Trends in substance use among sexual minority adolescents in South Korea.

PURPOSE: Substance use, that is of cigarettes, alcohol and chemical inhalants, is a major contributor to health-compromising behaviors and the related consequences among adolescents around the world. The purpose of this paper is to examine trends in this phenomenon in South Korea among sexually active adolescents who reported sexual minority behaviors as compared to their heterosexual (HS) peers. DESIGN AND METHODS: This study used data from the annual web-based survey called Korea Youth Risk Behavior Survey in 5-year intervals: 2006, 2011, and 2016. From 2017, the questions regarding the gender of sex partners were excluded from the survey, thus no data is available for sexual minorities after 2016. Selected data (Unweighted n = 10,029) was used to assess whether substance use increased, decreased, or remained unchanged among adolescents who reported same-sex (SS) behaviors and bisexual (BS) behaviors compared to their peers reporting HS behaviors. Demographic variables included age and assigned gender. Substances referred to are cigarettes, alcohol, and chemical inhalants. Logistic regression models were sex-stratified according to assigned gender. Trend analyses were carried out to examine disparities in substance use among sexually active adolescents across the three survey years. RESULTS: Across the three survey years, cigarette use, alcohol use, and problematic drinking declined among all sexually active youths, but there were some differences among the subgroups. In 2016, SS girls were more likely to use cigarettes than HS girls. The prevalence of alcohol use and problematic drinking among BS girls was relatively higher than among girls who exhibited either HS or SS behaviors. Inhalant use was very high among both boys and girls with SS and BS behaviors. PRACTICE IMPLICATIONS: The findings of the study reveal disparities in substance use between sexual minority and heterosexual adolescents in South Korea. This creates an alarm for collecting data separately for sexually diverse youth in future Korean national surveys with a goal of reducing substance use among all adolescents.

Social Support and Mental Health Among Transgender and Nonbinary Youth in Quebec.

Purpose: Transgender and nonbinary (TNB) youth face elevated levels of discrimination, stigma, mental health disorders, and suicidality when compared with their cisgender counterparts. Family and school support may mitigate some of the effects of the stressors facing TNB youth. This study aimed to better understand the impact of each of these sources of support on TNB youths' mental health and wellbeing. Methods: We used data collected between 2018 and 2019 as part of the Canadian Trans Youth Health Survey, a bilingual online survey to measure social support, physical health, and mental health in a sample of 220 TNB youth aged 14-25 living in Québec, Canada. We examined the relationships among different sources of support, and mental health and wellbeing outcomes using logistic regression. Analyses were conducted on the full sample and according to linguistic groups (French and English). Results: Participants reported high levels of mental health symptoms, self-harm, and suicidality, and mental health symptoms were higher in the English-speaking group (p = 0.005). In models controlling for age, family connectedness was associated with good/excellent self-reported mental health (odds ratio [OR] = 2.62, p = 0.001) and lower odds of having considered suicide (OR = 0.49, p = 0.003) or attempted suicide (OR = 0.43, p = 0.002), whereas school connectedness was associated with higher odds of good/very good/excellent general (OR = 2.42, p = 0.013) and good/excellent mental (OR = 2.45, p = 0.045) health. Conclusion: Family and school support present consistent associations with TNB youths' health and may constitute key areas for intervention for those supporting them.

Trends and Disparities in Suicidality Among Heterosexual and Sexual Minority/Two-Spirit Indigenous Adolescents in Canada.

PURPOSE: To explore trends in sexual orientation group differences in suicidality among Indigenous adolescents and evaluate whether gaps between heterosexual and sexual minority/Two-Spirit adolescents have changed over time. METHODS: Leveraging pooled school-based population data from five waves of the British Columbia Adolescent Health Survey (1998-2018), we used age-adjusted logistic regression models, separately for boys and girls, to examine 20-year trends and disparities in past year suicidal ideation and suicide attempts among heterosexual and sexual minority/Two-Spirit Indigenous adolescents (N = 13,788). RESULTS: Suicidal ideation increased among all sexual orientation groups in 2018 compared to previous survey waves. Suicide attempts spiked for heterosexual girls in 2003, remained stable for heterosexual boys, and decreased for sexual minority/Two-Spirit boys and girls over time. Compared to their heterosexual peers, sexual minority/Two-Spirit boys had higher odds of suicidal ideation since 1998, whereas sexual minority/Two-Spirit girls had higher odds of suicidal ideation since 2003. Sexual minority/Two-Spirit (vs. heterosexual) boys were approximately 4-7 times more likely to attempt suicide since 2008, whereas sexual-minority/Two-Spirit (vs. heterosexual) girls were approximately 3-4 times more likely to attempt suicide since 2003. These gaps in suicidality were persistent across time. DISCUSSION: Sexual minority/Two-Spirit Indigenous adolescents are at an elevated risk for suicidality compared to their heterosexual Indigenous peers. While trends of suicidal ideation worsened for all Indigenous adolescents, suicide attempts either lessened or remained stable over time. Greater efforts are needed to help reduce suicidality among Indigenous adolescents in Canada, especially among sexual minority/Two-Spirit young people.

Health and Healthcare Service Use: The Experiences of Runaway Trans Adolescents Compared to their Peers.

This study is the first trans-inclusive exploration of the relation between running away from home, health, and access to healthcare and supportive figures as a function of gender among adolescents. Secondary data analysis of the 2013 BC Adolescent Health Survey found that trans adolescents were 4.25 times as likely as males, and 3.0 times as likely as females, to have run away. Logistic regressions indicated that runaway adolescents of all genders had greater odds of reporting poor or fair overall health (OR: 2.9) and mental health (OR: 4.5), and of foregoing needed physical (OR: 4.8) and mental health care (OR: 4.5) compared to adolescents who had not run away. The relation between running away and health was exacerbated among trans adolescents. Trans and female youth were also less likely than males to report receiving helpful support. Findings highlight the importance of offering trans-affirming services and care to mitigate harms associated with running away from home.

Challenging the Stereotypes: Unexpected Features of Sexual Exploitation among Homeless and Street-Involved Boys in Western Canada.

Research about the sexual exploitation of homeless and street-involved boys is limited and often combined with that of girls. As aggregation can distort unique issues among genders which are exploited, this study provides information about the context of exploitation for homeless boys. Boys participated in the anonymous, multi-city British Columbia (BC), Canada Homeless and Street-Involved Youth Health paper surveys of 2006 and 2014. Measures included questions about trading sex for money, shelter, or other consideration; age first exploited; for whom; where they were living when first traded sex; gender of exploiters; and demographics. Analyses, separately for younger/older boys, explored the prevalence, timing of exploitation vs. homelessness, and ANOVAs to evaluate the patterns of the age of first exploitation by the genders of exploiters. Just over one in four boys reported exploitation (n = 132), with a median age of 14-15 in most groups. Most were runaway or homeless before their first exploitation, but 25.5% (2006) and 41% (2014) were living with family. Most boys were exploited by women (78%-85%), with 62%-65% were exclusively exploited by women.

Ten-Year Trends in Physical Dating Violence Victimization Among Adolescent Boys and Girls in British Columbia, Canada.

Physical dating violence (PDV) victimization among adolescents is a serious global problem. Although knowledge of trends in PDV victimization can help guide programming and health policies, little research has examined whether the prevalence of PDV victimization has increased, decreased, or remained stable over time among non-U.S.-based samples of youth. In addition, few studies have directly tested whether disparities in PDV victimization between boys and girls have narrowed, widened, or remained unchanged in recent years. To address these gaps, we used school-based data from the British Columbia Adolescent Health Survey (BC AHS) of 2003, 2008, and 2013 (n boys = 18,441 and n girls = 17,459) to examine 10-year trends in PDV victimization. We also tested whether trends differed across self-reported sex. Data from the 2003 to 2013 BC AHS revealed that recent PDV victimization rates had significantly decreased among youth overall (5.9%-5.0%) and boys (8.0%-5.8%), but not girls (5.3%-4.2%). Although boys had steeper declines than girls in PDV victimization rates, year-by-sex interactions indicate that the sex gap in PDV victimization had not significantly narrowed. Moreover, rates of PDV victimization over the 10-year period indicated significantly higher rates of PDV victimization among boys compared with girls. Despite positive declines in recent rates of PDV victimization among youth, important differences in rates of PDV victimization between boys and girls remain. These findings underscore the need for greater attention to sex differences in research and programming and health policies to reduce PDV victimization and the sex disparities therein.

First- and Second-Hand Experiences of Enacted Stigma Among LGBTQ Youth.

Research on enacted stigma, or stigma- and bias-based victimization, including bullying and harassment, among lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth often focuses on one context (e.g., school) or one form (e.g., bullying or microaggressions), which limits our understanding of these experiences. We conducted qualitative go-along interviews with 66 LGBTQ adolescents (14-19 years) in urban, suburban, town, and rural locations in the United States and Canada identified through purposive and snowball sampling. Forty-six participants (70%) described at least one instance of enacted stigma. Three primary themes emerged: (1) enacted stigma occurred in many contexts; (2) enacted stigma restricted movement; and (3) second-hand accounts of enacted stigma shaped perceptions of safety. Efforts to improve well-being among LGBTQ youth must address the diverse forms and contexts of enacted stigma that youth experience, which limit freedom of movement and potential access to opportunities that encourage positive youth development. School nurses can play a critical role in reducing enacted stigma in schools and in collaboration with community partners.

Conditions for shared decision making in the care of transgender youth in Canada.

Information is lacking on the role shared decision making plays in the care of transgender (trans) youth. This qualitative, descriptive study explored how trans youth, parents and health care providers engaged or did not engage in shared decision-making practices around hormone therapy initiation and what conditions supported shared decision-making approaches in clinical practice. Semi-structured interviews were conducted with 47 participants in British Columbia, Canada, and analyzed using a constructivist grounded theory approach. While formal shared decision-making models were not used in practice, many participants described elements of such approaches when asked about their health care decision-making processes. Others described health care interactions that were not conducive to a shared decision-making approach. The key finding that emerged through this analysis was a set of five conditions for supporting shared decision making when making decisions surrounding initiation of hormone therapy with trans youth. Both supportive relationships and open communication were necessary among participants to support shared decision making. All parties needed to agree regarding what decisions were to be made and what role each person would play in the process. Finally, adequate time was needed for decision-making processes to unfold. When stakeholders meet these five conditions, a gender-affirming and culturally safer shared decision-making approach may be used to support decision making about gender-affirming care. Implications for clinical practice and future research are discussed.

The link between LGBTQ-supportive communities, progressive political climate, and suicidality among sexual minority adolescents in Canada.

Despite supportive structural changes to reduce stigma towards lesbian, gay, and bisexual, transgender, queer, and questioning (LGBTQ) Canadian residents, sexual minority youth still face disparities compared to heterosexual peers. We aimed to characterize LGBTQ-supportive environments and political climates, and examine their links to suicidal behavior among sexual minority adolescents in western Canada. Data were from the 2013 British Columbia Adolescent Health Survey, a cluster-stratified random cross-sectional survey of public school students in BC, Canada; We sampled 2678 self-identified LGB and mostly heterosexual students (69% girls) from 274 schools, representing an estimated provincial population of 24,624 sexual minority students in weighted models. Student reports of past-year suicidal ideation, suicidal attempts, and self-harm behaviors were merged with community-level data assessing diverse aspects of LGBTQ-supportive resources and progressive political climates in communities surrounding the schools. Adjusted multilevel models showed that for sexual minority adolescent girls, higher community LGBTQ-supportiveness predicted marginally significant lower suicidal ideation (aOR = 0.94, 95% CI [0.88, 1.01]) and suicidal attempts (aOR = 0.91, 95% CI [0.83, 1.00]) and significantly lower self-harm behaviors (aOR = 0.91, 95% CI [0.85, 0.98]). Further, progressive political climates predicted marginally significant lower suicidal ideation (aOR = 0.89, 95% CI [0.78, 1.02]) and significantly lower self-harm behaviors (aOR = 0.87, 95% CI [0.77, 0.99]). For sexual minority adolescent boys, no community-level variables were associated with suicidal behavior in adjusted models. Thus, LGBTQ-supportive communities and progressive political climates appear to be protective against suicidal behavior among sexual minority adolescent girls, but not sexual minority adolescent boys.

Factors related to heavy drinking between British Columbia Asian adolescents and South Korean adolescents.

PURPOSE: The aim of this study is to compare the factors related to heavy drinking among British Columbia (BC) Asian adolescents and South Korean adolescents. DESIGN AND METHODS: A cross-sectional descriptive design was used. Participants were 72,422 adolescents (12,382 BC Asian adolescents and 60,040 South Korean adolescents) from the 2018 BC Adolescent Health Survey and the 2018 Korean Youth Risk Behavior Web-Based Survey. Complex samples descriptive statistics, Rao-Scott χ2 tests, and complex samples logistic regression analyses were performed. RESULTS: Heavy drinking was reported by 8.6% of BC Asian adolescents and 7.7% of South Korean adolescents. Asian adolescents in BC and South Korea shared six risk factors and one protective factor linked to odds of heavy drinking. The strongest risk factor for heavy drinking in each region was current cigarette smoking. Other risk factors for heavy drinking included older age/higher grade (10/12th), early initiation of sexual intercourse (age 14 or younger), experiences of bullying, depression, and exercise. The only protective factor for heavy drinking, sufficient sleep, was similar in both regions. PRACTICE IMPLICATIONS: This study suggests several nursing interventions and health promotion strategies to help us to prevent or reduce heavy drinking for BC Asian adolescents and South Korean adolescents.

It is time to mobilize suicide prevention for sexual and gender minorities in Canada.

Suicide is a significant health issue among sexual and gender minority adults (SGMA); yet, there are no tailored suicide prevention programs for these marginalized populations in Canada. We hosted two world cafés with community leaders, health professionals, policymakers, and researchers to identify recommendations for mobilizing SGMA-focused suicide prevention programs. We identified five priorities: (1) make society safer for sexual and gender minorities; (2) decrease barriers to mental health services; (3) support community-driven and community-based interventions; (4) increase suicide knowledge and reduce stigma; (5) expand the knowledge base on SGMA suicide. In the absence of a national Canadian SGMA suicide prevention policy, these priorities provide a starting point in addressing SGMA suicide inequities by advancing SGMA-tailored interventions.

Self-Reported Health and Patterns of Romantic Love in Adolescents from Eight European Countries and Regions.

Purpose: Sexual minority youth (SMY) are at increased risk of poor health, but it remains unclear whether this phenomenon is universal. In this study, nationally representative samples of 15-year olds from eight European countries and regions were investigated to test if adolescents who have been in love with same- or both-gender partners report poorer health than those exclusively in love with opposite-gender partners or who have never been in love. Methods: A subsample of 13,674 adolescents participating in the 2014 Health Behaviour in School-aged Children (HBSC) study was used. We conducted binary logistic regression, adjusted for gender, region, and relative family affluence, to analyze associations between self-reported romantic love, multiple psychosomatic symptoms, and poor self-rated health. Results: Adolescents reporting same-gender love (adjusted odds ratio [aOR] = 1.50, 95% confidence interval [CI]: 1.11-2.02) and both-gender love (aOR = 3.57, 95% CI: 2.65-4.83) had significantly higher odds for multiple psychosomatic symptoms than those who reported opposite-gender love. Similarly, both SMY groups had higher odds of poor self-rated health (aOR = 2.95, 95% CI: 1.64-5.31 and aOR = 3.08, 95% CI: 1.79-5.31, respectively). Those who reported that they have never been in love had significantly lower odds for multiple symptoms. Adjustment for sociodemographic variables and stratifying by gender did not substantially change the odds ratios. Conclusion: Adolescents in love with same- and both-gender partners reported poorer subjective health outcomes than those in love with opposite-gender partners or who reported never being in love, suggesting that SMY health inequalities are found across various European countries and regions.

Hormone therapy decision-making processes: Transgender youth and parents.

INTRODUCTION: This study explored how transgender (trans) youth and parents of trans youth made decisions around hormone therapy initiation as well as trans youth experiences of barriers to care. METHODS: Participants included 21 trans youth (ages 14-18) and 15 parents of trans youth who resided in British Columbia, Canada. Data for this grounded theory research consisted of transcripts and lifeline drawings collected through semi-structured interviews conducted August 2016 through February 2017. RESULTS: The decision-making processes of youth and of parents are illustrated in three-phase temporal models, starting with discovery, leading to (inter)action while seeking care, and reflection after hormone therapy initiation. Youth who sought hormone therapy were clear about their decision to access this care. Throughout these processes, youth experienced numerous parent- and system-related barriers to care. Youth with the lowest levels of parent support experienced more system barriers, with non-binary/genderfluid youth experiencing greater barriers and less support for hormone therapy than youth with binary genders. A new barrier identified in this study was health care provider imposed requirements for parental involvement and/or approval, which rendered some youth unable access to hormone therapy. CONCLUSIONS: Health care providers should be aware of the deliberation and information-seeking in which youth engage prior to seeking care as well as the temporally misaligned decision-making processes of youth and parents. Understanding the challenges trans youth experience due to insufficient parental support and system barriers can provide important context for health care providers striving to provide accessible, gender-affirming care and decision-making support for trans youth.

Associations Between Community-Level LGBTQ-Supportive Factors and Substance Use Among Sexual Minority Adolescents.

Purpose: Using representative school-based data and community-level primary data, we investigated how environmental factors (e.g., school and community climate) might be protective against substance use behaviors among a vulnerable population of adolescents. Methods: We analyzed a sample of 2678 sexual minority adolescents using a combination of student-level data (British Columbia Adolescent Health Survey) and primary community-level data (assessing lesbian, gay, bisexual, transgender, and queer [LGBTQ]-specific community and school environments). Using multilevel logistic regression models, we examined associations between lifetime substance use (alcohol, illegal drugs, marijuana, nonmedical use of prescription drugs, and smoking) and community-level predictors (community and school LGBTQ supportiveness). Results: Above and beyond student characteristics (e.g., age and years living in Canada), sexual minority adolescents residing in communities with more LGBTQ supports (i.e., more supportive climates) had lower odds of lifetime illegal drug use (for boys and girls), marijuana use (for girls), and smoking (for girls). Specifically, in communities with more frequent LGBTQ events (such as Pride events), the odds of substance use among sexual minority adolescents living in those communities was lower compared with their counterparts living in communities with fewer LGBTQ supports. Conclusions: The availability of LGBTQ community-level organizations, events, and programs may serve as protective factors for substance use among sexual minority adolescents. In particular, LGBTQ-supportive community factors were negatively associated with substance use, which has important implications for our investment in community programs, laws, and organizations that advance the visibility and rights of LGBTQ people.

Supportive Community Resources Are Associated with Lower Risk of Substance Use among Lesbian, Gay, Bisexual, and Questioning Adolescents in Minnesota.

Research has indicated that lesbian, gay, bisexual, and queer/questioning (LGBQ) adolescents have disproportionately high rates of substance use compared to heterosexual peers; yet certain features of schools and communities have been associated with lower substance use rates in this population. To advance this field, research examining multiple levels of influence using measures developed with youth input is needed. With community, school, and student data, this study tested hypotheses that LGBQ students attending high schools and living in communities with more LGBQ-supportive environments (assessed with a novel inventory tool) have lower odds of substance use behaviors (cigarette smoking, alcohol use, marijuana use, prescription drug misuse, and other drug use) than their peers in less supportive LGBQ environments. Multilevel models using data from 2454 LGBQ students (54.0% female, 63.9% non-Hispanic white) in 81 communities and adjusting for student and school covariates found that LGBQ adolescents who lived in areas with more community support had lower odds of frequent substance use, particularly among females. Expanding and strengthening community resources (e.g., LGBQ youth-serving organizations, LGBQ events such as a Pride parade, and LGBQ-friendly services) is recommended to further support LGBQ adolescents and reduce substance use disparities.

Health-Risk Behaviors and Protective Factors Among Adolescents in Rural British Columbia.

PURPOSE: This study explores the relationship between rural residency, selected protective factors (family and school connectedness along with prosocial peer attitudes), and health-compromising behaviors (alcohol and tobacco use and nonuse of seatbelt) among adolescents. METHODS: A subsample of adolescents residing in remote areas was extracted from a province-wide, school-based survey in British Columbia (BC), Canada (weighted N = 2,999). We employed χ2 statistic to test rural-urban differences separately by gender. Logistic regression analysis was used to examine the relationship between protective factors and behaviors compromising health. FINDINGS: In boys, rural residency was associated with multiple problem behaviors (binge drinking, smokeless tobacco use, and nonuse of seatbelt), whereas for girls it was linked to riding without a seatbelt. The final logistic regression models confirmed that rural environment was a significant risk factor for not wearing a seatbelt among both boys and girls, and smokeless tobacco among boys (adjusted odds ratio between 1.44 and 3.05). Rurality, on the other hand, did not predict binge drinking. Logistic regression analyses also revealed that both school connectedness and prosocial peer attitude protected boys against binge drinking and smokeless tobacco, but the results were not as robust for girls. CONCLUSIONS: These findings could provide information for location-based intervention efforts promoting adolescent health, highlighting the protective role of the school atmosphere and prosocial peer relationships, especially among boys.

Romantic Attraction and Substance Use in 15-Year-Old Adolescents from Eight European Countries.

Sexual minority youth are at higher risk of substance use than heterosexual youth. However, most evidence in this area is from North America, and it is unclear whether the findings can be generalized to other cultures and countries. In this investigation, we used data from the 2014 Health Behaviour in School-aged Children (HBSC) study to compare substance use in same- and both-gender attracted 15-year-old adolescents from eight European countries (n = 14,545) to that of their peers who reported opposite-gender attraction or have not been romantically attracted to anyone. Both-gender attracted, and to a lesser extent, same-gender attracted adolescents were significantly more likely to smoke cigarettes, consume alcohol, get drunk and use cannabis, or be involved in multiple substance use in the last 30 days compared to their opposite-gender attracted peers. Those adolescents who have not been in love had significantly lower odds for substance use than all other youth. The pattern of results remained the same after adjusting for country, gender and family affluence. These findings are compatible with the minority stress and romantic stress theories. They suggest that sexual minority stigma (and love on its own) may contribute to higher substance use among adolescents in European countries.

The Links Between Sexual Abuse Severity, Running Away, and Parental Connectedness Among Youth at a Hospital-Based Child Advocacy Center.

PURPOSE: Runaway adolescents often have strained relationships with their parents. Given parental support is an important protective resource for traumatized young people, understanding differences in support within parent-adolescent relationships could aid in designing more effective interventions. We hypothesized (1) runaway adolescents seen at a Child Advocacy Center (CAC) would have poorer parental relationships than adolescents without a history of running away and (2) severity of diagnosed sexual violence would be associated with lower parental connectedness. METHODS: Data were from 2,042 adolescents aged 10-19 years and their parents evaluated for any reason at our hospital-based CAC from 2008 to 2017. Parent-adolescent relationship scales were completed by adolescents and at least one parent/guardian (usually mothers). Sexual abuse was stratified at four levels, higher levels indicating increasingly severe forms of abuse. T-tests and analyses of variance to tested relationships between supportive and controlling parental behaviors by runaway status, and, among runaways, by the severity of sexual abuse. RESULTS: Runaway adolescents comprised 58.3% of adolescents seen at the CAC; runaways reported lower parental support and higher parental controlling than patients without a history of running away. Those with the most severe forms of sexual abuse (including sexual exploitation and gang rape) reported the least supportive and most controlling relationships with parents, as did their parents. CONCLUSIONS: Findings support our clinical observations that polyvictimization of adolescents who have spent significant time as runaways may further strain parent-adolescent relationships. Future clinical research should focus on developing interventions to promote parental connectedness after a runaway episode.

The LGBTQ Supportive Environments Inventory: Methods for Quantifying Supportive Environments for LGBTQ Youth.

The social environment in which lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth live influences health and wellbeing. We describe the development of the LGBTQ Supportive Environments Inventory (LGBTQ SEI), designed to quantify the LGBTQ-inclusiveness of social environments in the US and Canada. We quantify aspects of the social environment: 1) Presence/quality of LGBTQ youth-serving organizations; 2) LGBTQ-inclusive Community Resources; 3) Socioeconomic and Political environment. Using GIS tools, we aggregated data to buffers around 397 schools in 3 regions. The LGBTQ SEI can be used to assess the role of the social environment in reducing health disparities for LGBTQ youth.

Risk and protective factors for transgender youths' substance use.

Research at the intersection of substance use and protective factors among transgender youth is scarce; emerging evidence suggests high risk for substance use for transgender youth. We analyzed data from 323 transgender youth aged 14-18 (M age = 16.67) to investigate the extent that risk (enacted stigma) and protective factors (support from family, school, friends) were related to substance use (i.e., cannabis and tobacco use, binge drinking). Enacted stigma was linked to higher odds of substance use behaviors, family connectedness was related to lower levels of tobacco and cannabis use, and more than one protective factor significantly lowered the probability of engaging in substance use behaviors. Support from multiple sources may be differentially protective against substance use for transgender youth.