awareness about the conditions that young LGBTI persons face, and tasking key authorities with awarding the group a particular focus.

The survey of efforts carried out by NIKK includes measures taken at municipal, regional and national levels, in many different areas throughout the Nordic countries. The LGBTI organisations of the respective nations are the primary actors behind the activities aimed directly at the target group. Other actors can be found among recreation leaders and social welfare secretaries operating locally, in a municipality or region. Collaboration frequently occurs between organisations and occupational groups. LGBTI organisations tend to serve as repositories of knowledge, and provide professionals with education and in-service training covering issues pertaining to the health and life conditions of young LGBTI persons. Activities target both physical and mental health issues, and focus on, for example, the vulnerability of young people to bullying and discrimination, as well as family life and relationships. Efforts are undertaken locally and/or online. If they involve a chat or phone line, they are sometimes perceived as more accessible to a higher number of individuals, as these solutions do not require users to visit a particular location. This might be of great importance for people living in the more rural parts of the Nordic region. Additionally, technical solutions like these may also have been of particular importance during the ongoing Covid-19 pandemic, which has enforced social distancing. Meanwhile, fixed-location activities are better suited to the needs of a specific target group. Such needs include safe spaces and social relations.
 

Sammanfattning

Trots att livsvillkoren för LGBTI-personer^{[1]LGBTI är en förkortning av Lesbian, Gay, Bisexual, Transgender och Intersex. Denna förkortning används i nordiska, och många internationella, sammanhang.} i Norden har förändrats under de senaste sjuttio åren, visar större folkhälsoundersökningar att de har sämre psykisk och fysisk hälsa än den övriga befolkningen. Även bland yngre generationer av LGBTI-personer påverkas livet av att ha en sexualitet eller könsidentitet som faller utanför heteronormativiteten. Det beror bland annat på den utsatthet för stress som LGBTI-personer utsätts för i vardagen, så kallad minoritetsstress. Det handlar om risk för eller faktiska trakasserier, utsatthet och våld. Det handlar också om att i vardagen möta fördomar och diskriminering, att ibland behöva dölja sin identitet liksom om internaliserad homo- och transfobi, vilket i sin tur leder till ohälsa.

Nordiska ministerrådet har därför initierat ett projekt för att belysa unga LGBTI-personers välmående. Syftet med projektet är att sprida kunskap och erfarenheter i regionen, för att bidra till bättre levnadsvillkor för unga LGBTI-personer i Norden. Nordisk information för kunskap om kön, NIKK, har utfört projektet, som resulterat i denna rapport. Rapporten består av två delar:

• En forskningsöversikt som beskriver forskningsläget om unga LGBTI-personers välmående i de nordiska länderna och
• En kartläggning som presenterar ett urval av insatser för att förbättra unga LGBTI-personers välmående i Norden

Forskningsöversikt

Forskningsöversikten är baserad på en systematisk litteratursökning, med fokus på empiriska studier med unga LGBTI-personer i de nordiska länderna, publicerade mellan 2015 och 2020. Sammanlagt ligger 38 publikationer till grund för forskningsöversikten, bestående av kvantitativa såväl som kvalitativa studier. De är i forskningsöversikten tematiserade under två övergripande teman; hälsa samt normer och livsvillkor, med en rad underteman.

Hälsa

De studier som fokuserar på psykisk hälsa och erfarenheter av bland annat depression, ångest och stress visar att en sexualitet eller könsidentitet som går bortom normen förefaller ha stor påverkan på den psykiska hälsan. Särskilt transpersoner rapporterar högre nivåer av psykisk ohälsa. Det är även betydligt vanligare med självskadebeteende, såväl som med självmordstankar och självmordsförsök bland unga LGBTI-personer. Återigen sticker transpersoner ut, men även personer som har haft sex med någon av samma kön, men som inte identifierar sig som homo- eller bisexuell.

LGBTI-gruppen rapporterar också sämre fysisk hälsa, i synnerhet transpersoner. Det kan handla om värk av olika slag, stress, sömnsvårigheter, kroniska fysiska tillstånd samt självskattad fysisk hälsa. Flera studier pekar också mot att bruk av alkohol och droger är större i LGBTI-gruppen. Normer i sportsammanhang kan påverka vilka unga som känner sig välkomna där. Unga kan till exempel avstå från att gå till gym, av rädsla för transfobi.

En tidig sexuell debut ses som en vanlig riskfaktor för sexuell och reproduktiv hälsa. Studier visar att det är vanligare med en tidig sexuell debut bland bisexuella och bland de som rapporterar att de är osäkra på sin sexualitet – jämfört med unga heterosexuella. Unga homo- och bisexuella rapporterar högre sexuellt risktagande jämfört med heterosexuella.

Normer och livsvillkor

Studierna visar att många unga LGBTI-personer inte kan vara så öppna med sin sexualitet eller könsidentitet som de önskar. Sexuella trakasserier och utsatthet för våld förefaller vara vanligt bland unga LGBTI-personer. Särskilt transpersoner blir utsatta för kränkande bemötande, behandling eller trakasserier. Våldet polisanmäls sällan.

Studierna som fokuserar på skola visar att det är fler i LGBTI-gruppen än bland övriga elever som upplever svårigheter i skolmiljön. Gruppen beskriver miljön som heteronormativ, vilket exempelvis kan leda till större frånvaro, skoltrötthet och otrygghet i skolan. När det gäller mobbning pekar flera studier mot att unga LGBTI-personer löper större risk för att bli mobbade. Ett par studier pekar mot att små skolor eller landsbygdsskolor också kan göra LGBTI-elever mer utsatta. Skolsköterskan kan vara viktig i skolmiljön och potentiellt utgöra ett samtalsstöd, men det är viktigt att i denna yrkesroll ha god kompetens i LGBTI-frågor.

När det gäller studier inriktade på arbetsliv indikerar dessa att unga LGBTI-personer i större utsträckning har erfarenhet av långtidsarbetslöshet än andra unga. När det gäller trivsel är det en betydligt större andel icke-heterosexuella än heterosexuella som är missnöjda med sin arbets- eller skolsituation, som uppger att de utsatts för mobbning eller blivit utfrysta.

Studierna visar att det är vanligare bland transidentifierade unga att skatta sina relationer till föräldrarna som genomsnittliga eller dåliga jämfört med andra unga. Det är fler i LGBTI-gruppen som rapporterar oönskad ensamhet eller att de saknar praktiskt stöd från omgivningen, i synnerhet bland transpersoner och icke-binära.

Några kvalitativa studier visar också hur olika erfarenheter och sammanhang påverkar livsvillkoren för unga LGBTI-personer. Att växa upp på landsbygden kan exempelvis innebära särskilda erfarenheter. Platser där mängden sociala sammanhang är begränsade kan skapa oro bland föräldrar för vad andra i bygden ska säga. Geografi har också betydelse, där den geografiska platsen kan innebära olika kulturella förväntningar och erbjuda närhet eller distans till andra LGBTI-personer, platser och sammanhang. Platser där religion och konservativa normer är starka kan också försvåra att vara öppen. En studie visar hur samiskt ursprung lyfts som både något positivt och som ett problem. En annan studie belyser erfarenheterna hos unga asylsökande LGBTI-personer, där LGBTI-identiteten kan innebära att bli utsatt för mobbning och trakasserier på asylmottagningar eller asylboenden.

Av de identiteter som ryms inom LGBTI-akronymen är det framförallt intersex-erfarenheter som lyser med sin frånvaro i forskningen. De kvalitativa studier som genomförts visar hur det kan vara svårt att vara öppen med sitt tillstånd på grund av rädsla för att inte bli sedd som det kön personen identifierar sig med, att ses som konstig, avvikande eller att bara bli sin sjukdom. Unga med intersexerfarenheter upplever också att kunskapen om intersextillstånd i samhället är mycket bristfällig.

Faktorer som skapar skillnader inom LGBTI-gruppen

I studierna framkommer att unga transpersoner rapporterar såväl sämre psykisk som fysisk hälsa, än övriga i LGBTI-gruppen Även unga bisexuella uppvisar något sämre välmående jämfört med unga homosexuella. Det går att se skillnader mellan homo- och bisexuella tjejer och killar i flera studier. Det är fler tjejer än killar i gruppen med psykisk ohälsa. Bland tjejerna är det vanligt att ha självmordstankar eller att ha genomfört ett mindre antal självmordsförsök. Bland den mindre andelen killar är det dock fler som genomför många självmordsförsök. Bland killar finns ett tydligare samband mellan homosexualitet och utsatthet för sexuella trakasserier och de löper större risk att bli mobbade.

Bisexuella rapporterar ofta en större utsatthet än homosexuella, exempelvis när det gäller psykisk ohälsa, självmordsförsök och fysisk ohälsa. Det är också en större andel bisexuella jämfört med homosexuella som inte är öppna med sin sexuella läggning. De uppger dessutom att de sällan eller aldrig har kontakt med vänner eller har någon att prata med. I en studie som inkluderar personer som uppger att de har sex med andra av samma kön, men ej identifierar sig som homo- eller bisexuella, framkommer att de har högre grad lider av psykisk ohälsa och har gjort självmordsförsök jämfört med både bi- och homosexuella, vilket är värt att notera.

Utöver detta spelar även andra faktorer in och påverkar livsvillkoren bland unga LGBTI-personer. I vissa befolkningsstudier är det just bland dessa yngre åldersgrupper som det rapporteras ohälsa. Detta förstås genom teorier om åldersspecifik minoritetsstress, där personer som befinner sig i ungdomskategorin blir utsatta för fler stressorer under livsloppet, något som sedan gradvis avtar under livet. Socioekonomi är en annan faktor som kan påverka livsvillkoren för unga LGBTI-personer.

Behov och åtgärder

En återkommande förklaringsmodell i studierna är att de svårigheter som unga LGBTI-personer upplever i vardagen handlar om minoritetsstress. Mot bakgrund av detta hamnar kunskapshöjande åtgärder i fokus när studierna lyfter rekommendationer.

Flera studier är eniga i att det behövs en förändring av samhälleliga attityder, med större kunskaper kring sexuella minoriteter, transpersoner samt intersex. I många av studierna ges närmare rekommendationer på olika typer av förbättringsåtgärder. Mer kunskap om sexualiteter och könsidentiteter som hamnar utanför normen behövs: På utbildningar, i skolan, i sexualundervisningen, i familjer, inom vården, på asylmottagningar. Vissa studier har uppmärksammat att de unga som identifierar sig med mindre normativa identiteter (bortom hetero, homo- och bikategorier) som exempelvis queera, icke-binära eller asexuella särskilt behöver uppmärksammas.

Insatser i Norden

För att möta unga LGBTI-personers utsatthet genomför flera nordiska länder insatser för att förbättra hälsa, livsvillkor och välmående hos gruppen. Insatserna riktas direkt till de unga, såväl som till professioner som möter dem, exempelvis skol- och vårdpersonal. Andra åtgärder kan handla om att öka kunskapen om unga LGBTI-personers situation och att ge nyckelmyndigheter i uppdrag att särskilt fokusera på gruppen.

Kartläggningen av insatser som NIKK genomfört inbegriper insatser som utförs på kommunal, regional och nationell nivå, och är inhämtade från olika delar av Norden. Det är främst de nationella LGBTI-organisationerna som står bakom verksamheterna som riktar sig direkt till målgruppen. Men det kan även vara fritidsledare eller socialsekreterare lokalt i kommunen/regionen. Det är också vanligt med samarbeten mellan organisationerna och yrkesgrupperna. LGBTI-organisationer fungerar i regel som en kunskapsbank, och ger professionella utbildning och kompetensutveckling i frågor som rör unga LGBTI-personers hälsa och livsvillkor. Verksamheterna inriktar sig på såväl fysisk som psykisk ohälsa, samt fokuserar på exempelvis ungas utsatthet för mobbning och diskriminering samt familjeliv och relationer. Insatserna är platsbundna och/eller bedrivs digitalt. Insatser i form av exempelvis chatt eller telefonkontakt kan upplevas som tillgängliga för fler, då de inte kräver att de unga tar sig till en specifik plats. Detta kan vara av betydelse för personer som bor i Nordens mer rurala områden. De kan även varit särskilt betydelsefulla under rådande covid-19-pandemi, som ställer krav på social distansering. Samtidigt ökar den platsbundna verksamheten träffsäkerheten i relation till målgruppens behov, som är till exempel trygga rum och social samvaro.

About the report

In January 2020, the Nordic collaboration carried out through the Nordic Council of Ministers was extended to include work promoting equal rights, as well as treatment of, and opportunities for LGBTI persons in the Nordic countries. Under the Danish Chair of the Council that year, there was an initiative for a Nordic project to highlight the well-being of young LGBTI persons. The aim of this project is to promote knowledge and experiences throughout the region, in order to contribute to improved life conditions for young LGBTI persons in the Nordic countries.

The cooperation body of the Nordic Council of Ministers, the Nordic Information on Gender (NIKK), located at the Swedish Secretariat for Gender Research, has carried out the project which has resulted in this report. The report consists of two parts:

• A literature review describing the current state of research regarding the well-being of young LGBTI persons in the Nordic countries, and
• A survey, presenting a selection of efforts aimed at improving the well-being of young LGBTI persons in the Nordic countries.

The literature review is written by Anna Siverskog, Ph. D., lecturer at the School of Health and Welfare at Jönköping University. The survey has been carried out and written by journalist Ida Måwe.

Terminology

LGBTI

LGBTI is an acronym for Lesbian, Gay, Bisexual, Transgender, and Intersex. This umbrella term is used throughout this report, with exceptions made where studies are referenced in which other terms are used, or where particular subsets of the group are studied or targeted. These subsets may include HBT, HBTQ or LBTQ. HBT is short for homosexuals, bisexuals and trans persons. The acronyms HBTQ and LBTQ also identify people who identify as queer and lesbian. Even if LGBTI is used throughout, this is done knowing there is little balance between the subsets included in the term; for example, intersex features particularly rarely in the research.
 

Trans person

An umbrella term for various individuals who experience that the legal gender they have been assigned at birth does not match their gender identity and/or their gender expression.

Nonbinary person

A person feeling neither like a woman nor a man, but instead like both, in between, fluid, or entirely beyond any gender categories.
 

Intersex variations/variations in sex characteristics

Intersex variations, also termed variations in sex characteristics, involve several different medical conditions where a person is born with an internal or external anatomy that diverges from the idea of what a typically male or female body is expected to be like. An intersex variation may be a difference in external anatomy, but it may also be a hormonal or genetic difference, which might not manifest in any apparent anatomical difference. There is a wide spectrum of intersex variations, some of which are treated medically and others that are not.
 

Queer

Queer may have several different meanings. It may be used as an identity, in which case it might represent a desire to be exempt from identification with something, and a wish to contest gender and sexuality norms. In addition, Queer is a notion that can express a critical stance in relation to norms, and in this instance cover both gender and sexual orientation.
 

Cis person

A person identifying with the legally recognised gender they have been assigned at birth.

Legally recognised gender

The gender registered for a person in the national registration records of the Nordic countries. In the absolute majority of cases, the legally recognised gender is assigned based on the apparent external anatomy of the newborn child.
 

Gender identity

The self-experienced gender of a person, that is, the gender with which you identify. Gender identity is sometimes termed psychological or mental gender.
 

Gender-affirming care and treatment

An umbrella term for various methods used to change the body, to make it better align with a person’s gender identity. 
​

Minority stress

Being in a minority position means an increased risk of exposure to various psychosocial stressors, such as coping with bullying, discrimination, violence, etcetera. Such stressors may have a negative impact on mental health, and this phenomenon is known as minority stress.

LGBTI politics in the Nordic countries

In an international perspective, the Nordic countries have long been considered progressive within the LGBTI field, but lately they have fallen behind in certain areas, and are still facing a number of challenges before LGBTI persons have the same rights and opportunities as the majority of the population (The Nordic Council of Ministers, 2020).

International LGBTI organisation ILGA performs an annual review of LGBTI related laws and policy in 49 European countries. These countries are ranked according to their anti-discrimination laws, family law, protection against hate crime, trans rights, civil society, and asylum legislation. In the 2020 review, Denmark and Norway shared the ranking as third, (68% of criteria entirely met), Finland ranked fifth (shared, at 66%), Sweden ranked sixth, at 63% (with nine other countries ranking higher), and Iceland ranked ninth (with thirteen other countries ranking higher) at 54%. According to ILGA, the Nordic countries are progressive when it comes to family law, but lacking in the recognition of legal gender and protection against discrimination of trans persons, and of persons with intersex variations (ILGA Europe, 2020). A survey analysing the LGBTI field in the Nordic countries shows that all of the nations address LGBTI politics, and that efforts are made in sectors including education, healthcare, and civil society. The situation varies, however, between the respective nations. Denmark, Norway and Sweden have plans of action in place, spanning several political areas. Finland lacks an LGBTI focused plan of action, but instead, issues are addressed within the context of other national action plans. In Finland, the focus on legal improvement is connected to legislation concerning trans and intersex. Similarly, Iceland also lacks a specific LGBTI plan of action, but the nation has taken a number of legal measures, and adopted a progressive gender identity legislation. The self-governing areas of the Faeroe Islands, Greenland and the Åland Islands currently lack any LGBTI plans of action (The Nordic Council of Ministers, 2020).

Throughout history, as well as in our own time, LGBTI organisations have been an important driving force for legal and social change within the Nordic countries. Their work matters a great deal for the development of LGBTI politics, as well as its implementation. Further examples of this are presented in the second part of this report, which has a focus on activities aimed at improving the health, well-being and life conditions of young LGBTI persons.

Part 1. Literature review

Introduction

The life conditions of LGBTI persons in the Nordic countries have changed radically in the last seventy years. Those belonging to the older generations of LGBTI persons today, have lived through times when their sexuality and gender identities were perceived as both criminal and pathological. These people have also experienced the improvement over time of their legal and social situation (Bromseth & Siverskog, 2013). Despite legal improvement, reinforced rights, increased visibility, and the gradual development of interest groups, social movements, and meeting-places, major public health surveys demonstrate the fact that an LGBTI identity has a significant impact when it comes to mental and physical health, compared to the population in general. Among the younger generations of LGBTI persons growing up in more recent times, life is similarly impacted by having a sexuality or gender identity that falls outside of heteronormativity (Bindesbøl Holm Johansen et al., 2015; Public Health Agency of Sweden, 2014, 2015; Gisladottir et al., 2018; Jokela et al., 2020). The Swedish Research Council for Health, Working Life and Welfare has presented a report on the international research available on young HBTQ persons. The review shows plainly that young HBTQ persons run an increased risk of suffering from mental and physical health issues. This is explained in turn by the vulnerability to stress which HBTQ persons experience in daily life, known as minority stress. This might include the stigma associated with an HBTQ identity, as well as coping on an everyday basis with bullying, discrimination, violence, openness, etcetera. The review also indicates that a great deal of the knowledge available is based on North American studies (Bränström, 2018). Previous studies have shown how national legislation, policy, and societal norms and attitudes toward LGBTI persons affect well-being and health within the LGBTI group (Pachankis & Bränström, 2018; van der Star et al., 2020). In order to find out more about the well-being of young LGBTI persons in the Nordic countries, we need, therefore, to assess more closely any studies made in these particular contexts.

In this literature review, based on a systematic search, empirical studies are presented that concern the health and well-being of young LGBTI persons, and have been carried out in the Nordic countries. The studies in question are published between 2015 and 2020. In the context of this overview, the phrase LGBTI persons is employed as an umbrella term for the group whose sexualities and gender identities fall outside the norm, with exceptions made in instances where the studies cited use other terms, or where specific subsets of the group are in focus. Well-being is broadly defined, and includes mental and physical health, as well as norms and life conditions. Young people are defined as persons between 13 and 30 years of age, even if age spans may differ across the various studies. The method section and method appendix include a more detailed description of processes for inclusion and selection, as well as search terms used for the literature searches.

The literature review aims to describe the current state of the research field concerning the well-being of young LGBTI persons in the Nordic countries. Core questions through the production of the report have been:

• What is the current state of the research field; what kind of studies are available, and which groups have been included in the studies?
• Which themes are highlighted, and what do the results of the studies indicate?
• Are there any variations within the LGBTI group concerning well-being?
• What is being held forth as vital social and political measures?
• What knowledge is still lacking in this field? 

The literature review is written by Anna Siverskog, Ph. D., lecturer at the School of Health and Welfare at Jönköping University. The text has been produced in co-operation and consultation with a working team from the Swedish Secretariat for Gender Research, including Elin Engström, Kajsa Widegren (Ph. D.), and Sanna Hellgren, librarian at KvinnSam^{[1]KvinnSam is the national library for gender research, and a university-wide research infrastructure at the University of Gothenburg. For more information: http://www2.ub.gu.se/kvinn/}, who has performed searches and reference management.

As the work group has been allocated to Sweden, a reference group with representatives from the remaining Nordic countries has been tied to the project. This group has consisted of the following people:

• Iceland: Jón Ingvar Kjaran, Professor, Faculty of Education and Diversity, University of Iceland. 
• Denmark: Michael Nebeling Petersen, Associate Professor, Department for the Study of Culture, University of Southern Denmark. 
• Norway: Janne Bromseth, Ph. D., Independent scholar, Forskerkollektivet, Oslo. 
• Finland: Antu Sorainen, Associate Professor, Department of Cultures, University of Helsinki.

Method

A complete description of the method used for the production of this report can be found in appendix 1. A search strategy based on the method for a systematic review has been applied (The Campbell Collaboration, 2020). Four key terms; young; LGBTI; well-being, and; the Nordic countries were used to generate a search phrase with multiple synonyms and terms. The search was limited to materials published between 2015 and 2020. The search was carried out in the Scopus, Web of Science, and ProQuest Social Sciences databases. Due to the geographic definition of the subject, searches were also performed in the respective Nordic languages, in the Nordic databases for scientific publication. The search generated a total of 443 results. These were assessed by two people in so-called blind mode, and in a secondary stage, a full-text reading was undertaken. Here, the inclusion criteria were, among others, that the studies should be empirical, be focused on participants between 13 and 30 years of age (or an even narrower scope), involve LGBTI persons, be focused on well-being, and include demographies from one or several of the Nordic countries. All in all, 29 peer reviewed scientific articles were included, which had all undergone peer review.  

In order to include what is commonly referred to as grey material, such as reports and other types of publications from authorities, interest groups and other actors, targeted searches were performed on the respective websites of a number of actors. For each of the Nordic countries, two or three (depending on the extant actors of the various nations) bespoke programmed search engines were created. Due to the necessity of performing a full-text assessment of these publications already at the primary stage, the selection process took place immediately during the assessment of search results as they presented themselves. The first 20 results of each search were inspected. The selection criteria were the same as presented above the aforementioned databases. Apart from these criteria, manuals, plans of action, handbooks, and studies that were focused on efforts and measures were also excluded. All in all, the grey material searches yielded another 8 results consisting of reports, three of which were from Norway, one from Finland, two from Sweden, and two from Denmark. Further, one other Norwegian report was included as per the recommendation of the reference group. The total sum of publications on which the report is based is 38. All articles were written in English, and the grey materials in the respective Nordic language.

Research field overview

The selected studies consist of both quantitative and qualitative studies, and include anything from large-scale population studies to small-scale interview studies. At times, trans and nonbinary persons are examined separately, sometimes this is true for non-heterosexuals, and sometimes, the entire LGBTI group is included. Within larger, quantitative studies, comparisons to the general population are often made. Below is a thematic presentation of the results of these studies, structured according to two overarching themes; health and norms and life conditions, with a number of subthemes. These themes outline the research available for the respective themes, meaning there is sometimes no research available from one or more of the Nordic countries, or that no research is available that focuses on every particular subgroup within the LGBTI group. Studies which include LGBTI persons of various ages, from a particular national context, but where young people are not presented separately and no data can subsequently be retrieved about this group, have been excluded from the presentation below.

Health

Within this primary, overarching theme are several subthemes that focus on health aspects, specifically; mental health; suicide and self-injury; physical health, and; sexual and reproductive health.

Mental health

Mental health issues include experiences of, among other things, depression, anxiety, and stress. Mental health is primarily examined through quantitative studies, but the same themes recur in some of the qualitative studies. Initially, we aim to present here the studies focused on sexual minorities, secondly, those that encompass the LGBT group in its entirety, and finally those who include trans individuals.

Mental health among homo- and bisexual individuals

In a study on health indicators among sexual minorities in Norway and the US, data has been included from 2 423 individuals in Norway, between 19 and 27 years old, out of which 232 identified as homo- or bisexual. Regarding depression symptoms, 5.3% of the young heterosexuals reported having experienced such symptoms, which is the same percentage as among bisexual youths. The corresponding percentage for those who identified as gay or lesbian amounted to 11.6%. Among those who had sex with people of the same sex, but did not identify as LGB, the corresponding percentage was 37.4% (Watson et al., 2015).

In a national Icelandic survey, gathering data from a total of 11 116 students aged between 16 and 20, out of which 1 143 students identified as being somewhere on the LGB spectrum, mental health among sexual minorities was examined. Among other issues, depressive tendencies, anger, and stress were investigated. The analysis indicated less well-being among homo- and bisexual youths compared to other participants in the study. The most marked difference appeared when comparing lesbian and heterosexual youths (Gisladottir et al., 2018).

A Swedish study based on data from the Swedish Twin Registry examines the connection between sexual minority status and mental health among young people who took part in a survey at age 18. The total number of respondents were 4 898, 8.3% of which reported belonging to a sexual minority, that is, homo-, bisexual, or other. In this group, it was more common than among the total number of respondents to report a higher frequency of mental health issues, such as anxiety, depression, hyperactivity, eating disorders, and abuse of alcohol and other substances (Donahue et al., 2017).

Mental health within the LGBT group

A large-scale population study in Finland examines students’ health (years 8, 9, 1 and 2 in upper secondary school, and in vocational training). Of the 153 143 persons that took part in the survey, 12 947 identified as sexual minorities, and 4 720 as gender minorities. The differences in health between the LGBT young and other young people were significant. The young in the LGBT group estimated their health to be average or poor twice as often compared to other young people. Further, depression symptoms and mood swings were much more frequent among LGBT young. Regarding anxiety, it was three times more common in the LGBT group. LGBT young also experienced less frequently than other young people that when needed, they received help from parents or friends in matters relating to their health (Jokela et al., 2020).

One Danish study on health and well-being involved a total of 14 265 respondents, out of which 103 participants were homo- and bisexual, and 100 were trans persons aged 15 to 34. The number of persons estimating their general health as good or very good amounted to 98% for the homosexuals, 88% for the bisexuals, and 69% for the trans persons. Looking at mental health in this group, 16% of the homosexuals, 31% of the bisexuals, and 57% of trans persons rated their mental health as poor, compared to 12% of the heterosexuals. Regarding the percentage experiencing stress (questions dealt, among other things, with the ability to cope with unpredictable events, problems, and challenges), 33% of the homosexuals, 52% of the bisexuals, and 76% of trans persons reported having experienced stress during the past month, compared to 31% of the heterosexuals. It is primarily trans persons and bisexuals who report health issues (Bindesbøl Holm Johansen et al., 2015).

In a Norwegian study based on qualitative interviews with 24 LGBT persons, mainly between the ages of 15 and 30, and residing in communities with less than 20 000 inhabitants, health issues were not explicitly brought up by researchers during the interviews, but many informants did report mental health issues. Nine participants had experienced mental health problems such as anxiety, depression and self-injury. Several of the respondents connected these issues to bullying, exclusion, and loneliness. Others linked them with experiences of sexual abuse, or with insecure conditions when growing up, as well as inner and outer pressure to “be perfect”. Several participants explained their own mental health issues with the burden incurred by rejecting hetero and/or gender norms. Three of the trans person who were part of the study reported severe mental health issues, family conflicts, and difficulty to finish their education. Two of them reported suicide attempts. Not being a cis person was described by some of the participants in the study as brutal and hard (Eggebø et al., 2015).

Mental health among trans and nonbinary persons

As shown by the abovementioned studies, young LGBT persons report a higher incidence of mental health issues compared to other participants, and young people with a trans identity particularly stand out. Some studies specifically examine mental health in young trans persons. In a Finnish study, the well-being and mental health of young trans persons is examined through a survey including 370 trans persons between 15 and 25 years of age, compared to 1 243 cis persons (most of which identified as sexual minorities). The trans identifying young reported significantly lower levels of well-being than the cis persons in the study (Alanko & Lund, 2020).

In a Norwegian national survey regarding the health and well-being of students, the replies from 115 trans persons aged on average 23 to 24 were analysed and compared to those of other participants in the study. Regarding life satisfaction, trans identifying young reported significantly lower levels compared to cis identifying participants. 70% of trans persons and 64% of the nonbinary reported being dissatisfied with life, compared to 34 –35% of the cis identifying respondents. The discrepancy remained when accounting for age, income and other factors. There were significant differences, too, when it came to mental health issues, with trans persons reporting a higher incidence compared to the cis identifying respondents. 50% of trans persons and 62.7% of nonbinary persons in the study reported high levels of anxiety and depression symptoms (the corresponding numbers for cis men were 15.6% and 31.6% for cis women). 57–59% of trans persons and nonbinary persons in the study reported suffering from a mental illness, compared to 18% of cis women and 11% of cis men (Anderssen et al., 2020).

In a Swedish survey, the replies from 137 nonbinary respondents aged 13 to 17 are examined. Their reponses are also compared to those of other respondents in the study; 8 383 young people in total. The nonbinary young ran a significantly higher risk of developing mental health issues, compared to other participants in the study (Durbeej et al., 2019).

In a Finnish study, the impact of relationships on the well-being and mental health of young trans persons was investigated, through a survey answered by 370 trans persons aged between 15 and 25. Their data was compared to the answers of 1 243 cis persons (most of which identified as sexual minorities). The study, which is discussed more in-depth as part of the relationship theme (in the below section on norms and life conditions), showed that trans identifying young reported lower levels of well-being compared to other respondents in the study, and that the quality of their relationships mattered a great deal for their well-being (Alanko & Lund, 2020).

A Swedish survey involving 800 trans persons of various ages includes 424 persons aged 15 to 29. Comparatively, a higher number of people in the lower age span report an inferior quality of life; more than half of the participants aged 15 to 19, and over 35% aged 20 to 29 estimate their quality of life as poor. Further, the study shows that sadness is most common among younger respondents. 58% aged 15 to 19, and 45% among those aged 20 to 29 report often or always feeling unhappy or sad in the last few weeks. Across the entire group of respondents, 15% have experienced significant stress in the last few weeks, which is five times the reported number for the population in general. Those experiencing significant levels of stress are predominantly found among the youngest respondents (The Public Health Agency of Sweden, 2015).

Conclusion - mental health among young LGBTI persons

In conclusion, these studies show that a sexuality or gender identity outside the norm seems to have a major impact on mental health. In each of these studies, it is shown to affect mental well-being. Trans persons are particularly represented in these figures, but it is also worth noting the results from the Norwegian study, where persons who report having sex with people of the same sex, but do not identify as LGB feature prominently among respondents reporting mental health issues. (Watson et al., 2015).

Differences between the LGBT group and other young persons in the surveys could be understood in, among other things, the context of the stigma associated with not living up to a heterosexual norm. Despite progressive politics in the LGBTI area, the differences in mental health are very large when comparing LGBT young and other young persons. Minority stress is being highlighted as one model of explanation, where young sexual minorities often experience an increased vulnerability, and harassment (Gisladottir et al., 2018). Regarding trans persons, the differences in mental health are explained as caused by extant gender norms; both norms that outline the expected behaviour of men and women respectively, and cis norms creating the notion that no more than two genders exist. These norms are mirrored throughout society, and are taken for granted by, among others, healthcare staff and school personnel. Young trans persons who diverge from these norms meet with great challenges, and run the risk of facing discrimination (Anderssen et al., 2020).

Self injury and suicide

Among studies that investigate the incidence of self harm and suicide (including both suicidal thoughts and suicide), quantitative studies are the most common.

Self harm and suicide among homo- and bisexuals

In a study on health indicators among sexual minorities in Norway and the US, data has been included from 2 423 individuals in Norway, 19 to 27 years old, out of which 232 identify as homo- or bisexual. Regarding suicide attempts, the prevalence is higher among those identifying as gay or lesbian (12.2%), bisexuals (33.3%) and persons who report having sex with people of the same sex but do not identify as LGB (40.1%) compared to heterosexual respondents (7%) (Watson et al., 2015).

Another study investigates connections between sexual orientation, self-injury and suicide, using data from the Swedish Twin Registry, collected on several occasions (at 9 or 12, 15, and 18 years of age). Results show that respondents who identify as sexual minorities run a higher risk of developing behaviours that involve self-injury and suicide attempts. Bisexual persons are particularly represented in this instance. One potential explanation held forth is the minority stress under which sexual minorities live, where prejudice, discrimination, concealing your identity, and experiencing internalized homophobia lead to an increased risk of mental health issues (O’Reilly et al., 2020).

One Icelandic study also examines the link between sexual orientation and the risk of suicide, based on a survey involving 3 813 young people in year 10 (on average 15.6 years old), of which 1.5% reported having been attracted to a person of the same sex, and 1.7% had engaged in sexual activities with another person of the same sex. Among the students identifying as LGB, suicidal thoughts were twice as common when compared to the heterosexual students. For the former group, it was also five to six times as common to have had suicidal thoughts on multiple occasions. Among boys, it was more than four times as common among the LGB identifying to have attempted suicide, and more than six times as common among LGB identifying girls, compared to the young heterosexuals. To have carried out five or more suicide attempts was six times as common among LGB girls, while among LGB boys it was seventeen times as common to have attempted suicide. The differences remained even when tested against protective factors such as good communication with parents, having a best friend, having highly educated parents, and enjoying school. The most significant risk was found among students who reported having had sex with another person of the same sex; these ran a risk six times the average of attempting suicide more frequently (Arnarsson et al., 2015).

A Swedish survey examines the replies from 5 750 upper secondary school students with an average age of 18, in order to analyse the occurrence of self-reported frequency of sex as self injury (SASI). This is defined as the pursuit of sexual situations that cause mental or physical harm to oneself. As an example, selling sex is reported as one way of emotionally shutting down. The analysis seeks to trace connections between the occurrence of SASI and sociodemographic factors, mental health, etcetera. Results show that among the young reporting to have used sex as self-injury, a greater percentage belong to a sexual minority. A mere 60% in the SASI group reported being heterosexual compared to 88% in the reference group (Fredlund et al., 2017).

A Swedish survey investigating experiences of violence involves 1 051 women between 15 and 22, 10% of which state that they are homosexual, bisexual, or not sure. The study examines experiences of being subjected to emotional, physical, sexual, or family-related violence. Results show that a higher percentage among the homo- and bisexuals report having suicidal thoughts and behaviour involving self-injury (Palm et al., 2016).

Self-injury and suicide among trans and nonbinary persons

In a Norwegian national survey regarding the health and well-being of students, the replies from 115 trans persons on average 23 to 24 years old were analysed.

Self-harm and suicidal thoughts were significantly more common among trans and nonbinary persons, compared to the cis identifying (54–58% compared to 11–13% among cis men, and 24–27% among cis women). Similar patterns were observed for suicidal thoughts, with a much higher prevalence among trans and nonbinary persons compared to cis persons (62–64% compared to 18% among cis men, and 22% among cis women). Regarding suicide attempts, there was a similar trend (21–23% among trans persons, compared to 3% and 4.7% respectively among cis men and women) (Anderssen et al., 2020).

One Swedish study draws on a survey involving a total of 796 trans identifying persons between the ages of 15 and 96. The study aims to investigate the connections between risk factors, protective factors, and suicidality. Of the respondents, 53 persons are found in the age span 15 to 29 years, and age is only presented separately in the article regarding suicide. For suicidal thoughts in the last twelve months, 57% of respondents aged 15 to 19 report having such, and 41% of respondents aged 20 to 29. For suicide attempts, 40% of respondents aged 15 to 19 report having attempted suicide, and 37% of respondents aged 20 to 29. The result of the study shows that this correlates with age, as suicidal thoughts are less frequent with age (Zeluf et al., 2018).

In a Swedish study including 800 trans persons, 57% of respondents aged 15 to 19 reported seriously considering taking their own life at least once in the past 12 months. The corresponding percentage for the group aged 20 to 29 was 41%. 40% in the age span 15 to 19 years reported at least one suicide attempt (The Public Health Agency of Sweden, 2015).

Summary self-injury and suicide among young LGBTI persons

In summary, these studies illustrate that self-injury as well as suicidal thoughts and suicide attempts are significantly more common among young LGBTI persons. Once again, trans persons stand out, as well as persons who report having sex with people of the same sex, but do not identify as LGB. 

Physical health

Physical health may include a number of different factors, such as aches and pains, chronic physical conditions, and use of alcohol and drugs. These factors are mainly examined through quantitative studies.

An Icelandic survey involving youths from year 10 (average age 16), has 9 297 respondents. 353 of these identify as LGB, and their answers are compared to the responses of other youths in the study (Thorsteinsson et al., 2017). General health is defined here according to a checklist covering various health issues, such as headaches, stomach ache, back pains, sadness, mood dips, stress, trouble sleeping, and feeling weak. The LGB group reports being generally less healthy (on a scale of 1–5, 3.06 compared to 3.68 among the heterosexual students). Results indicate a connection between general health condition and enjoying school, having friendly classmates, being accepted, not being bullied or bullying others, to be content in life, and your economic situation (Thorsteinsson et al., 2017).

One Swedish study examines the importance of sexual orientation for physical health, according to a national population survey. All in all, 60 922 persons aged 18 to 84 are included, of which 280 people aged 16 to 25 identify as homo- or bisexual. Physical health is measured as self-assessed general health, as well as a number of physical symptoms, such as pain in various body parts, chronic physical conditions etc. Homo- and bisexual men and women between 16 and 25 report being generally less physically healthy, compared to the heterosexual group (26.9% of homo- and bisexual men reported poor health compared to 11.7% among heterosexuals; 35.2% among homo- and bisexual women compared to 16.8% among heterosexual women). Regarding the number of physical symptoms and conditions, homo- and bisexuals reported more of these compared to heterosexuals (3.4 on average among homo- and bisexual men, compared to 2.2 among heterosexual men; for women, the corresponding percentages reported were 4.4, and 3.2). When accounting for all age groups, results show that the difference between homo- and bisexuals compared to heterosexuals is most pronounced among the younger age groups. Authors argue that these results reinforce theories about age-specific minority stress, where people in the youth category are exposed to a higher number of stressors, which gradually cease during life. Authors hold that it is perceived as more stressful to navigate a stigmatized identity as a child or young person, and this in turn will also have a negative impact on a person’s health, compared to later points in life (Bränström et al., 2016).

One Danish study on health and well-being among LGBT persons involved a total of 14 265 respondents of different ages, with various sexualities and gender identities. Among the participants were 103 homo- and bisexuals, and 100 trans persons aged between 15 and 34. Regarding physical health in this group, 2% of homo-, bi- and heterosexuals, and 3% of the trans persons had rated their physical health as poor (Bindesbøl Holm Johansen et al., 2015). Regarding perceived pain or discomfort during the past 14 days, trans persons stood out. While 36% of heterosexual respondents reported such experiences, the corresponding numbers among homosexuals were 34%, 48% for bisexuals, and 72% among trans persons (Bindesbøl Holm Johansen et al., 2015).

In a survey conducted by the Public Health Agency of Sweden, and involving 800 trans persons, results showed that over 40% of the younger respondents reported having a problematic relation to food and eating. When participants assessed their overall health, it was generally poorer among younger respondents. About one fifth of participants aged between 15 and 29 rated their general health as poor. Half of participants aged 15 to 19, and over 40% of participants between 20 and 29 reported that their work capacity or daily life suffered to some degree, due to physical or mental illness. In total, across all the age groups, 17% reported severe issues due to aches and pains, but most of these people were found in the lower age brackets. 74% of the younger participants (15 to 19 years old) and 72% in the group aged 20 to 29 had abstained from various activities out of fear of being mistreated or discriminated against due to their trans identity over the past 12 months. The most common thing was to abstain from going to the gym, or from working out (The Public Health Agency of Sweden, 2015).

Being able to participate in sports and leisure activities is a factor that can potentially contribute to physical well-being. One Finnish study examines norms and openness within various lifestyle sports, such as skateboarding, longboarding, parkour, and roller derby, through qualitative and quantitative data on practisers of these sports. The study consists of 501 survey replies and 24 interviews. Regarding questions about whether participants know of anyone belonging to a sexual minority or gender minority, and who is also practising the sport, replies vary between the respective sports. While 94% of roller derby practisers report that they do, the replies for other sports are between 39 and 45%. It is mainly the non-heterosexuality of women that is being highlighted, both when it comes to roller derby and skateboarding. Regarding roller derby, participants report that there are even stereotypical ideas that all practisers are lesbians. A twenty-year-old derby player says; 

Another stereotype is that everyone is a lesbian. There has been a lot of talk about that. But in our club, for example, we are not interested in people’s private disposition. If someone wants to share, that’s fine. But we don’t care. We don’t mind, but it’s fine. We’re a sport, and those things have nothing to do with the sport itself. (2016:1103, translated)

Male homosexuality surfaces less frequently in the study, as do trans persons (Rannikko et al., 2016). 

When it comes to smoking and use of alcohol and drugs, multiple studies indicate that young LGBT persons display a higher substance intake than heterosexuals. One Norwegian study reports a higher percentage of smokers, marijuana users, and heavy drug users in the LGB group, compared to the heterosexuals in the study (Watson et al., 2015). One Danish study on health and well-being reported a higher percentage of smokers among LGBT persons. Hazardous use of alcohol was less common among bisexuals compared to heterosexuals (6% compared to 10%), but more common among homo- and bisexuals as well as trans persons (12% and 18% respectively). Further, more people in the LGBT group have smoked hash in the last year, compared to heterosexuals (24–37% compared to 17%) (Bindesbøl Holm Johansen et al., 2015).

Conclusion physical health

In conclusion, results show that the LGBT group reports poorer physical health, in particular among trans persons. Health issues may include aches and pains, stress, sleep disturbance, chronic physical conditions, and self-assessed physical health. Multiple studies also indicate that use of alcohol and drugs is more extensive within the LGBT group. Norms within sports contexts may affect which young people feel welcome there. They may, for example, abstain from going to the gym out of fear of transphobia. 

Sexual health

Concerning sexual health among young LGBTI persons, investigations have so far been limited to quantitative studies. Above all, so-called sexual risk behaviour is being researched. Studies focus on age of sexual debut, condom use, and HIV-testing.

With the assumption that an early sexual debut is a common risk factor for sexual and reproductive health, a Swedish study examines 5 321 survey replies from young people aged between 16 and 28. Results show that both girls and boys who identify as bisexual report, to a greater extent, an early sexual debut (defined as pre 14 years old). However, there are no differences between those who state that they are homosexual, compared to those who identify as heterosexual. A larger percentage of girls report negative experiences regarding their sexual debut (Kågesten & Blum, 2015). In a study comparing the health and risk behaviour of young people in relation to sexual orientation, survey results from young people in Sweden and Thailand are compared. The Swedish material includes 2 381 responses from young people aged 17 to 18. Of these, 102 persons identify as bisexual, 19 as homosexual, and 96 as uncertain about their sexuality. Those who report being not sure also report a significantly higher frequence of early sexual debuts, but among homo- and bisexual youths, too, a higher frequency of early sexual debuts (defined as pre 15 years old) is reported, compared to other participants in the study (Thitasan et al., 2019).

Regarding sexual risk-taking among young men, this is explored, among other places, in a Swedish study based on a survey with replies from a total of 452 men between the ages of 18 and 30, who visited a clinic to get tested for sexually transmitted diseases. 75 respondents reported having sex with men. Compared to those who had sex with women, a significantly higher number of men having sex with men stated that they had been under the influence of alcohol during their last sexual encounter. In addition, a significantly higher number of respondents in this group had experiences of being forced to have sex. One third of the MSM group (men who have sex with men) had experienced sexual coercion, compared to one tenth of the MSW group (men who have sex with women). Other than this, no differences were evident regarding age at sexual debut, unprotected sex, or use of drugs during sex (Helsing et al., 2020).

In another Swedish survey, factors affecting condom use and HIV testing are examined, in a respondent group consisting of 763 men between 15 and 29, who have sex with men. 37% reported that during their latest sexual encounter (anal intercourse) they had used no condom. Factors that influence the avoidance of condoms during temporary sexual encounters are low education levels, doubts about one’s HIV status, living in a larger city, and being single. 42% of respondents had been tested for HIV in the last 12 months. Factors that affected those who had not been tested included low education levels, being born in Sweden, and lacking information about where to get tested (Johansson et al., 2018). One Icelandic survey targeting young people with an average age of 16 found that condom use was lower among homo- and bisexual youths, compared to those who identified as heterosexual. Condom use dipped between 2010 and 2014, and had practically halved between these two years (Thorsteinsson et al., 2017).
 

Conclusion sexual health

Studies show that an early sexual debut, which is considered a common risk factor for sexual and reproductive health, is more common among bisexuals, and among those who report they are not sure about their sexuality – compared to young heterosexuals. Young homo- and bisexuals report a higher frequency of sexual risk-taking compared to heterosexuals. 

Norms and life conditions 

This second theme is focused on studies that concern norms and life conditions; openness; discrimination and harassment; being LGBTI in rural areas; the experiences of young asylum-seeking LGBTI persons; experiences from school, working life, and contacts with the healthcare system; relationships; and, intersex: atypical sex development in young people. Within some of these fields, knowledge is limited, which is why the few qualitative studies that exist have been given more room. This includes, among others, the sections about being young and LGBTI in a rural community, or going through an asylum-seeking process, as well as the section that focuses on intersex.

Openness

One major, Danish population study about sex assembled materials from a total of 62 675 respondents of all ages, with various gender identities and sexualities. Most of the survey questions are not presented in a way that makes it possible to discern the younger LGBT group, but in part of the report, the LGBT group is separately assessed. Here, we are informed that 24% of the men between 15 and 24 can, to a minor degree or not at all, be as open about their sexuality as they would like; the corresponding percentage for women is 19%. Among those who are not open about their sexuality (all ages), the percentage is larger among those living outside the capital and the areas surrounding it; among persons with Muslim backgrounds; and, significantly higher among bisexuals (Frisch et al., 2019).

Discrimination and harassment

A Finnish study examines experiences of sexual harassment, and whether such experiences are more common among young people belonging to a sexual minority. Sexual harassment is defined here as discrimination creating a hostile environment in school/at the workplace, which affects the person targeted to a high degree. This might include gender-based harassment or unwanted sexual attention (verbal or non-verbal), or sexual coercion. The study is based on data from a larger, nationwide survey, with a total of 120 400 participants from two age groups, with an average age of 15.3 and 17.5 respectively. Within the younger age group, exposure to all types of sexual harassment occurred more frequently among those who reported being interested in the same or both sexes, compared to those who identify as heterosexuals. In the older age group, boys and girls interested in the same or both sexes more commonly report experiences of sexual harassment. Having a romantic or erotic interest that goes beyond the heterosexual norm, therefore, is connected with an increased risk of being subjected to sexual harassment, and this connection is even more pronounced among boys (10–17 times more common among those who identify as homo- or bisexual compared to heterosexuals in the younger age group; versus 2–5 times as common for homo- and bisexual girls compared to heterosexuals in the same age group). The authors hold that these differences can be understood against a backdrop of various societal attitudes toward male and female homosexuality, and that going against a gender norm is perceived differently depending on whether the individual in question is male or female. This, in turn, might contribute to higher levels of minority stress among boys (Kaltiala-Heino et al., 2019).

One Swedish survey studies experiences of being subjected to emotional, physical, sexual, or family-related violence. The study includes 1 051 women between 15 and 22 years old, of which 10% report being homo- or bisexual, or not sure about their sexual orientation. Results show that those who belong to sexual minorities report significantly higher numbers regarding vulnerability to violence; 60% in this group report that they have been subjected to violence on multiple occasions, compared to 31% among all women (Palm et al., 2016).

In a Swedish survey with a total of 800 trans identifying respondents, of which 424 persons were between 15 and 29, health and life conditions were investigated. Here, mainly people from the younger age groups reported being subjected to offensive treatment in the last three months. 74% in the younger age span (15–19 years old) and 72% of those aged 20 to 29 had abstained from various activities in the last 12 months, for fear of being mistreated or discriminated against because of their trans experience. The most common thing to abstain from was going to the gym or working out, followed by attending social events, approaching people you do not know, flirting, or trying to pick someone up. The exposure to violence was more than twice as high among the respondents than among the population in general. Vulnerability to physical violence was most common in the group aged 15 to 19, where 11% of respondents reported having been subjected to physical violence in the last 12 months. The majority of those exposed to violence had been so at the hands of a stranger, by a police officer on duty, or by their partner. 52% of those aged 15 to 19 had been subjected to psychological violence in the last 12 months. 24% of those aged 15 to 19 and 36% of those aged 20 to 29 had been forced to have sex against their will. Over one third of those who had been forced to have sex against their will had been so by a steady or temporary partner. In one fourth of the cases, the person forcing them had been a stranger. The violence to which respondents were exposed was rarely reported; only about one tenth of respondents had reported such violence to the police. Of these, 1% were satisfied or very satisfied with their subsequent treatment. Over half of the participants aged 15 to 29 reported sometimes or often abstaining from going out alone for fear of being assaulted, robbed, or otherwise harassed. The corresponding percentage for the overall population amounts to one fifth (The Public Health Agency of Sweden, 2015).

Being LGBTI in rural areas

In a Norwegian study based on qualitative interviews with 24 LGBT persons aged mainly between 15 and 30, from communities with less than 20 000 inhabitants, openness is a theme (Eggebø et al., 2015). The experiences of coming out are different. Some immediately come out with their LGBT identity, while others respond that coming out has been out of the question, for example in school, due to homonegativism, bullying or that “those were things you sort of kept hidden.” Negative reactions from others are the main reason for not daring to be open. However, none of the respondents talk about “escaping the village.” Some have faced negative reactions, and have come out only after leaving their local area, but they have moved away because of studies or work. In several interviews, the young express that religious faith can affect whether their sexuality is accepted. Another impact factor in this case are parents who might express worries about what other local residents might think. One 20-year-old girl from a smaller village, recounts that her mother had a breakdown when told about her daughter’s sexual orientation:

She has tried not to talk about it, but today when we spoke on the phone, I pressured her a little bit, and she just fell apart. She said she was unable to do what she needed at work, because she was so depressed about me being gay [informant’s wording]. She’s off sick until the winter holidays. I feel that’s terrible. Good grief, what am I supposed to do? […] I think she’s afraid to talk about it where we live. She doesn’t want others to just automatically think «mother of a lesbian», I suppose. (2015:40)

In another Norwegian report, based on interviews with health professionals and young LGBT persons aged 16 to 29, the use and experiences of municipal health services throughout Norway are examined (Stubberud et al., 2018). The interviews concern on one hand the process of coming out, and the fact that this has been considered hard by several of the participants. But some have had experiences not all bad, and one of the respondents relate:

My mother was surprised when I told her. She claimed I had always been so girly, worn makeup and always wanted high-heeled shoes. When she understood I was serious, she entered a state of grief. Because her daughter had, just like, died. But then I told her that ‘I’m not dead, I’m right here. I might look a bit different, I might sound a bit different. But it’s still me. I haven’t changed my personality or anything like that.’ And that made her understand better. I have met no adversity from anyone else in my family, either. They were told by and by. (Pansexual/bisexual trans man, 28).

During the interview, the informant says he does not fit into the traditional account of the trans experience. It was not something he understood during childhood, but only later, in his teens. He also says he had a good life growing up as a woman, and has relatively unproblematic experiences of coming out as trans, both in his family and in the community where he lives (Stubberud et al., 2018). This study also includes young LGBT persons in Sápmi. Coming out as LGBT has, for some, been unproblematic within the Sami context, while for others it is described as difficult; that they have faced negative reactions, and that family ties have been broken as a consequence. In some cities, Laestadianism is strong, which contributes to a conservative, religious environment with heteronormative life expectations. Sami roots are highlighted both as a problem and as something positive. Several participants stress the fact that there was a lack of role models in the Sami context, and that one strategy was instead to be open on their own part, and to come out in local and regional media, to become to others the person they had lacked themselves. One 22-year-old homosexual man says;

When I came out I really was the only gay in the village. Everyone knew who I was. The first years after I came out, I used the opportunity to speak in the media, and that made many other people with the same kind of problems contact me.” (2018:13).

Over time, various initiatives within Sápmi have developed, which have led to increased visibility, such as the Sápmi Pride and Queering Sápmi^[1]. The Sami language is emphasized as crucial by many participants, as it lacks gendered pronouns, which may facilitate things for people who can consequently avoid being assigned the wrong gender (Stubberud et al., 2018).

Young asylum-seeking LGBT persons

One Norwegian study interviews unaccompanied, asylum-seeking children, who break the norms of gender and sexuality (Stubberud & Akin, 2018). All participants agree that gender and sexuality have not been prominent enough themes in the refugee reception centres and/or care facilities where they have been, and that they have not received any information on the subject following their arrival to Norway. Instead, they have looked for information online, per their own initiative; a fact that underscores the importance of digital competence, as well as access to computers and the internet. Replies from participants vary regarding whether they wish to be open about their gender identity or sexuality. Being open through the asylum-seeking process is described in the study as a complex matter. On one hand, it might be required in order to receive support and help, emotional backup, and contacts with LGBT networks, and – importantly – it might be a decisive factor, if it is a reason for applying for asylum. Meanwhile, it may be dangerous and result in poor treatment in, for example, asylum housing facilities, and cause worry that the news might spread back home, in your country of origin, and in the family. Respondents describe various degrees of depression, shame, fear, insecurity, and problems accepting your sexuality or gender identity. All participants except one have experiences of bullying and harassment because of their LGBT identity, by other residents in asylum receptions or care facilities. These experiences include verbal abuse, sexual harassment, exclusion, or physical violence. Among the particularly exposed are those who break gender norms, such as boys with a feminine gender expression. In spite of this, not everyone reports their experiences to the staff. To those who have done so, the staff has been able to provide support and protection for the LGBT youths. But some types of housing lack 24-hour staff, and also do not have any staff present on weekends, which creates an unsafe environment. Sometimes the young persons lose faith in the system, due to the frequently long and taxing wait for decisions regarding asylum, and the fear of having your application dismissed, along with experiences of bullying or harassment in schools, or at the asylum receptions or housing facilities. This loss of faith might manifest as disappearing from their housing, quitting school, or quitting any introduction programmes in which they are enrolled. The consequences, instead, are feelings of isolation and loneliness. The authors conclude that it might be of great importance for people living in exile to have friends, family, and networks that share their experiences. However, contacts with persons from the same country may pose a risk, in cases where you do not wish to share information about your sexuality or gender identity. Therefore, it might be important for young, unaccompanied LGBT persons to find LGBT contacts and companionship. All the respondents in the study have contact with LGBT groups, and describe this as something that has given them hope, security and companionship (Stubberud & Akin, 2018).
 

Experiences from school

A number of studies investigate experiences from school, through quantitative as well as qualitative studies, with themes such as attitudes toward school, school results, bullying, and relations with classmates and friends. A number of studies highlight experiences from working life, and some focus on the experiences of young LGBTI persons interacting with the healthcare system.

Experiences from everyday life in school

A major population study in Finland, examining health in schools, includes a total of 153 143 students (in years 8, 9, as well as 1 and 2 in upper secondary school, and in vocational training programmes). Out of these, 4 720 identify as gender minorities, and 12 947 as sexual minorities. The rainbow young, as the group is referred to by the authors, experience several kinds of trouble in connection with their education. A lot less frequently than other young, they report feeling they are part of the community in school or elsewhere, and things such as experience of loneliness during recess are many times more common among the rainbow young than among others. Over half of the rainbow young have trouble related to learning disabilities and absence from school, and school fatigue is more common among them than among other young. Further, the rainbow young experience more frequently than others that the school environment is lacking and unsafe (Jokela et al., 2020).

In an Icelandic survey of young people from year 10 (average age 16), in three groups born in different years, 353 young persons participated who identified as LGB. Their replies were compared to those of other young. In total, 9 297 young people participated in the study. Results showed that the LGB identifying young had more negative experiences of school when it came to liking school, and to being accepted and liked by classmates (Thorsteinsson et al., 2017).

One Swedish survey reviews the replies from 137 nonbinary persons aged 13 to 17. Their replies are also compared to those of others in the study; 8 383 young persons in total. The study shows that, compared to young people with a binary gender identity, a larger percentage among the nonbinary report being absent from school (49.6% compared to 36.5%), having failed at least one subject (36.5% compared to 21.5%) and having a rather bleak or very bleak outlook on their future (23.4% compared to 4.6%). By drawing on previous research, the authors of the study argue that these results can be understood in light of how it is a challenge for these young people to adapt to the existing gender norms, as well as cope with discrimination in the school environment (Durbeej et al., 2019).

In another Swedish study, eight people between 18 and 25, who identified as gay or lesbian, were interviewed about their experiences of school environments (Hammarlund et al., 2017). Participants in the study expressed experience of loneliness and exposure, and having been, as a consequence, excluded from social networks in the school environment. They perceived themselves as different. They did not just have to relate to norms for sexuality, but also to norms concerning gender, and expectations about what it is supposed to mean to be a boy or girl. Participants also experienced silence surrounding homosexuality, leading in turn to insecurity regarding their own sexuality, and not being acknowledged in it. Fear of not being accepted had kept several people from coming out, something that was described as both physically and mentally taxing. One participant described the situation as feeling like there was a lump in their stomach every morning, and unwillingness to go to school. Another factor was the lack of role models or networks in their environment. Participants experienced that their mental health suffered due to fears and feelings of shame, and that this might manifest as self-injury, alcohol or drug use, feelings of hopelessness, and, in some cases, suicidal thoughts. Once participants had come out, they had often met with positive reactions from friends and family, and the ability to be open was described as a relief, and as something significant for your well-being (Hammarlund et al., 2017).

In one Icelandic interview study, involving seven LGBTI students aged 18 to 19, authors examined how sexualities and gendered bodies are constructed in school (Kjaran & Kristinsdóttir, 2015). All of the informants experienced the school environment as a heteronormative one. This manifested in the fact that their sexualities or gender identities were not respected or accepted, more or less openly, by classmates and/or teachers. Identifying as a trans girl is described as a constant effort to fit into binary gender norms, which regulate what a female body can be, and what it is supposed to look like. Experiences of stigmatization and homo- and transphobia seem to have been most palpable among the male participants in the study, who had all plainly felt the disciplinary power of a heteronormative environment. Not least, this had been made apparent in sports contexts and locker rooms. One young homosexual man relates how he always tried to shower before the other guys did, as he was aware he made them uncomfortable. On one occasion, when the others had found him in the locker room, they rushed out. The presence of an LGBTI student makes others uncomfortable, causing the LGBTI student to attempt being less visible in the school environment (Kjaran & Kristinsdóttir, 2015).

The aforementioned Finnish study shows that among Rainbow Young, the need for conversation therapy is more than twice that of other young (Jokela et al., 2020). At best, the school nurse can be a person to turn to, in order to speak about your gender identity or sexuality in school, but another Finnish study shows that it is crucial that these meetings are not guided by heteronormative expectations. If this is indeed the case, such meetings are not at all helpful to the acknowledgement of the LGBTQ student’s identity, nor to their health or well-being (Laiti et al., 2020). This study evaluates experiences of meeting a school nurse during the time in school, through a qualitative survey including 35 LGBTQ identifying students aged 16 to 19. Empirical data outlines how some individuals had positive experiences of meeting a school nurse, while others had met with heteronormative expectations and assumptions. These included presuppositions that the students were heterosexual, that sexuality was only brought into the conversation from this point of view, and that physical development adhered to a binary gender perspective. The students had met school nurses who had not always been qualified to discuss sexualities and gender identities beyond the norm. Sometimes, the LGBTQ identity was perceived as something problematic, in need of “fixing” through psychiatric help. In addition, there were experiences of not being taken seriously, as students’ gender identity or sexuality was considered a phase that would pass. In the conclusion of the study, it is established that school nurses may have a crucial role in creating an inclusive and safe school environment for LGBTQ students (Laiti et al., 2020). In a Norwegian interview study, some of the LGBT young report that they have not felt the school nurse was available to them, but rather a stranger, to whom they saw no reason to open up. Someone also mentioned that the expedition of the school nurse was located in a very public place in the school. This might be positive, as it is made clear that it exists; meanwhile, a highly exposed location may become a hindrance to anyone who does not wish to make their visits known. Someone experienced that the school nurse lacked in their trans related qualifications. Another informant related how she had needed and would have liked to be able to talk about her LGBT identity with the school nurse. But as she was from a small town, and the school nurse was related to her family, with which she had a problematic relationship, she did not consider this contact possible. Other informants reported positive experiences regarding their school nurse (Stubberud et al., 2018).

Bullying in the school environment

Regarding studies that examine experiences of bullying, results are somewhat varied. In the Swedish study looking into the experiences of young nonbinary persons, there were no significant differences when it came to exposure to bullying, compared to the other youths in the study (Durbeej et al., 2019). On the other hand, a Finnish population survey shows that trans identifying young have experienced bullying in school, as well as physical threats, more often than other young persons (Jokela et al., 2020). In the abovementioned Icelandic survey, it was made evident that LGB identifying young ran a greater risk of being bullied, but that they also were more likely to bully others. For boys in the LGB group, the risk was greater than among the girls to be bullied, or to bully others (Thorsteinsson et al., 2017). Another Icelandic survey with participants aged on average 15, showed marked differences when it came to bullying between LGB young and heterosexual young. Just 3% of heterosexual students reported having been bullied two to three times a month, while the corresponding numbers among LGB identifying students was 36.5%. The same study also points to a clear connection between enjoying your time at school, and less tendencies to have suicidal thoughts (Arnarsson et al., 2015).

One Finnish study examines a school survey with respondents from years 8 and 9. In total, 81 640 young are included in the study, 7 213 of which report being attracted by someone of the same sex, or by both girls and boys. The study investigates the connections between sexuality and bullying, and the results show that it is more common to be subjected to bullying among those who report being attracted by the same or both sexes. This holds true even when measured against sociodemographic variables and mental health issues. In the study, it is explained by a theory stating that the bullies are trying to maintain a heterosexual order by disciplining those who do not live up to the heteronormativity. The girls in the older age span who report being attracted by both sexes are particularly prominent in the statistics, and report more bullying than the rest of the group (Kurki-Kangas et al., 2019). Another article from the same study investigates the link between bullying and mental health issues. Regardless of sexual preferences, the risk of depression and anxiety is increased among those who are subjected to bullying, but the connection proves to be somewhat less pronounced among young sexual minorities. This is explained by the idea that a person forced to relate to minority stress might also have acquired coping mechanisms and strategies (Kurki-Kangas et al., 2020).

One interview study with a focus on Swedish students in year 9 examines experiences of belonging to a sexual minority in a rural school setting (Odenbring, 2019). The study shows that it might be very difficult to belong to a sexual minority, and that students who do are exposed to various forms of violence in this school setting. They get beaten in school, are subjected to homophobic slurs, and may sometimes be victims of stalking when they leave the school premises. The local school environment is described as hostile to anyone belonging to a minority of any kind. In the interviews, students describe a violent group, and says no one dares to intervene because they are afraid, too. This, in turn, has created a school environment where it is the norm to pretend not to see that another person is being abused. To have supportive friends and school staff is described as an enabling factor to the youths belonging to a sexual minority in everyday life at school. One bisexual boy who is given more space in the article describes how he is forced to accept homophobic slurs on a daily basis. He means that it takes mental as well as physical strength in order to “survive” school. The homophobia and violence are not only upholding a heterosexual order, but in addition, an order of hegemonic masculinity as the dominant one. This affects everyone in the school environment, not just those who identify as non-heterosexual (Odenbring, 2019).

Similar experiences can be found in a Norwegian study based on qualitative interviews with 24 LGBT persons aged mainly between 15 and 30, from communities with less than 20 000 inhabitants (Eggebø et al., 2015). Many of the informants report prejudice, bullying, harassment, being rendered invisible, and meeting adults who do not treat them the way they would like. Eight informants report having been bullied. One of them, who is called Chris and is trans identifying, reports that he was bullied for nine and a half years in school, suffering both verbal and physical abuse. Despite the fact that he sought help from adults, nothing improved. His experience is that those who did not fit the “A4 standard” were bullied in the school environment (2015:47). Several informants describe that the bullying in school made coming out seem impossible. For example, one informant named Harald describes how another boy in his school was bullied for being a homosexual, and that it was hard to watch the way he was treated. This made Harald fear throughout his time in school that someone would find out that he, too, was a homosexual. He says things were not made easier by the fact that it was a small school (2015:48). The authors interpret this, along with other stories, as an indication that geography matters here, where smaller schools and a rural environment may render LGBT persons more vulnerable (Eggebø et al., 2015).
 

Conclusion school environments

All in all, the studies focused on school environments indicate that compared to other students, a larger share of LGBTI students experience difficulties in the school environment, which is described as heteronormative. This might include increased absence, school fatigue, and insecurity in school. When it comes to bullying, multiple studies indicate that LGB young run a higher risk of being bullied. A couple of studies indicate that small schools or rural schools may render LGBTI students more exposed. The school nurse may be a key player in the school environment, and may also serve as a potential counselling support, but it is vital that this contact is not tinged with heteronormativity. 

Experiences from working life

In a report from the Swedish Agency for Youth and Civil Society, the establishment of young HBTQ persons in working life is spotlighted (Odenbring, 2017). This report is based on a youth survey, carried out by the agency in 2012 and 2015, with complementary materials from other sources. 160 respondents identify as trans persons, and 481 as non-heterosexuals. In the larger reference group, 4 169 persons identify as cis persons, and 3 901 as heterosexual. The study shows that young HBTQ persons have more experience of long-term unemployment compared to other young persons. 21.2% of trans persons compared to 13.3% of cis persons, 21.3% of the non-heterosexuals, and 12.8% of the heterosexuals state that they have been unemployed for 6 months or longer. Regarding comfort in school or in the workplace, a significantly higher share of non-heterosexuals compared to heterosexuals report being subjected to bullying or freezing out in school, education, or work contexts (17.8% compared to 8.9%). In addition, a larger share in the same group are unhappy with their work/school situation compared to heterosexuals (27.7% compared to 15%). Regarding satisfaction, and being happy with your situation in school or in the workplace, a higher percentage of cis persons report satisfaction compared to trans persons (67.5% compared to 51.9%) (Ohlström, 2017). About 60% of the young trans persons aged between 20 and 29 who feature in the survey of the Public Health Agency of Sweden report a somewhat reduced or highly reduced ability to work (The Public Health Agency of Sweden, 2015).

Contacts with the healthcare system

A Swedish survey analyses qualities of the reception of young visitors to youth clinics, as well as any impact of sociodemographic factors in these instances. In total, 1 110 young persons aged 16 to 25 participated, of which 150 categorised themselves as homo-, bisexual or other, and 15 as trans persons. The study looked into experiences and perceptions of accessibility, equality, respect, confidentiality, non-judgmental stance, and quality. The young persons defining themselves as “other” in their sexuality rated the clinics lower regarding accessibility in relation to sexual health, as well as respect, compared to the ratings of other groups. Persons with trans experiences were less satisfied with perceived accessibility relating to information on sexual health, but more so when it came to actual contacts, compared to the cis persons in the study. The study found no notable differences between heterosexuals, homosexuals and bisexual young, but the young who identified as queer, asexual, and those with trans experience reported generally less satisfaction with the reception they had had. Authors mean that the healthcare staff may have received skill enhancement relating to young LGB persons, but that young people with less normative identities (beyond hetero-, homo- and bi-categories) still feel there are barriers in their access to healthcare and service (Waenerlund et al., 2020).

A Norwegian report based on interviews with healthcare staff, as well as with young LGBT persons aged 16 to 29, examines contacts with and experiences of municipal health services throughout Norway (Stubberud et al., 2018). Few of the participants have talked to a school nurse or other healthcare staff about being LGBT, while it is all the more common to find information online; through blogs, web pages, porn, dating sites, and social media. But several of those who had had no contacts with school nurses had instead seen a psychologist or psychiatrist, which had meant a lot to them. Participants underscore that it is vital for healthcare staff to signal that it is safe to speak of LGBT experiences. One 22-year-old lesbian woman says: 

Something that would have helped matters [in meetings with healthcare staff] would have been little symbols and signs – such as the rainbow flag, for example. And maybe if they had said it was safe to talk about it. (Stubberud et al., 2018:21)

Among the trans persons in the Norwegian study about young LGBT persons in rural areas, there are two issues related to the healthcare sector that stand out as core problems. One of them is the lack of competence regarding gender and trans prob|lems. The other is the lack of available gender-affirming treatment. Participants also express frustration regarding norms within trans healthcare, where there are persis|tent ideas about having a clear-cut female or male identity (Eggebø et al., 2015).

Relationships

Having supportive relationships promotes the well-being of young LGBTI persons, and what the relationships to parents, friends, and partners are like matter a great deal for a person’s mental well-being. In a Finnish study, factors affecting the well-being and mental health of young trans persons are being examined through a survey involving 370 trans persons aged between 15 and 25, who are compared to 1 243 cis persons (most of which belong to sexual minorities) (Alanko & Lund, 2020). The study finds significant differences in relations to mothers and fathers respectively, with relationships to fathers much more commonly rated as poor. It is more common in this study for trans identifying young to rate the relationship to their parents as average or poor, compared to the cis identifying young. The study shows a clear connection between assessing your relations as high-quality, and having a good level of well-being. The trans identifying young in the study report generally less well-being, but their well-being increases when their relationships are good (and when they are good, the well-being of the trans identifying young are comparable to the levels of well-being of the cis identifying respondents in the study). In other words, relationships are crucial to a person’s well-being. Strong and close relationships help young people cope with difficulties in life. This also indicates that children and young persons who are supported in their gender identity and their gender expression are doing much better than those who find no such support in their relationships. Good parental support contributes significantly to better well-being. The support of mothers has the greatest effect, followed by friends and fathers. However, only 11% of the trans identifying young reported having parental support regarding their gender identity. 40% stated they had a partner, but only 25% reported that their previous or present partners were supportive. 5% reported having no friends, compared to 3% in the reference group (Alanko & Lund, 2020). Similar conclusions are drawn in the Icelandic survey of young people with an average age of 16, which finds that social support from friends has a highly protective effect on the LGB group. Here, there is a connection between satisfaction in life, and being accepted by classmates and in your family. Kindness from schoolmates, and acceptance, are associated with a lesser degree of bullying, as well as bullying others (Thorsteinsson et al., 2017).

A Finnish study investigates, among other things, the significance of relationships to 52 persons aged 15 to 20, who had initiated hormone therapy. At the time of the study, they were living in what is known as the “real life-phase” which is part of the gender-affirming treatment. One presupposition in the study is that the difficulties experienced by many young trans persons in their relations with the surrounding world are associated with prejudice and discrimination, and with being unable to pass as your preferred gender. One thesis, therefore, is that the phase involving desired physical changes due to hormone therapy, would improve the opportunity to have relationships. However, results show that those young who have previously experienced difficulties in contacts with people of the same age continue to do so, even in the real life-phase. Among those who have previously had positive relationships, one out of ten report meeting with new difficulties during this phase (Kaltiala et al., 2020).

A Danish study about the health and well-being among LGBT persons included a total of 14 265 respondents of all ages, with different sexualities and gender identities. Out of these, 103 were homo- and bisexual, and 100 were trans persons, all aged between 15 and 34 years. One question in the study concerned how frequently respondents were in contact with their family. 6–8% among hetero, homo- and bisexual respondents reported they never were, and 25% of trans persons. Another question concerned how frequently respondents were in contact with friends. Of those who reported rarely or never having such contacts, 2% were hetero- and homosexual, 6% bisexual and 5% trans persons. Another question concerned undesired loneliness, with 6% of the heterosexuals, 13% of the homosexuals, 20% of the bisexuals and 24% of trans persons reporting unwanted loneliness. When it came to the share reporting that they did not count on being able to get any help with practical things, the numbers were as follows; 1% of the heterosexuals did not count on it, while the corresponding percentages were 2% for the homo- and bisexuals, and 13% for trans persons. On the question about whether they had someone to talk to if they had problems, 2% of the heterosexuals stated that they rarely or never had anyone to talk to, with corresponding percentages of 0% for homosexuals, 10% for bisexuals and 13% for trans persons (Bindesbøl Holm Johansen et al., 2015).

A qualitative Danish study on gender norms, flirting and alcohol consumption among young people in Denmark interviewed 140 young between 18 and 25, with different sexual orientations, who regularly use alcohol. The theoretical baseline in the study is, among other things, that the informants relate to a heteronormative logic, with associated gender norms and ideas about what constitutes “normal” sexual behaviour, and about flirting as a specific type of interaction which is fluid, playful, and contradictory. The study examines how this is navigated, reproduced and challenged by the young, through flirting in mainstream nighttime environments in Denmark. The heteronormativity as well as the binary gender norms create a feeling of discomfort, and are also challenging, not just to the queer respondents but also to those who identify as heterosexual. This reveals how heteronormativity and narrowly defined gender roles have a restraining effect, even on the heterosexual young. Geography matters here, too; one of the participants, aged 20 and identifying as genderqueer, relates how it would not be possible for him to meet a boy in his old hometown, because “men are men there.” (Jensen et al., 2019:366). Another informant says he works as a bartender in a smaller town, but avoids being open about his sexual experiences for fear of being perceived as gay, and in case the bar where he works would receive fewer guests as a consequence. Drinking alcohol is a challenge in the tension between following your queer desire and participating at the same time in a heteronormative nighttime environment/culture. For the girls in the study, the use of alcohol might facilitate playing with expectations of gender and sexuality, and also prompt a more tolerant climate for such play, and for indulging in queer flirting (Jensen et al., 2019).

Geography as a potential factor in relationships is something that features repeatedly in several studies. In one Norwegian study, based on qualitative interviews with 24 LGBT persons aged mainly between 15 and 30, from communities with less than 20 000 inhabitants, participants display great variety in their social relations and networks. To some, LGBT contexts where they can meet other like-minded people are very important, while others do not wish to involve themselves in such contexts. When it comes to having close friends, more people in the larger municipalities report having at least one close friend. Everyone included in the study uses social media in some way, and this is particularly important to those who lack social networks and friends in their own city, even if they say it does not quite compare to having local ties where they live. A recurring experience in the study is that, on one hand, queer persons are perceived as invisible in the local environment, but that an individual might experience a kind of hypervisibility (as homo) in the same place (Eggebø et al., 2015).

A major population study in Finland examines health in school, and includes a total of 153 143 students (years 8, 9; 1, 2 in upper secondary school, and in vocational training programmes) (Jokela et al., 2020). Among these, 4 720 identify as gender minorities, and 12 947 as sexual minorities. Young LGBT persons in this study experience discontent in their lives more often than other young, and are more frequently lonely. Experiences of community are less common among the young who belong both to gender minorities and sexual minorities, compared to other young. The results show how significantly fewer LGBT identifying persons who are in a relationship feel they are happy about their own body, compared to young cis persons and young heterosexual persons in a relationship. However, the majority does feel there is appreciation, trust and respect in their relationship. Almost all the LGBT persons who are in a relationship feel they can be entirely themselves and express intimacy and love for one another. Results also show that experiences of violence are remarkably common among the LGBT identifying. More than two out of every five in the group have experienced psychological violence at the hands of parents or other caregivers. Experiences of physical violence at the hands of parents or other caregivers are twice as common compared to other young. LGBT young also experience less frequently than others that they receive help when needed, from parents or friends, concerning mood issues (Jokela et al., 2020).

In a Norwegian national survey about students’ health and well-being, the responses from 115 trans persons aged on average 23 to 24 were analysed and compared to those of other respondents in the study. Trans and nonbinary persons reported substantially more loneliness than the cis identifying in the study. 38–52% of the trans persons stated they frequently felt the lack of community, felt excluded, or felt isolated from others. Among the nonbinary, the percentages were 38–48%. The corresponding share for cis men was 15–21% and 17–24% for cis women (Anderssen et al., 2020).

Summary relationship

The studies have shown that it is more common among trans identifying young to rate their relationships to parents as average or poor, compared to other young. A higher number of people in the LGBTI group report unwanted loneliness, and a lack of practical support from their surroundings. This is true in particular for trans and nonbinary persons.
 

Intersex: atypical sex development in young people 

The physical changes that are related to development in adolescence, such as bodily changes, menstruation and intensity of sex drive are often associated with and shaped by gendered connotations and images of femininity and masculinity. Among the identities included in the LGBTI acronym, it is above all the intersex experience that is plainly absent within the research, and it is also noted that the research regarding intersex conditions – life experiences in particular – are limited in the Nordic context (Guntram & Zeiler, 2016). Therefore, we have chosen to present the existing knowledge in a joint section, and the two publications focusing on intersex will be given more room.

A Norwegian study commissioned by the Norwegian Directorate for Children, Youth and Family Affairs carried out qualitative interviews with a total of 46 persons, 15 parents of children and young persons, and 27 persons who display various kinds of atypical sex development and intersex variations, aged 18 to 70 (Billaud Feragen et al., 2019). Here, the empirical results regarding people between 18 and 30 will be presented.

Openness

Most of the participants in the study have reflected a lot on the pros and cons of being open. Their everyday life experiences have also influenced their degree of openness. One informant says that it is nice to be able to be open, but it depends on who you are talking to; 

It is not something I want to share with just anyone. (2019:47)

It is mainly in close and safe relationships that participants report feeling they can be open. Several of the participants describe actual experiences of, as well as fears of, not being seen as belonging to the gender with which they identify, being considered strange or divergent, or to “become your condition only.” One of them says;  

I am in fact very careful [...] about saying what my condition is called, because I don’t want them to start ‘googling’ it [...] and – be all like ‘Oh my God, have you got a penis, or what?’, ‘Did you have surgery?’, ‘Are you – what are you?’. I can’t deal with that [...]. It is a very vulnerable thing. You are baring yourself in that. Completely. It is also something that can be easily misunderstood, and in a way you’ll just get branded. I mean, you do not want to be your condition. (2019:50)

Another participant says it would have been easier to be open if there had been more knowledge in society, and if there had been more people who were open in their turn, who could act as role models. This is pointed out by several participants; that the knowledge about the condition is so very lacking throughout society. What is being held forth as positive about coming out, is that it might contribute to feeling less alone, and also to the possibility of receiving more social support and understanding from others; 

It’s really true, it helps so much to just talk to people. It really makes it easier to handle things. That you have a lot more people to rely on in case you have another one of those streaks. (Billaud Feragen et al., 2019:48). 

Mental health issues

Several of the participants describe reduced mental health; some consider it tied to their atypical sex development and its consequences, such as not being able to have your own biological children, while others are less certain about a connection. The time after you have received your diagnosis is mentioned by several informants as a particularly vulnerable period in life. Several of them also report having had, or still having, serious suicidal thoughts:

I had a hard time with – with suicidal thoughts, too, obviously [...]. I have made preparations to – to hang myself, but I didn’t go through with it, tried I mean, 100% tried, I don’t know what to call it. [...] No, I mean [...]. Yeah, it was all set up and arranged and – I had it around me, but I didn’t do it. (2019:126)

A few of the informants also report self-injury, by alcohol or other means. Beneficial factors held forth as vital to good mental health include social support from family, from friends, and from others with the same condition.

Social support and social relations

While some of the participants feel no need to be in contact with others who share their experiences, there are others who express this desire;

It would have been so nice to know some other girl [with MRKH], which I would sort of actually get along with, that I could hang out with a bit. [...]. Just that someone actually knew what it was like for me. [...] My friends are really amazing [...] and very understanding, but in a way they just don’t know what it’s like. So [...], someone I could have exchanged experiences with [...]. Because there is no one who can relate to what I’m saying. [...] Meet someone who was in the same boat, sort of. (2019:41)

It would have been easier for me to accept myself and not feel so alone [...] It’s been so many years when I have felt that it was just me. (2019:41)

Many people with atypical sex development cannot have biological children, and to find this out is something that many participants hold forth as one of the most devastating aspects of being diagnosed. Two participants express it this way:

I have fretted so very much about this period in my life. Because it is one thing when you are 20, you do not want children at that point, but of course I knew things would become different with age. So [...] I feel that I have prepared myself for this period a long time. Actually, since I was like, 17. [...] I’m not going about all depressed. But every now and then I become just very very sad, you know. (2019:70)

That was probably the hardest part, I guess, to be told as a [teenager]. [...] I have received help to accept it more fully [...]. It’s not like there is just one way to have a child, though. [...] But yes, it has definitely been one of the hardest things about the diagnosis. (2019:70)

​Telling a partner is also described as a very hard thing to do. A few have negative experiences of this, while others relate that most partners have handled it well. Regarding social relations with others, participant experiences vary.
Several of them describe growing up safe, with good parental support. Friends are described by many participants as important, offering support and contributing to a better everyday life in different ways. But there are other experiences, of social exclusion, and some participants report having been bullied in school, which they sometimes link to their condition and how it has been physically visible. Some stories concern evasion of particular situations, for example in the school environment, in order to prevent others from noticing participants’ atypical body development (Billaud Ferragen et al., 2019).​

Health, and contacts with the healthcare system

Participants in the study speak of how their parents received information about their condition in connection with them being diagnosed, but that they would have appreciated a repetition themselves, as they grew older:

Looking back, I feel I could have been given a repetition of the information somehow, there is so much you forget when you are that young. [...]. [And I] don’t really remember much of what they said by now, because I think they used quite a lot of big words, which you didn’t understand. (2019:96)

Certain intersex conditions are adjusted through surgery, frequently when the child is small. Many conditions also require medication throughout life. Medical treatment is often part of the daily routine, and several participants express that this requires a measure of responsibility in daily life. Some, too, say it can be challenging to find a good balance in their medication, where they attain hormonal equilibrium. Several participants express that neither they nor their parents were included in any discussions or decisions regarding what surgery would be performed, and that post-op and post-treatment follow-up have been lacking. Here, too, a measure of responsibility is required, for example after the construction of a vagina, which might require a dilator – an implement for expanding the vagina, in order to be able to have vaginal intercourse. Several participants request better follow-up, and improved opportunities to speak to someone about their condition (2019:11).

Affect and physicality among young women with atypical physical development

One Swedish qualitative interview study examines affect and physicality through interviews with ten women aged 20 to 26, displaying atypical sex development, lacking a womb and having no vagina or a “small” vagina (Guntram & Zeiler, 2016). None of the informants identify as intersex, or considered themselves part of any intersex activism. The interviews focus on affect in the form of, for example, fear and frustration on occasions when informants are telling others about their atypical sex development. With a theoretical framework focused on the performativity of affect and emotions, they investigate the effects of affective dissonance through three identified narratives; how it helps the women in positioning themselves in relation to other individuals, and how it can amplify or challenge norms surrounding female physicality and heterosexuality. In addition, the article focuses on how the reactions of others contribute to creating the women’s understanding of their bodies, how they impact any future disclosure of this information, and how their relationships turn out. The women report feelings of shock, disbelief and stress when they found out they displayed an atypical sex development, and that the issue could be perceived as a major taboo. Telling others brought with it the fear of not being perceived as a “real woman,” as well as the fear of being discarded. One participant, Elsa, says she has not yet had a boyfriend, but that she is worried that a future partner might think there is something wrong with her, and that she wonders if anyone will ever want to be with her. Not being able to get pregnant was also discussed. Patricia, another participant in the study, says:
​​​

​You are afraid that the other will not accept it, or think you are no real girl […] what happens if we take this relationship to the next level, and I have to tell them? And I get dumped. That’s the greatest fear, I think, that someone would say, “All right, you’re not for me then.” (2016:66).

Another recurring point made in the study was that the women did not wish to incur anyone’s pity. Anna, one of the participants, reports that she stopped wanting to tell other people, as she “found they all reacted with having a breakdown.” The reactions of others put the women in a position where others feel sorry for them, and where their lives are considered unlivable. But they also have stories from situations where friends and relatives have acted as a support, and positioned them in ways that have been strengthening. Several among the women express a desire to speak to other women with similar experiences, and say they have been looking for information online (Guntram & Zeiler, 2016).

Current state of research: concluding summary 

This literature review has aimed to investigate the current state of knowledge regarding the well-being of young LGBTI persons in the Nordic countries. It is worth noting here that empirical studies are lacking from the Faroe Islands, Greenland, and the Åland Islands. Quantitative as well as qualitative studies from the various Nordic contexts have formed the base of this review. These studies have shown how a gender identity or sexuality that falls outside of current norms has a considerable impact on the health and well-being of young people. Exact figures may vary between studies and contexts, and it may be hard to draw conclusions about national differences, since the studies are often so differently designed. But the overall trend is clear: young LGBTI persons report consistently less well-being compared to other young people. This goes for mental health as well as physical health, and regarding experiences of discrimination and vulnerability. Young people from the LGBTI group report more frequent experiences of self-injury, suicidal thoughts and attempts, sexual risk-taking, discrimination, and harassment, as well as difficulties in school and within working life. Meanwhile, other factors are also in play, such as age, ethnicity, citizenship, socioeconomic situation, and geography, These, too, shape the experiences, and create different opportunities within the group. ​

Variations within the LGBTI group

In the larger, quantitative studies in the review, a general pattern is discernible, regardless of any national context, where the LGBTI group reports less well-being compared to young heterosexuals. Young bisexuals frequently report somewhat less well-being compared to young homosexuals, and trans persons feature particularly in the studies when it comes to health problems. ​

There are certain differences between homo- and bisexual girls and boys in several studies. Girls are more frequently represented in the group reporting mental health issues (Gisladottir et al., 2018). Among the girls, suicidal thoughts are common, as is having carried out a smaller amount of suicide attempts (Arnarsson et al., 2015). Additionally, more girls than boys report poor physical health (Bränström et al., 2016). The boys represented in the group reporting mental health issues are fewer in number, but a proportionally larger amount of them carry out a number of suicide attempts (Arnarsson et al., 2015). Among boys, there is a more prominent link between homosexuality and vulnerability to sexual harassment (Kaltiala-Heino et al., 2019), and they run a greater risk of being bullied (Thorsteinsson et al., 2017).

Bisexuals often report greater vulnerability than homosexuals, for example regarding mental health issues (Bindesbøl Holm Johansen et al., 2015), suicide attempts (O’Reilly et al., 2020; Watson et al., 2015), and physical health issues (Bindesbøl Holm Johansen et al., 2015; Bränström et al., 2016). In addition, a larger portion of bisexuals compared to homosexuals do not openly display their sexual orientation (Frisch et al., 2019). Further, they report few or no contacts with friends, and having no one to talk to (Bindesbøl Holm Johansen et al., 2015). One study includes survey responses from a group of people who report having sex with others of the same sex, but do not identify as homo- or bisexual. Persons in this group report a higher frequency of mental health issues and suicide attempts compared to both bi- and homosexuals, which is worth noting (Watson et al., 2015).

There is very little research on young intersex / persons with atypical sex development, which makes the knowledge about this group in the study at hand very inadequate.

Trans persons as a group really stand out when compared to other persons on the LGBTI spectrum. Trans persons report a higher frequency of mental and physical health issues, and compared to hetero-, homo- and bisexuals, state more frequently that they have few or no contacts with friends, have no one to talk to, and do not count on being able to receive any practical help from others (Bindesbøl Holm Johansen et al., 2015). A larger percentage of trans persons experience long-term unemployment, as well as being dissatisfied with their situation in school or at work (Ohlström, 2017). Studies that specifically examine trans persons and non-binaries (and where comparisons are sometimes made with cis persons) also report disturbing results concerning mental health issues (Alanko & Lund, 2020; Anderssen et al., 2020; Durbeej et al., 2019; The Public Health Agency of Sweden, 2014), suicidal thoughts and suicide attempts (Anderssen et al., 2020; The Public Health Agency of Sweden, 2015; Zeluf et al., 2018), vulnerability to offensive treatment, and to psychological, physical, or sexual abuse (The Public Health Agency of Sweden, 2014), difficulty in school (Durbeej et al., 2019) as well as higher degrees of perceived loneliness, lack of community, and feelings of exclusion and isolation, compared to cis persons (Anderssen et al., 2020).

Intersectional perspectives

In several studies involving people of all ages, results also show that particularly the younger age groups report more health issues. For example, one study shows that homo- and bisexual women and men report a generally higher incidence of health issues compared to heterosexuals, and that the difference between the groups is most prominent among the younger age groups (Bränström et al., 2016). In a study on health and life conditions among trans persons, it was mainly people in the younger age groups who reported having been victims of offensive treatment in the last three months. (The Public Health Agency of Sweden, 2015). This can be understood through theories about age-specific minority stress, where people in the youth category are exposed to multiple stressors, which then recede gradually throughout life. Bränström and others mean that it is perceived as more stressful to navigate a stigmatized identity during childhood and as a young person, which also leads to further impairments of physical health compared to later points in life (Bränström et al., 2016). From a life-cycle perspective, we can also understand young persons as an age group whose members are often less free to choose their contexts and the places they wish to frequent, as well as the people they meet, by being tied to, for example, compulsory school attendance, the family in which one is raised, or a particular home. This could offer another explanation for why young LGBTI persons report more – and sometimes more severe – health issues.

Socioeconomy is a factor that might impact the life conditions of young LGBTI persons. In one study, socioeconomic vulnerability was more commonly reported in the group of nonbinary persons, compared to other groups included the study (Durbeej et al., 2019). One Swedish report on HBTQ young in working life shows that a significantly larger share of non-heterosexuals than heterosexuals (20.9% compared to 12.9%) report having had difficulties, on multiple occasions in the last 12 months, to manage running costs. In this report, no significant differences between trans and cis persons could be found, which might be explained by the fact that the group of young trans respondents was so small (Ohlström, 2017). One study on sexual risk behaviour found a link between low levels of education and having unprotected sex. It also found that high levels of education increased the likelihood of having been tested for HIV (Johansson et al., 2018).

Ethnicity and migration experiences may also have an impact on LGBTI persons. One qualitative study on young, unaccompanied LGBT persons highlights the vulnerability that an LGBT identity might constitute during the asylum-seeking process, or in an asylum housing or other care facility (Stubberud & Akin, 2018). One Danish study found it was more common to have a Muslim background among those who were not open about their sexuality (Frisch et al., 2019). In the study interviewing young LGBTI persons in Sápmi, religion is also highlighted as a sometimes impairing factor. In certain areas where Laestadianism is firmly embedded in society, it contributes to a conservative, religious environment with heteronormative expectations on life (Stubberud et al., 2018). This also indicates how different locations enable or hinder LGBTI practices. The geographic location can bring various cultural expectations, and offer proximity to, or distance from other LGBTI persons, locations, and contexts. This is also illustrated in the Norwegian study where young people from communities with less than 20 000 inhabitants have been interviewed, and where results indicate that smaller schools and rural environments can render LGBT young more vulnerable (Eggebø et al., 2015). In one Danish population study, too, it is more common among the homo- and bisexual living in the capital and its surrounding areas to live openly (Frisch et al., 2019).

There are additional structural factors that may have an impact; such as functionality, which is not included in any of the studies that are part of the review.

Minority stress

One recurring model of explanation in the studies is that the difficulties experienced by young LGBTI persons in their everyday life may be caused by minority stress. This includes the risk of or actual harassment, vulnerability and violence. Further, it includes meeting prejudice and discrimination in your daily life, having to sometimes conceal your identity, and internalized homo- and transphobia, all in turn causing health issues (Eggebø et al., 2015; Gisladottir et al., 2018; Kurki-Kangas et al., 2020; O’Reilly et al., 2020). One qualitative study indicates that even if several participants had experiences of violence and harassment, it was the having to always explain yourself, the not living up to the norm, that was perceived as most taxing (Eggebø et al., 2015:84).
 
With this background, awareness-raising efforts are in focus when the studies make any recommendations. Further knowledge on sexualities and gender identities that fall outside the norm is needed; in education, in school, in sex education, in families, within healthcare, and in asylum reception centres. It is important to note, in this matter, that some studies have highlighted the fact that young people who identify with less normative identities (beyond the hetero-, homo- and bi categories) such as, for example, queer, nonbinary or asexual, require particular attention (Waenerlund et al., 2020).

Implications and recommendation

Several studies agree that a change in societal attitudes is needed, with more knowledge about sexual minorities, trans persons and intersex (Alanko & Lund, 2020; Billaud Feragen et al., 2019; Guntram & Zeiler, 2016). Many of the studies provide fairly detailed recommendations for various kinds of improvement activities. These centre on, among other things, awareness-raising efforts within schools and healthcare systems, suicide prevention, and sexual health. They are discussed in this section.
 

School environment and working life 

The school environment should be inclusive in its nature, and offer a protective setting for LGBTI-students, both on policy levels and in practice, in the everyday school endeavour (Anderssen et al., 2020; Gisladottir et al., 2018; Hammarlund et al., 2017; Thorsteinsson et al., 2017). The learning environment should be hallmarked by norm-critical thinking regarding gender; the education should not be gender-normative, in order to avoid any structural discrimination of nonbinary students (Durbeej et al., 2019). The responsibility to ensure that LGBTI students do not feel alienated or different rests, of course, with the school management and staff. School staff must be comfortable talking about sexuality, and address the matter early, both in teaching and in the school environment. It is important that they use the names and pronouns preferred by the individual students. In addition, school staff must be ready to stand up for the well-being and health of LGBTI students (Anderssen et al., 2020; Hammarlund et al., 2017). There is a need for increased knowledge among school staff meeting sexual minorities in their daily work. Particularly since lack of knowledge risks to further increase the vulnerability of these groups. By paying attention to the experiences of the LGBTI group, listening to and learning from them, we are able to address more efficiently the heterosexism and violence in school, and thereby create a safer school environment. Students need support in challenging unfair power structures that exist between students. Boys need additional support in questioning and challenging hegemonic masculinity (Odenbring, 2019). LGBTI identities need to be more visible in the school environment, for example in course and education materials. Toilets should not be segregated according to gender. It is important, too, that the school supports groups that address young LGBTI persons (Anderssen et al., 2020; Hammarlund et al., 2017). Regarding efforts against bullying, these should be particularly targeted toward young LGBTI persons. The school should take measures to prevent prejudice, and teachers need to be proactive in this matter (Anderssen et al., 2020; Kurki-Kangas et al., 2019). Sex education in schools should include a LHBT perspective, also involving identities that go beyond binary categories (Gisladottir et al., 2018; Johansson et al., 2018; Stubberud et al., 2018).

School staff working with health issues (such as school nurses) should be aware of any challenges for young people in this group, and their work should include counselling if needed, or referral to such services. As the studies find that trans persons may have difficulty in requesting support, Durbeej et al. also recommend online therapy for this group (Durbeej et al., 2019). Specifically for school nurses, Latiti et. al (2020) suggest three areas of improvement. First, school nurses require additional training regarding LGBTI identities, sexual health within this group, and knowledge about gender and sexuality. This should be included both in the training for future nurses, and as in-service training for those already in the profession. Second, school nurses also require tools and training to accommodate LGBTI students regarding, for example, inclusive language, and in creating an open and accepting environment in matters concerning gender and sexuality when meeting students. Finally, policies and guidelines need to be updated, in order to reflect the variety of gender identities and sexualities (Laiti et al., 2020). Stubberud et. al (2018), too, highlight the importance of adequate competence among school nurses regarding gender identity and gender expression. They also emphasize the importance of placing the school nurse’s office in a place that is accessible, but also possible to visit anonymously (Stubberud et al., 2018). 

In order to improve the opportunities for young LGBTI persons to establish themselves in working life, more extensive and intensified efforts are required to attain more inclusive workplaces, and to counter discrimination and excluding norms. Based on these assessments, the Swedish Agency for Youth and Civil Society has presented two suggestions for further efforts. The first one is about strengthening the work of the respective actors of the labour market to bring about a more inclusive working life. The second would aim to increase the knowledge among young HBTQ persons regarding their own rights (Ohlström, 2017).

​Preventive work

As the prevalence of suicidal thoughts and suicide attempts is disproportionately high among younger trans persons, and is so strongly linked to trans related vulnerability and harassment, there is a need for targeted preventive activities in this field. Differences in health status need to be remedied, and there is need for suicide prevention through trans inclusive healthcare efforts, as well as destigmatizing activities. The responsibility for analysing health factors among LGBTI persons, and for designing specific preventive strategies against suicide among trans persons lies with various authorities, such as the Public Health Agency, in a Swedish context (Zeluf et al., 2018). O’Reilly and others further hold that sexual minorities may benefit from preventive efforts, and from interventions focused on self-injury and suicide (O’Reilly et al., 2020). Patterns in factors linked to sexual health are complex, and depend on both personal and structural factors. Prevention must be adapted accordingly, and take into account relationship status, levels of education, geography, age, and availability for testing. Knowledge and awareness among healthcare staff also need further development (Johansson et al., 2018). As many men who have sex with men have experiences of sexual coercion, there is a need to make note of and further discuss consent and sexual coercion, in clinical contexts as well as within prevention strategies (Helsing et al., 2020). 

It is also important to be aware of where young people turn for information. Larger LGBTI organisations may, to a greater extent, appeal to young people in major cities, which makes it important that healthcare staff are aware of LGBTI organisations, and can inform young people about them. There is a need for knowledge within the medical and care professions; knowledge that makes it possible to listen to, support, and acknowledge young LGBTI persons. Within this sector, knowledge is also needed about breaking away from norms for gender and sexuality (Stubberud et al., 2018). 

The lack of studies focused on young people displaying an atypical sex development is palpable. Guntram and Zeiler indicate the importance of finding the right ways to support individuals displaying atypical sex development in their attempts to challenge assumptions regarding binary physicality, and get their experiences recognized. This requires efforts within medical education, and increased knowledge regarding such experiences within the practice of medical care and healthcare. The general public, too, needs more knowledge about intersex conditions, through, for example, sex education in schools, and through organisations working with information on sexual matters. Such strategies could potentially contribute to making certain bodies and lives less difficult to talk about (Guntram & Zeiler, 2016). 

Asylum reception staff, and staff of housing facilities for unaccompanied asylum-seekers need adequate competence regarding a variety of gender identities and sexualities. Young, unaccompanied LGBTI persons must feel there is someone they can confide in. Staff must also be aware that there is a risk involved for the young in being open, and therefore be very careful regarding how they share this information in turn. LGBTI materials should be available in these locations, as well as active prevention of bullying and harassment of people with LGBTI identities. Further recommendations include using interpreters who are comfortable speaking about LGBTI issues, and co-operation with LGBTI organisations (Stubberud & Akin, 2018).

Several studies indicate the importance of further research regarding the situation of young LGBTI persons. Odenbring means there is a need for research on violence in school, and in everyday life, particularly qualitative studies that might provide knowledge beyond the quantitative ones that have so far been dominant within this field. Odenbring also states that it is important to examine how the trend of right-wing extremism within Sweden and Europe impact fear among sexual minorities of being exposed to hate crime (Odenbring, 2019). There is also need for research that focuses on knowledge levels among school nurses and other staff (Laiti et al., 2020). The lack of studies focusing on intersex and on atypical sex conditions indicates the importance of further inquiry into these matters. Results also indicate the importance of including, in large-scale population studies, response alternatives surrounding gender identity and sexuality which make it possible to target young people with identities that go beyond any binary categories, and who also do not fit into the LGBTI spectrum. 

Finally, it is important to take relationships into account when working to promote the well-being of young LGBTI persons, not least since multiple studies show that good relationships are of vital importance for young LGBTI persons, and that they have a major impact on well-being (Alanko & Lund, 2020; Thorsteinsson et al., 2017). Support is needed for young trans persons who report few or no relations to others, and there is also need for information targeting parents and other relatives of young LGBTI persons (Alanko & Lund, 2020; Gisladottir et al., 2018). Multiple studies have shown the importance of being able to be part of LGBTI groups and contexts in order to gain a sense of community, but also the importance of places to turn for support. This connects to the second part of this report, which is focused precisely on activities that improve the health, life conditions and well-being of young LGBTI persons.

Part 2. Efforts promoting health, well-being and life conditions of young LGBTI persons in the Nordic countries.

Introduction

LGBTI issues have been consulted, as well as municipalities and strategic authorities in the respective countries. 

Following an initial overview, a selection of efforts has been made by NIKK, while maintaining a dialogue with the Danish 2020 Chair of the Nordic Council of Ministers, on whose initiative this report has been produced. The selection has been made with the intent to showcase the breadth and variety of activities within the region. The endeavours highlighted here are focused on both physical and mental health issues, as well as, for example, family life and relationships, and young people’s vulnerability to bullying and discrimination. One of the goals of this survey has been to make visible the work that target particularly vulnerable groups, such as newly arrived migrants, socially vulnerable persons, or people with disabilities. Such efforts are available in selected locations throughout the region. The age span is limited to young LGBTI persons up to 30 years old. The information has been acquired through interviews and through retrieval of data from online sources. 

All in all, it can be said that efforts have been made in multiple places throughout the region, but that current conditions vary between the respective Nordic countries. The Faeroe Islands and Greenland stand out in this respect, as they seem to completely lack any explicit efforts on behalf of this group. In every Nordic country, it is primarily the LGBTI organisations that are behind the endeavours directly aimed at the target group. Other actors include recreation leaders or social workers operating locally, on a municipal or regional level, or national/governmental actors. Collaboration occurs frequently between the organisations and the various professional groups. LGBTI organisations tend to serve as knowledge repositories, and provide education and in-service training for professionals in matters related to the health and life conditions of young LGBTI persons. The activities are often funded by municipal and governmental assets, or by various foundation grants. However, several of the actors behind the endeavours described in this survey confirm that limited resources and short-term financing affect the possibilities for long-term work and for meeting existing needs. 

Efforts are location-specific, and/or conducted digitally. Activities in the form of, for example, chat or helpline contacts can be perceived as accessible by a larger number of people, as such efforts do not require the young people to be present in a particular place. This could be of vital importance to people living in more rural areas in the Nordic countries, particularly during the ongoing pandemic, which requires social distancing. Meanwhile, location-specific work promotes accuracy in relation to the needs of a particular target group, such as safe spaces and companionship. 

In the following section, activities have been divided into the categories meeting-places, conversation and counselling, awareness-raising efforts, and health and well-being. As the activities differ in aim and scope, the categories sometimes overlap to a certain degree. 

Selected efforts in the Nordic countries

Meeting-places

In several places in the Nordic countries, there are initiatives offering meeting-places for young LGBTI persons. These initiatives aim to create safe spaces, and opportunities to meet other young LGBTI persons. The meeting-places offer social activities, group meetings, and sometimes other initiatives that provide, for example, support and counselling.

Reykjavik Queer Youth Center (IS)
The meeting-place for young LGBTI persons in Iceland

Every Tuesday, about 120 teens visit the Reykjavik Queer Youth Center. This is the only meeting-place specifically available for young LGBTI persons in Iceland, and some of them travel a long way, from other municipalities, to come here. 

The need is enormous. Above all, the Center is a place where our young can feel that they belong. Many feel exposed in multiple contexts in their daily life; in school, at home, or in sports related situations. In that case, it feels good to have a place where you can just be yourself, says Hrefna Thorarinsdottir, centre leader since 2016. 

The Reykjavik Queer Youth Center is a collaboration between Iceland’s HBTQI organisation Samtökin, and the City of Reykjavik. Previously, Samtökin offered youth activities in the cramped venue of the society, but this proved an unsustainable solution. Therefore, they contacted the city, asking for new premises and professional assistance. Hrefna Thorarinsdottir, who has previously done research within youth work, is currently on staff with a part-time position (25%), and collaborates with 13 volunteers from Samtökin. The youth centre offers various things to do; visitors can record podcasts in the studio, watch movies in the tv room, or play games. Meet-ups start with a round of introductions. 

The participants decide what we talk about. It might be how to manage your economy, where to buy binders for your breasts, or how to handle your family. I try to give them hope, and tools, says Hrefna Thorarinsdottir. 

She has become a kind of knowledge repository on the subject, and provides training and guidance for other professionals in Iceland who meet young LGBTI persons. Samtökin finances its work through municipal funding. Applications for further funding are made on an ongoing basis.

The economy is a major challenge. Despite the great need, our work is based largely on the work of our volunteers, says Daníel E. Arnarsson, Samtökin. 

Read more about the endeavour here (in Icelandic):  https://samtokin78.is/starfsemin/felagsmidstod/

AURA (DK)
Social meeting-place led by volunteers

AURA is a social meeting-place for LGBTQ+ persons under 18 in Denmark. The first AURA effort was launched in Copenhagen in 2015, and can now be found in additional locations in Aabenraa, Esbjerg, Viborg, Aalborg, Vejle and Aarhus. The aim is to expand and become nationwide, with meeting-places in at least ten Danish cities.

The purpose of AURA is to offer safe spaces where young LGBTQ+ persons can meet and get to know each other. Meet-ups are hosted approximately twice a month, and activities vary. Sometimes they focus on board games or movies, and sometimes there are conversations around themes such as sexuality or norm criticism.

In Copenhagen, on average 25 people attend the meet-ups, which are led by young adult volunteers. The volunteers receive training regarding the project and its working methods. The work of AURA is coordinated nationally by a project leader from the organisation LGBT+ Danmark. This organisation manages the endeavour, provides training and support for the volunteers, and works through an outreach programme in order to find its target group. The organisation collaborates with municipal youth centres, who in turn make their premises available, and assists in recruitment.

The endeavour is funded by municipal and private funds, such as Dansk Tennis Fond and Det Obelske Familiefond. 

Read more about the endeavour: https://www.lgbt.dk/en/aura/

KAAREVA (FI)
Youth recreation centre for young LGBTI persons 

In Tammerfors, the municipality has made efforts to develop their youth activities in co-operation with the LGBTIQA organisation Sinuiksi (Birkalands Seta).

The municipality has provided education on LGBTI issues and minority stress for its youth leaders, and assigned five recreation leaders to work specifically with the target group.

2019 saw the opening of Kaareva, a youth activity programme aimed specifically at the rainbow group – with a focus on young people experiencing health issues. The youth centre is open on Mondays, and receives about 40 visitors weekly. The venue offers a place to hang out, cook, play the piano, talk to the leaders, or attend lectures. Tiina-Liisa Vehkalahti is the municipal coordinator of the centre: 

To some young, it takes weeks before they muster the courage to go in, they just circle outside. Once inside Kaareva there are no obligations to participate in any activities. They can just hang out. Many young people help out, and look to one another for support, too. 

Kaareva is meant to be a place belonging to the young. But they can always come and find the youth leaders if they need support.

We can guide them to the right place, and provide further contacts in case they need professional counsellors or social workers. The recreation leaders can also accompany them to an appointment if necessary, says Tiina-Liisa Vehkalahti. 

Apart from Kaareva, there is also a conversation group, and a support line to call, as well as anonymous chat platforms for young LGBTI persons, which are operated by the (Seta) Sinuiksi endeavour. The city has an additional project, carried out in co-operation with the organisation, to ensure that every student in year 8 receives education regarding sexual orientation and gender identity. So far, about 170 workshops have been hosted. 

School surveys, on a national level, show that young people in the rainbow group experience health issues, and run a higher risk of being marginalised. Therefore, we are very pleased about our co-operation with the city. Our activities for rainbow young here in Tampere are unique, and we can monitor the well-being of the young, and do regular follow-ups, says Mikko Ala-Kapee, leader of the (Seta) Sinuiksi endeavour.

Read more about the endeavor (in Finnish):  https://www.tampere.fi/kulttuuri-ja-vapaa-aika/nuorten-tampere/apua/

Skeiv Verden (NO)
A member organisation for LGBTI persons with minority backgrounds

Skeiv Verden is a Norwegian member organisation for LGBTI persons with a minority background. This diverse target group includes asylum-seeking individuals, foreign labourers and Norwegian-born individuals with a minority background. Skeiv Verden was initiated as a project by the Norwegian umbrella organisation FRI, but was formally made a separate organisation in 2010. Today, Skeiv Verden conducts its work through four local branches, and is present as a network in several Norwegian cities.

Skeiv Verden seeks to create safe meeting-places, where visitors can be themselves, and open. Here, they can make contact with others who have similar experiences, and receive support and knowledge that makes it easier to be LGBTI with a minority background. Skeiv Verden offers, among other things, free telephone, email and chat counselling. They also provide education and skill enhancement efforts for schools, leisure activities, and actors within healthcare and medicine, among others.

Skeiv Verden hosts a youth group for persons aged 14 to 25, who wish to meet other young LGBTI persons with a minority background. The group decides for themselves what activities to engage in together, such as bowling or movie nights. The effort is run by ten employees, supported by volunteers. It is mainly funded by government subsidies, but receives additional means in the form of membership fees.

Read more about the endeavour: https://www.skeivverden.no/other-languages

Rainbow café (AX)
Girl and boy group method adapted for LGBTI persons

For about 20 years, an approach known as the Girl and Boy Group Method has been employed in the Åland Islands. Within the local leisure activity organisation, there are specific groups for girls, with participants in years 7 to 9, where one of the purposes is to strengthen young women, and provide an opportunity to reflect on the gender balance in society, as well as equality issues. In more recent years, the method has been developed and adapted for young LGBTI persons, with a gender-neutral and inclusive perspective.

Twice a month, the LGBTI organisation Regnbågsfyren hosts a rainbow café, in co-operation with the City of Mariehamn, and with support from the organisation Folkhälsan. The rainbow café sets various themes for each meet-up, and the leaders instruct the conversation without admonishing. Themes might include eating disorders, self-injury, or sexual harassment, as well as topics such as love, or favourite music. Conversations alternate with physical activities, such as climbing or crafts. Studies show that young LGBTI persons in the Åland Islands experience health issues. The two-hour rainbow cafés make a great difference in the young people’s lives.

Many people live from café to café. Participants say that “school is something you survive, but the rainbow café gives you a chance to breathe,” says Mio Sommardahl, leader of the rainbow café and youth leader in the City of Mariehamn.

Read more about the endeavor (in Swedish): ​ https://regnbagsfyren.wordpress.com/2019/04/08/valkommen-pa-regnbagsfika-2/

Counselling

In the Nordic countries, there are several initiatives that provide counselling and support for young LGBTI persons. The conversations are held both face to face and online, with volunteers or with trained staff.

Accredited counselling service (DK)
Professionalized counselling

The umbrella organisations LGBT+ Danmark and LGBT+ ungdom run an accredited counselling service, which is open one day a week for LGBT persons in need of help. The service receives visits in person, emails, chat, and phonecalls, and is based in Copenhagen and Aarhus. Each week, 20–25 people contact the counselling service, about 40 percent of which are young LGBT persons under 25. The counselling service is run by volunteers who are themselves LGBT persons. It has been active since the 1980s, but in the last few years, the initiative has been professionalized, and its quality ensured by it being accredited by the trade association RådgivningsDanmark.

Read more about the endeavour: https://www.lgbt.dk/en/lgbt-counselling/​​

​Pegasus Råd och Stöd (SE)
Supporting young LGBTI persons who sell sex 

Despite the fact that it is more common among young LGBTI persons than among young heterosexuals to provide sex in exchange for reimbursement, there was previously no support in Sweden aimed specifically at the former target group. Therefore, the national LGBTI organisation RFSL Ungdom launched a support initiative in 2015. Pegasus Råd och Stöd has a norm-critical perspective in these matters. 

Our target group is seldom heard, and they are absent in the public debate on buying sex. Today, there is a great lack of knowledge and few specialized efforts aimed at this target group, says Virág Finta, project leader of Pegasus Råd och Stöd. 

Today, the effort has recruited three professional counsellors/project leaders and one communicator. Beyond face-to-face and digital counselling, there is also an anonymous drop-in chat. The staff trains professionals who meet young people in their work. The target group is young people aged 15 to 25.

Pegasus Råd och Stöd is supported by a public fund, through a grant that will expire in the spring of 2021. The project has not currently applied for any further funding, but plans instead to apply for grants for a project with a wider scope, centered on preventing and offsetting mental health issues among young LGBTI persons.

Whenever we apply for money, there is pressure to use it for new projects, or at least for something with a new twist. This makes is difficult for anyone working within the civil sector on a national level to engage in any long-term endeavours, says Virág Finta.

Read more about the endeavor (in Swedish):  https://pegasus.se/rad-och-stod/

Ungdomstelefonen (NO)
Open five nights a week

Through the popular initiative known as Ungdomstelefonen, the organisation Skeiv Ungdom offers support to young people in need of someone to talk to in matters regarding sexuality, gender, and identity. This support is available via phone, chat, and email. The volunteers of Ungdomstelefonen are young adults aged 18 to 30, with LGBTI experience of their own. The service is open five nights a week, and the volunteers can guide callers to further professional help if necessary. The endeavour is funded by the Norwegian Directorate of Health.

Read more about the endeavor (in Norwegian):  https://ungdomstelefonen.no/

Suicide preventive work (SE)
Advice and support for young trans persons 

The Swedish LGBTI organisation RFSL Ungdom conducts suicide preventive work. Their internal work includes awareness-raising activities in order to improve support to people with suicidal thoughts, who contact the various branches of the organisation. They also work actively to prevent suicide, by using the support email function of their initiative, Transformering, where trans persons can turn for advice and support. 

It is important that we are not afraid to highlight the suicide issue, for example if anyone expresses things like “not being able to take it any longer.” There are incorrect notions that you might give someone ideas by starting to talk about suicide, but that is simply not true, says Vierge Hård, trans issues specialist of RFSL Ungdom, and one of the people in charge of the Transformering email support service. 

Transformering receives about 90 to 95 emails per month. Over 30% of the emails received concern mental health issues, and about 10% concern suicide. Vierge Hård believes trans competence is vital in the suicide preventive work aimed at trans persons. For example, it is important to know there are situations linked to an increased risk of suicide. These include the period right at the beginning of a transition, and immediately following surgery. Certain types of self-medication may also increase the risk of depression. Transformering is run by RFSL and RFSL Ungdom. The effort is funded by the Public Health Agency of Sweden, through various operating and project grants for mental health efforts and suicide prevention.

Read more about the endeavor (in Swedish):  http://www.transformering.se/

TRANSIT (DK)
Conversation groups about gender identity

The TRANSIT initiative hosts conversation groups for young people with questions about their gender identity. The concept was first introduced by the RFSL organisation in Sweden, and can also be found in Denmark, where LGBT+ Danmark hosts conversation groups in Copenhagen and Aarhus.

The Danish TRANSIT effort was launched as a pilot project in 2016–2017. The initiative is now funded until 2022, with grants from the municipality of Copenhagen, and from a private fund. 

The conversation groups have participants grouped according to age. There are groups for people aged 15 to 24, and others for people aged 25 and up. Groups include eight participants and two leaders, who meet eight times. Conversations in the groups touch on varying subjects, including what it is like to be a trans person and/or nonbinary in a cis-normative society; about family and romantic relationships; about being yourself, in your body; and wishes and visions for the future.

Read more about the endeavor (in Danish): ​ http://lgbt.dk/transit/

Awareness-raising efforts

Several activities in the Nordic countries are made to increase knowledge about the life conditions and well-being of young LGBTI persons. The information is aimed, for example, at students and professionals who meet young LGBTI persons, and at politicians and officials who make decisions that affect the group.

Sex som funker (NO)
Disability, chronic illness and sexual health 

What challenges exist for young people with disabilities and chronic illness when it comes to sexual health? And what are the solutions? In Norway, the organisation known as the Norwegian Association of Youth with Disabilities run a project called Sex som funker, focused on functional ability, chronic illness, and sexual health. The project has an LGBTI perspective throughout, both regarding materials and talks, to ensure that all people with disabilities and chronic illness are included. This extends to image selection, and to examples of practical solutions. In co-operation with the Centre for Equality, several initiatives have been offered, including the design of an e-learning tool for healthcare staff and teachers regarding disabilities, chronic illness, and sexual health, as well as guidance regarding various kinds of technological sex aid. The Sex som funker initiative is supported by the Norwegian Directorate of Health.

Read more about the endeavor (in Norwegian):  https://ungefunksjonshemmede.no/ressurser/kurs/sexsomfunker/

Restart (NO)
Counteracting student bullying

Through the Restart project, the LGBTI organisation Skeiv Ungdom meets students in their schools in Norway, to talk about sexual orientation, gender identity, and gender expression. The aim is to counteract bullying of students who are HBTQ+, by increasing knowledge and contribute to a better understanding of the issue among the students in general. The education programme includes three lessons, and is age adapted for various school years, from ages 10 to 19.

Skeiv Ungdom co-operates both with individual schools and with municipalities. Each year, over 8 000 students are trained by Restart. During the lessons, various norms and expectations are explored and challenged, through a mix of lectures, discussions, and exercises.

The project is supported by the Norwegian Directorate for Children, Youth and Family Affairs, and by the Norwegian Directorate for Education and Training.

Read more about the endeavor (in Norwegian):  https://skeivungdom.no/prosjekter/restart/

Training for professionals (FI)
Additional training provides additional leaders of conversation groups 

For a fee, the LGBTI organisation Seta trains professionals who meet young LGBTI persons. In later years, the demand for in-service training has increased. Interested parties include recreation leaders, social workers, and healthcare staff, among others. Seta co-operates with regional actors who organise training for professionals, and also hosts its own sessions. In addition, the organisation trains recreation leaders, so they in turn can host conversation groups for young LGBTI persons. Throughout Finland, there are currently about 30 conversation groups, which are mainly hosted by Seta – but some ten groups are hosted by individual municipalities. The conversation groups serve as safe spaces for young LGBTI persons. Within the groups, participants may raise issues such as minority stress and health, and can find someone to help them with their problems.

Read more about the endeavour here: https://en.seta.fi/​

Rosa kompetanse (NO)
In-service training for professionals

Rosa kompetanse is an educational initiative aimed at professional groups. It is adapted to their workplaces and needs. The purpose is to increase competence regarding gender, sexuality, identity, and norms.

The educational initiative is organised as its own branch of the Norwegian LGBTI organisation, FRI, and has existed since 2006. It is divided into several specialist fields: schools and daycare, child care, health and social sector, police, and prosecution authorities. All in all, 12 people work within the Rosa kompetanse, and the endeavour has grown over the years. In 2019, Rosa kompetanse visited about 250 different operations in Norway.

The in-service training is provided in close collaboration with professional associations and trade unions within the respective sectors. When working with schools, Rosa kompetanse uses the policy documents and aims of the respective schools as a jumping-off point, helping the school staff to attain them. Educators working with schools also have their own relevant professional experience from the field, and are familiar with the matters at hand. Rosa kompetense is funded through grants from the Norwegian Directorate of Health, the Norwegian Directorate for Children, Youth and Family Affairs, the Norwegian Directorate for Education and Training, and the former Norwegian Crime Prevention Centre, Kompetansesenter for kriminalitetsforebygging. The cost of the training programmes vary depending on the client. Despite the funding, money is the greatest challenge for Rosa kompetanse. While the demand increases for the services of the organisation, funding always comes with a time limit.

Read more about the endeavor (in Norwegian):  https://www.foreningenfri.no/rosa-kompetanse/

Initiatives to increase knowledge in schools (DK)
Guidance materials and courses to strengthen teachers 

On a national level, Denmark has designed an inspirational guidance material for schools and youth training institutions, regarding challenges for, among others, young homosexuals and trans persons. The material shows how management, teachers, and education staff can support their well-being, and promote openness and understanding in schools. In order to further strengthen knowledge, the organisation LGBT+ Danmark has also developed a training programme for teachers and special needs teachers. Here, participants get to practise by presenting solutions to practical situations, such as LGBTI related bullying. The organisation has also created a norm-critical teaching material, with a focus on rights, aimed at students aged 13 to 15, including three animated movies where young LGBTI persons share their stories.

Read more about the endeavour (in Danish):  https://emu.dk/grundskole/dansk/saet-fokus-paa-lgbti-og-mangfoldighed

Strategic HBTQ agency for improvement (SE)
Support materials provide hands-on tips

The Swedish Agency for Youth and Civil Society (MUCF) is one of Sweden’s HBTQ-strategic government agencies^{[1]The other HBTQ strategic agencies are: the Ombudsman for Children in Sweden, the Equality Ombudsman (DO), the Public Health Agency of Sweden, the Swedish Gender Equality Agency, the Swedish Migration Agency, the Swedish Police Authority, the National Board of Health and Welfare, the Swedish Arts Council, and the National Agency for Education.}. They both collect and produce new knowledge on the life conditions of young HBTQ persons, and are tasked to improve conditions in schools, and ensure there are meeting-places. The agency also co-operates with the organisers of free recreational activities, where they provide HBTQ-related support materials for the staff. In these support materials, MUCF has collected knowledge about norm-conscious working methods, which create safety, and hands-on tips for inclusive treatment of young people. The material includes descriptions of difficult situations which recreation leaders may need to handle, as well as examples of how to counteract offensive treatment and harassment.

Read more about the endeavor (in Swedish):  https://www.mucf.se/publikationer/oppna-fritidsverksamheten-hbtq-normer-inkludering

The Gothenburg LGBTQ Council (SE)
Has increased knowledge on LGBTI and honour

In the 2000s, Gothenburg gained a reputation as a city where several LGBTI persons had been murdered. This made the city act forcefully to improve life conditions for LGBTI persons. Today, Gothenburg is home to Sweden’s only municipal LGBTQ council, whose strategies have a major impact, and much effect on the situation of young people. The LGBTQ council includes six politicians from the municipal executive board, along with 13 representatives from the Gothenburg HBTQ organisations. In order to ensure an intersectional perspective, representatives are chosen based on seven different grounds for discrimination, one of which is age. The youngest representative is 16 years old. The council provides plans of action, serves as one of the bodies to which any proposed measures are referred, and can summon heads of administration for direct dialogue.

The LGBTQ council convenes six times annually in the venue of the municipal executive board, and its work has a lot of focus on the health of young LGBTI persons. One concrete example is how a dialogue has been conducted between the council and the city’s resource teams, that work with honour based violence and oppression, to improve LGBTI competence within the teams. This has made it possible to reach young, exposed LGBTI persons which have otherwise been overlooked by the Social Administration.

The method of appointing a municipal LGBTQ council is currently also found in Oslo, inspired by the Gothenburg initiative.

Read more about the endeavor (in Swedish):  https://goteborg.se/wps/portal/start/kommun-o-politik/kommunens-organisation/kommunstyrelsen/goteborgs-stads-hbtqrad?uri=gbglnk%3A20131209-1503

Health and well-being

In several places in the Nordic countries, there are efforts to even out differences in health between LGBTI persons and the rest of the population. This is done, for example, by setting up clinics and centres especially for LGBTI persons, but also by increasing the knowledge about the well-being of this group.

HBTQ certified youth clinic (SE)
Trained staff familiar with terminology

In the publicly operated youth clinic in Borlänge, LGBTI issues have priority. All young people should feel they can turn to the clinic with their questions, and the staff should have the competence to help them.

The work at the clinic is HBTQ certified by the Swedish umbrella organisation RFSL since 2017. The certification is a mark of quality showing that the staff has undergone the RFSL training programme. HBTQ issues permeate everything the clinic does. For example, this includes not making any assumptions about visitors. Staff use the word partner rather than girlfriend or boyfriend, and will ask which pronoun to use for any paperwork. They also have clear routines for how to handle various situations, for example if anyone wishes to talk about their gender identity, or has questions regarding gender-affirming treatment.
 

It is really important that we possess this knowledge, and know the terms used. The young people who come here should not have to explain. The RFSL training also makes the staff feel very secure in their work, which in turn increases the feeling of safety for the young HBTQ persons coming to see us, says midwife Ulrika Andersson.

In order to be able to offer guidance to young HBTQ persons, the staff also keep an ear to the ground regarding what is going on within the HBTQ movement.

We try to stay updated, so we can let people know about pride events and other activities, and also about various groups in social media that you can join, says Ulrika Andersson.

In the future, they would like to start their own conversation group for young HBTQ persons. So far, this is still in the planning stage, and they need to wait until the pandemic allows meetings of this kind. 

We can see that there is a great need for it. Many people ask where they might turn in order to meet other HBTQ persons their own age, and there are simply not enough meeting-places like that here, in the Province of Dalarna, says Ulrika Andersson. 

Youth clinics can be found in nearly every municipality in Sweden, and are most frequently funded by the municipalities or by the regions. Many of them are HBTQ certified by RFSL.

Read more about the endeavor (in Swedish): https://www.borlange.se/omsorg-och-hjalp/familj-barn-och-ungdom/ungdomsmottagning

Helsestasjon for kjønn og seksualitet (NO)
A safe healthcare environment

At the Helsestasjon for kjønn og seksualitet in Oslo, young LGBTI persons are met by professional competence in a safe environment. The basic viewpoint here is that societal norms are behind many of the health issues experienced by young LGBTI persons.

The health station opened in 2002 and is run by the government. Today, it has a focus on gender, sexuality, and mental health. The station has four people on staff, full-time; a doctor, a psychologist, and sexologist counsellors. Services offered by the clinic, ranging from counselling and professional advice to medical care, such as hormone therapy, are free of charge for visitors. Their age span is between 0 and 30. The initiative is permanent, and funded by the Oslo municipality and the Norwegian Directorate of Health. 

There is a month’s waiting time due to high demand. Some people seek our care due to social exclusion and minority stress linked to their sexuality. In the last few years, we have seen an increase mainly in cases relating to gender identity, says Ingun Wik, head of the centre. 

The centre also hosts conversation groups and a national chat, open for two afternoons each week. The staff offers additional skill enhancement efforts aimed at other professionals. The health station co-operates closely with the Norwegian LGBTI organisations. There are plans to introduce similar initiatives in Bergen and Trondheim. 

Today, there is precious little healthcare aimed at young LGBTI persons in Norway, and many young people move to Oslo in order to be received at the health station. Some young people get referred to psychiatry and receive the wrong type of care. This has consequences both for the individual and for society, says Ingun Wik. 

For the staff at the health station, it is vital to see the overall picture, and to provide continuity. Their outlook is that visitors are healthy, no matter how they identify. 

Regarding gender identity, maybe everyone does not need gender-affirming treatment as provided by specialist medical care. Instead, this is very much about tailoring the aid to the individual, and to see that it is the narrow norms of society that create health issues. Gender dysphoria is not a mental illness – it’s society that’s at fault, says Ingun Wik. 

Read more about the endeavor (in Norwegian): https://www.oslo.kommune.no/helse-og-omsorg/helsetjenester/helsestasjon-og-vaksine/helsestasjon-for-ungdom-hfu/helsestasjon-for-kjonn-og-seksualitet-hks/

National health surveys (FI) 
Important to include LGBTI 

Every other year, the Finnish Institute for Health and Welfare conducts a national survey on student health, mapping the well-being, health and schoolwork among Finnish children and youths. The last two surveys have included questions about the sexual orientation and gender identity of the respondents. This has made it possible to filter results specifically for data on LGBTI persons. In this way, the knowledge about the well-being of this group has increased. 

Read more about the endavour: https://thl.fi/enthlfi-en/research-and-development/research-and-projects/school-health-promotion-study​

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Appendix 1. Method

Search strategy outline

The literature which forms the base of this research overview has been selected using a search strategy based on the method for a systematic overview. The purpose of a systematic overview is to summarize the available research within a specific field.

The method is characterized by the transparency of the procedure employed when searching for, retrieving, and evaluating literature. The procedure is thoroughly accounted for, and outlined in detail, both in order to make the study repeatable, and to minimize bias.^{[1]The Campbell Collaboration, “What Is a Systematic Review? - The Campbell Collaboration.”}

The search strategy had been designed by the report production team. Information searches and reference management tasks have been carried out by librarian Sanna Hellgren of KvinnSam, the National Resource Library for Gender Studies at the Gothenburg University Library. The establishment of selection criteria as well as the selection process itself have been carried out by the author, in co-operation with Kajsa Widegren. The evaluation of references on a title and abstract level was performed in blind mode to avoid any potential bias, and thereby ensure the scientific quality of the report.

The concept known as "grey literature” is frequently used to describe materials published outside of academia, such as reports and other types of documents from the authorities and within civil society, but in some cases, the term also includes publications such as dissertations and conference papers. In this report, materials have been categorized to give the scientific publications a primary focus, but publications from civil society, such as those issued by authorities and organisations in any way operating within the LGBTI field, may be of vital importance. Therefore, a separate search strategy has been included, to retrieve any relevant grey literature from the respective Nordic countries.

Cochrane reviews, being the standard for systematic overviews mainly within healthcare and medicine, recommends the inclusion of searches for grey material, and Campbell collaborations, which features more prominently within social sciences, requires such materials to be included.^{[2]Higgins et al., “Cochrane Handbook for Systematic Reviews of Interventions. Version 6.1”; The Campbell Collaboration, “What Is a Systematic Review? - The Campbell Collaboration.”} However, there are no clear directives for any specific search strategies and associated documentation, which often yields a descriptive text, where the possibility for any reproduction of a search is rather slim.^{[3]Godin et al., “Applying Systematic Review Search Methods to the Grey Literature.”} Regarding the search strategy used to find grey materials for this study, the aim has been to make this work systematic, too, and thereby more reproducible.​

Search terms

In order to find literature within the field, four key concepts were selected: 

1. Young
2. LGBTI
3. Well-being
4. Nordic countries

Each concept was enriched with synonyms to form search blocks by use of the boolean operator OR. The blocks were then combined in turn with AND, to ensure that at least one of the words in the respective blocks was included in the search results returned, and in order to retrieve as much material as possible through the search. The resulting search string was designed as follows:

(youth* OR adolescen* OR young* OR teen*) AND (LGB OR LGBQ OR LGBT OR LGBTI OR LGBTQ OR LGBTQI OR GLB OR GLBQ OR GLBT OR GLBTI OR GLBTQ OR GLBTQI OR transgender* OR transsexual* OR transvesti* OR “trans female” OR “trans male” OR “trans man” OR “trans men” OR “trans people*” OR “trans person*” OR “trans woman” OR “trans women” OR homosexual* OR lesbian* OR gay OR bisexual* OR bicurious* OR queer* OR lesbigay OR intersex* OR intergender* OR pansexual* OR “women identified” OR femme OR butch OR crossgender* OR “gender change” OR “gender transformation” OR “gender transition” OR genderqueer* OR “gender dysphoria” OR “gender nonbinary” OR “nonbinary gender” OR “gender binary” OR “gender identit*” OR “gender identity disorder” OR “gender minorit*” OR “sexual minorities” OR “sexual orientation” OR SOGI OR “Sexual Orientation and Gender Identity” OR “men loving men” OR "men who have sex with men" OR “same sex couples” OR “same sex relation” OR “women loving women” OR "women who have sex with women" OR “non-heterosexual*”) AND (health* OR “minority stress” OR “quality of life” OR depression* OR suicid* OR “well being” OR anxiet* OR “mental disorder*” OR harass* OR exclusion*) AND (nordic* OR “northern countr*” OR scandinavi* OR swed* OR Finland* OR finnish* OR norway* OR norwegian* OR Denmark* OR danish* OR Iceland* OR “Faroe Islands” OR Faroese* OR “Åland*” OR Greenland*)

Limitations and databases

The searches were limited to include scientific articles published no earlier than 2015, as the main purpose of the study is to describe the current state of knowledge, and not, for example, to describe changes over time. Due to the nature of the subject, three interdisciplinary article databases were selected as the relevant search fields:

• Scopus

Large, interdisciplinary database with references that have undergone peer review, within STEM, social sciences, arts, and humanities. 

• Web of Science

Large, interdisciplinary database with references spanning STEM, social sciences, arts, and humanities.

• ProQuest Social Sciences

A joint search interface for several databases including the Criminal Justice Database, Education Collection, IBSS, PILOTS, Politics Collection, ProQuest Dissertations & Theses Global: Social Sciences, PsycARTICLES, PsycINFO, Social Science Database, and Sociology Collection.^{[1]Descriptions from the database list of the Gothenburg University Library. https://www.ub.gu.se/sv/databaser/}

Due to the geographic definition of the subject, additional searches were carried out in the scientific publication databases of the respective Nordic countries:

• Sweden
  Swepub.kb.se contains scientific publications from Swedish seats of learning. Publication types represented are articles, conference papers, dissertations, and other scientific materials. http://swepub.kb.se/ 
• Denmark
  Forskningsdatabasen.dk contains research publications collected from the research databases of 15 Danish universities and research institutes. https://forskningsdatabasen.dk ^{[2]Forskningsdatabasen.dk was discontinued in January, 2021.} 
• Norway
  Nora.openaccess.no contains publications from Norwegian scientific databases, accessible through a joint platform. https://nora.openaccess.no 
• Finland
  Juuli.fi contains references to research publications from Finnish universities and research institutes. https://Juuli.fi 
• Iceland
  opinvisindi.is contains research publications from Icelandic universities published from 2016 onward. https://opinvisindi.is/ ^{[3]Descriptions of the Nordic databases sourced from the websites of the respective databases.} 

In preparation of these accessory searches, search terms were translated to the respective Nordic languages, and searches performed both in these languages and in English. In some of the Nordic databases, the number of results was relatively small, which prompted the removal of the search block “Nordic countries”, as this might be considered redundant when used in a specifically Nordic database. The number of results, with associated technical comments regarding the search method, are detailed below:

Selection

The 443 results were reviewed in blind mode. Inclusion and exclusion processes are commonly done by two people, independently of one another, in order to secure the final selection; this method was employed here. After joint review of any cases assessed differently, and of any doubtful ones, the search results yielded a total of 53 articles which were included, and 389 which were excluded, according to the criteria in the table below.

After full text reading, further materials were excluded, the majority of these because results were not presented in a way that separately accounted for the younger age span and/or the Nordic context. This might include, for example, studies involving people of all ages, or reviews of various national contexts. The number of articles included after full text reading amounted to 29.

Grey material

In order to include grey material such as reports and other kinds of published material issued by various actors, such as authorities and interest groups, targeted searches were carried out on a number of specific actors’ web pages. For this purpose, customized Google search engines were programmed, making it possible to list a number of web pages in which to search for documents published through these pages only. Depending on the focus of the identified actors, searches were designed in different ways. In order to identify published documents, the search prefix “filetype:pdf” was applied, to target pdf files only in the web pages at hand, thus excluding any html sources.

For the respective Nordic countries, two or three (depending on extant national actors) customized search engines were created for different actors, based on the various search blocks. Subsequently, different combinations of the search blocks were used in the respective search engines. Due to the lack of bibliographic posts, the metadata associated with pdf files on the web pages of most organisations is insufficient, which in turn makes it difficult to export the collected search results. These searches, therefore, saw the initiation of the selection process directly during review of the list of results, as the full text of these publications needed assessment already at the initial stage. The first 20 results of every search were reviewed. The selection criteria matched those described above, in the section on databases. Apart from these, other materials excluded were: manuals, plans of action, handbooks, and studies focused on resources/efforts. All in all, the search for grey material yielded another 8 results, three of which were from Norway, one from Finland, two from Sweden, and two from Denmark. Further, one report from Norway was included as per the recommendation of the reference group. In total, 38 publications form the basis of the research overview.

Selection process

About this publication

Health, well-being and life conditions of young LGBTI persons 
in the Nordic countries

A literature review and survey of efforts

Anna Siverskog, Ph. D., lecturer at the School of Health and Welfare at Jönköping University and journalist Ida Måwe, on behalf of Nordic Information on Gender, NIKK.

ISBN 978-92-893-7169-8 (PDF)
ISBN 978-92-893-7170-4 (ONLINE)
http://dx.doi.org/10.6027/temanord2021-534

TemaNord 2021:534
ISSN 0908-6692

© Nordic Council of Ministers 2021

Cover photo: Genessa Panainte / Unsplash
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Published: 14/8/2021
Updated: 12/10/2021

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