Mental Health of Adolescents in Juvenile Correctional Facilities Across Axes of Sexual Orientation,Gender Identity,Race,and Ethnicity: Minnesota Student Survey,2019

Abstract

Background:

Sexual and gender minority (SGM) and racial and ethnical minority (REM) adolescents are overrepresented in carceral settings, yet little research examines their mental health at intersections of SGM and REM statuses.

Methods:

Population-based, cross-sectional data were drawn from the 2019 Minnesota Student Survey (n = 221 incarcerated adolescents; M_age = 15.5 years, range = 11–21 years). Using descriptive statistics and multivariable logistic regression, we examined differences in mental health indicators across four groups with intersecting SGM and REM statuses (−SGM/−REM, −SGM/+REM, +SGM/−REM, +SGM/+REM).

Results:

+SGM/−REM adolescents had the highest prevalence of past-year suicidal ideation (44.4%), suicide attempts (50.0%), self-harm (61.1%), and recent depressive symptoms (33.3%). After adjusting for covariates, +SGM/−REM and +SGM/+REM adolescents had significantly higher odds of past-year self-harm and suicide attempts than −SGM/+REM adolescents.

Discussion:

Findings point to high risk for self-harm in all four groups and heightened risks of suicide attempts and self-harm among incarcerated SGM adolescents, regardless of REM status, emphasizing the need for focused public mental health responses.

Conclusions:

SGM status is a key risk marker for poor mental health among incarcerated adolescents. This underscores the need for interventions—both before and during incarceration—that are culturally responsive and tailored to the unique, intersectional challenges SGM adolescents face across REM statuses.

Keywords

incarceration mental health sexual and gender minorities ethnic and racial minorities health services intersectional framework correctional facilities suicide prevention adolescent

Background

The United States incarcerates disproportionately more adolescents than any other developed country within a carceral system often defined by an emphasis on punishment and crime control versus social welfare and rehabilitation.¹ In 2021, nearly 25,000 adolescents under age 18 were incarcerated in juvenile jails and prisons in the United States.² Approximately two-thirds of incarcerated adolescents have at least one diagnosable mental health disorder, compared with an estimated 9–22% of the adolescent general population.^3,4

Rates of adolescent incarceration are not evenly distributed across racial and ethnic minority (REM) or sexual and gender minority (SGM) statuses. As a result of historical and contemporary structural racism and heteronormativity in the United States,⁵ REM adolescents, particularly Black adolescents, are approximately 4 times more likely to be incarcerated than their non-Hispanic White peers, and Latino youth are 1.6 times more likely.⁶ Related to SGM status, in a survey of 2,100 youths in six juvenile justice jurisdictions across the country, SGM youth were twice as likely as their cisgender, heterosexual peers to be detained for truancy, warrants, probation violations, running away or prostitution.⁷

In the field of public health, intersectionality refers to the ways that multiple disempowered or privileged identities interact to uniquely compound or create social inequities and health disparities.^8,9 This concept was first published by legal scholar Kimberlé Crenshaw and developed within Black feminist theory to better explicate the situation of Black women in the United States.¹⁰ Yet most studies have historically used unitary approaches investigating how single minoritized identities in isolation (e.g., SGM, REM) may be associated with health outcomes including mental health in carceral contexts. For example, regarding SGM status, research shows that SGM young people who were arrested or detained in the past year experienced more than six times greater odds of attempting suicide in the past year compared with SGM peers who had never been arrested or detained.¹¹ Regarding REM status, research shows that Black and Latino youth who are justice-involved show a higher prevalence of anxiety and substance use disorders as compared with non-Hispanic, white youth.¹² While research shows that youth who hold more than one disadvantaged status may experience “double discrimination” and associated poorer health than their singly disadvantaged counterparts,¹³ few studies have specifically assessed how REM and SGM statuses and mental health may intersect within the context of the carceral system. This is a notable gap given that prior research shows that Black and Latinx adolescents make up the vast majority (85%) of LGBTQ incarcerated adolescents.¹⁴ SGM and REM adolescents may experience compounding vulnerabilities linked with both higher odds of arrest and incarceration as well as poorer health outcomes.

In sum, previous research shows that SGM and REM adolescents, separately, are overrepresented in carceral settings, and for each group, carceral contact is associated with poorer mental health. Yet intersectional approaches have rarely been applied in previous research. To begin filling this gap, the current study drew upon a population-based sample of adolescents held in juvenile detention in Minnesota to explore associations among intersecting minoritized statuses (SGM, REM) and mental health indicators within a context characterized by compounded systems of oppression including incarceration, gender- and hetero-normativity, and racism.

Methods

Data and participants

This study used data from the 2019 Minnesota Student Survey (MSS), an anonymized population-based health survey of adolescents obtained through a data request form and user agreement submitted to the Minnesota Department of Education.¹⁵ The MSS is administered triennially to 5th-, 8th-, 9th-, and 11th-grade students in public schools, charter schools, and tribal schools in Minnesota as well as adolescents detained in Minnesota’s juvenile correctional centers. The analyses in this study were approved by the Vanderbilt University Institutional Review Board (IRB #220457). The current analytic sample consisted of 221 adolescents in juvenile correctional facilities (M_age = 15.5 years). Based on self-reported sexual orientation, gender identity, race, and ethnicity, we created four mutually exclusive groups across intersections of SGM (+SGM = sexual and gender minority, −SGM = heterosexual, cisgender) and REM (+REM = racial and ethnic minority, −REM = non-Hispanic, White) identities. The four resulting respondent groups were: (1) −SGM/−REM (n = 50), (2) +SGM/−REM (n = 18), (3) −SGM/+REM (n = 107), (4) +SGM/+REM (n = 46). Considering the small sample sizes among respondent groups, these analyses are considered exploratory.

Measures

Mental health indicators and receipt of behavioral health care: We studied the endorsement of four mental health indicators within the past year: suicidal ideation, suicide attempt, self-harm, and respondent-reported depressive symptoms within the past 2 weeks. A question assessing receipt of behavioral health care was included as a covariate. Item wording for all measures is available in the Supplementary Data (Supplementary Table S1).

Analyses: Descriptive statistics were calculated to compare study variables among the four identity groups. Multivariable logistic regression models were used to assess associations between SGM and REM statuses and each binary mental health indicator after controlling for age (in years), sex (0 = male, 1 = female), and receipt of behavioral health care in the past year (0 = did not receive, 1 = received). The −SGM/+REM group, the largest respondent group, was the referent. Analyses with −SGM/−REM group as referent are included in Supplementary Table S2. There was very little missing data on variables of interest (<5%), which was handled through listwise deletion.¹⁶ Analyses were conducted using R version 4.3.0.¹⁷

Results

Demographic snapshot

Table 1 presents all demographic characteristics. A higher proportion of SGM adolescents across REM statuses were assigned “female” versus “male” sex at birth. Approximately 70% of the sample were REM, with about 15% each reporting a Black/African American or American Indian/Alaska Native identity. Past-year receipt of behavioral health care services ranged from 42% (−SGM/+REM incarcerated adolescents) to 65% (+SGM/+REM incarcerated adolescents).

Table 1.

Sociodemographic Characteristics by SGM and REM Statuses, N = 221

	Total sample (N = 221)	−SGM/−REM adolescents (N = 50)	+SGM/−REM adolescents (N = 18)	−SGM/+REM adolescents (N = 107)	+SGM/+REM adolescents (N = 46)	p value
Characteristic	n (%)	n (%)	n (%)	n (%)	n (%)	p value
Age, mean (SD)^a	15.5 (1.6)	15.2 (1.6)	14.8 (1.7)	15.9 (1.5)	15.1 (1.7)	0.004
Sex assigned at birth^b
Male	151 (68.3)	42 (84.0)	7 (38.9)	86 (80.4)	16 (34.8)	<0.001
Female	70 (31.7)	8 (16.0)	11 (61.1)	21 (19.6)	30 (65.2)
Race/ethnicity
American Indian or Alaska Native	33 (14.9)	0 (0.0)	0 (0.0)	20 (18.7)	13 (28.3)	<0.001
Asian or Asian American; Native Hawaiian or Pacific Islander	<5	0 (0.0)	0 (0.0)	<5	<5
Black or African American	34 (15.4)	0 (0.0)	0 (0.0)	26 (24.3)	8 (17.4)
Hispanic/Latinx	14 (6.3)	0 (0.0)	0 (0.0)	10 (9.3)	4 (8.7)
>1 race	70 (31.7)	0 (0.0)	0 (0.0)	50 (46.7)	20 (43.5)
Non-Hispanic white	68 (30.8)	50 (100.0)	18 (100.0)	0 (0.0)	0 (0.0)
Sexual orientation
Heterosexual/cisgender	158 (71.5)	50 (100.0)	0 (0.0)	107 (100.0)	1 (2.2)
Bisexual	28 (12.7)	0 (0.0)	8 (44.4)	0 (0.0)	20 (43.5)
Gay or lesbian	6 (2.7)	0 (0.0)	0 (0.0)	0 (0.0)	6 (13.0)
Pansexual	8 (3.6)	0 (0.0)	2 (11.1)	0 (0.0)	6 (13.0)
Queer	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Questioning/not sure	5 (2.3)	0 (0.0)	4 (22.2)	0 (0.0)	1 (2.2)
I don’t describe myself in any of these ways	16 (7.2)	0 (0.0)	4 (22.2)	0 (0.0)	12 (26.1)
Gender identity^c
Identifies as transgender/genderqueer/genderfluid; Not sure about gender identity	14 (6.3)	0 (0.0)	4 (22.2)	0 (0.0)	10 (21.7)
No/do not understand question/No answer	207 (93.7)	50 (100.0)	14 (77.8)	107 (100.0)	36 (78.3)
Suicidal ideation (past year)^d
Yes	64 (30.0)	12 (24.0)	8 (44.4)	25 (23.4)	19 (41.3)	0.046
No	155 (70.1)	38 (76.0)	10 (55.6)	81 (75.7)	26 (56.5)
No answer	<5	<5	<5	<5	<5
Suicide attempt (past year)^e
Yes	52 (23.5)	10 (20.0)	9 (50.0)	18 (16.8)	15 (32.6)	0.021
No	167 (75.6)	40 (80.0)	9 (50.0)	88 (82.2)	30 (65.2)
No answer	<5	<5	<5	<5	<5
Self-harm (past year)^f
Yes	88 (39.8)	19 (38.0)	11 (61.1)	32 (29.9)	26 (56.5)	0.111
No	128 (57.9)	31 (62.0)	7 (38.9)	71 (66.4)	19 (41.3)
No answer	5 (2.3)	0 (0.0	0 (0.0)	4 (3.7)	1 (2.2)
Depressive symptoms (past 2 weeks)^g
PHQ-2 sum score > 3	44 (19.9)	8 (16.0)	6 (33.3)	19 (17.8)	11 (23.9)	0.385
PHQ-2 sum score ≤ 3	171 (77.4)	41 (82.0)	12 (66.7)	84 (78.5)	34 (73.9)
No answer	6 (2.7)	1 (2.0)	0 (0.0)	4 (3.7)	1 (2.2)
Receipt of behavioral health care^h
Yes (During the last year ONLY; During the last year & More than a year ago)	108 (48.9)	22 (44.0)	11 (61.1)	45 (42.0)	30 (65.2)	0.227
No (More than a year ago ONLY; Not at all)	109 (49.3)	26 (52.0)	7 (38.9)	60 (56.1)	16 (34.8)
No answer	<5	<5	<5	<5	<5

Age: n = 220.

Sex: responses to the question, “What is your biological sex?”, where responses could either be “male” or “female.”

Gender identity: n = 207.

Suicidal ideation: n = 219.

Suicide attempt: n = 219.

Self harm: n = 216.

Depressive symptoms: n = 215.

Receipt of behavioral health care: n = 217.

+REM, racial and ethnic minority; −REM, non-racial and ethnic minority (non-Hispanic, White); +SGM, sexual and gender minority; −SGM, non-sexual and gender minority (heterosexual, cisgender); <5, cells with fewer than 5 respondents in the total sample were suppressed to protect participant anonymity.

Prevalence of negative mental health indicators

All four negative mental health indicators were highly prevalent across all four identity groups ranging from 23.4% (−SGM/+REM) to 44.4% (+SGM/−REM) for suicidal ideation, 16.8% (−SGM/+REM) to 50.0% (+SGM/−REM) for suicide attempt, 29.9% (−SGM/+REM) to 61.1% (+SGM/−REM) for self-harm, and 16.0% (−SGM/−REM) to 33.3% (+SGM/−REM) for depressive symptoms (Table 1).

Results from multivariable logistic regressions

In unadjusted multivariable models, +SGM/−REM and +SGM/+REM incarcerated adolescents generally demonstrated elevated odds of suicidal ideation, suicide attempt, and self-harm when compared with −SGM/+REM incarcerated adolescents. In adjusted multivariable models, compared with −SGM/+REM incarcerated adolescents, +SGM/−REM incarcerated adolescents demonstrated statistically significantly higher odds of past-year suicide attempt (adjusted odds ratio [aOR] = 3.35, 95% confidence interval [95% CI] = 1.01–11.20). +SGM/−REM incarcerated adolescents also reported higher odds of past-year self-harm (aOR = 2.58, 95% CI = 0.85–8.25), as did +SGM/+REM incarcerated adolescents (aOR = 2.05, 95% CI = 0.90–4.69) (Table 2).

Table 2.

Odds of Poor Mental Health Indicators across 4 SGM and REM Status Groups in Juvenile Correctional Facilities of Minnesota

	Suicidal ideation (n = 218)^a		Suicide attempt (n = 218)^b		Self-Harm (n = 215)^c		Depressive symptoms (n = 214)^d
	OR (95% CI)^e	aOR (95% CI)^f	OR (95% CI)^e	aOR (95% CI)^f	OR (95% CI)^e	aOR (95% CI)^f	OR (95% CI)^e	aOR (95% CI)^f
−SGM/+REM Adolescents	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
−SGM/-REM Adolescents	1.02 (0.45–2.22)	0.92 (0.36–2.21)	1.22 (0.50–2.84)	1.09 (0.41–2.75)	1.36 (0.67–2.75)	1.34 (0.62–2.89)	0.98 (0.85–1.12)	1.01 (0.88–1.17)
+SGM/−REM Adolescents	2.59 (0.90–7.30)	1.59 (0.48–5.10)	4.89 (1.69–14.28)**	3.35 (1.01–11.20)*	3.49 (1.26–10.27)*	2.58 (0.85–8.25)	1.16 (0.95–1.42)	1.08 (0.88–1.33)
+SGM/+REM Adolescents	2.37 (1.12–4.99)*	1.20 (0.49–2.90)	2.44 (1.09–5.46)*	1.29 (0.50–3.29)	3.04 (1.48–6.34)**	2.05 (0.90–4.69)	1.06 (0.92–1.22)	0.97 (0.83–1.13)

Suicidal ideation (past year) assessed by affirmative response to “Have you seriously considered attempting suicide during the last year?”

Suicide attempt (past year) assessed by affirmative response to “Have you ever actually attempted suicide during the last year?”

Self-harm (past year) assessed by reporting one or more times to “During the last 12 months, how many times did you do something to purposely hurt or injure yourself without wanting to die, such as cutting, burning, or bruising yourself on purpose?”

Depressive symptoms (past 2 weeks) assessed with sum score on the Patient Health Questionnaire (PHQ)−2 (>3).

Unadjusted models.

Models adjusted for the following covariates: age [continuous], sex assigned at birth, and receipt of behavioral health care in the past year.

*p < 0.05, **p < 0.01; ***p < 0.001.

OR, odds ratio; aOR, adjusted odds ratio; Ref, reference group; +REM, racial and ethnic minority; −REM, non-racial and ethnic minority; +SGM, sexual and gender minority; −SGM, non-sexual and gender minority.

Discussion

In this population-based study of adolescents in juvenile correctional facilities in Minnesota, we sought to examine differences in four mental health indicators (suicidal ideation, suicide attempt, self-harm, depressive symptoms) by SGM and REM statuses. Compared with −SGM/+REM adolescents, +SGM/−REM, and +SGM/+REM adolescents demonstrated elevated odds of suicide attempt and self-harm after adjusting for sociodemographic covariates and receipt of behavioral health care. These findings underscore the heightened mental health risks faced by incarcerated SGM adolescents, regardless of REM status, emphasizing the need for targeted research and interventions to support this vulnerable population.

SGM adolescents may be particularly exposed to minority stress experiences—a term describing forms of elevated stress experienced by stigmatized groups—that can lead to poorer mental and behavioral health and precipitate criminal–legal contact.¹⁸ In a cross-sectional analysis of SGM youth with and without arrest history, SGM youth with arrest history disproportionately reported experiences of bullying and parental rejection, reflecting greater exposure to minority stress.¹⁸ Criminal–legal contact may further exacerbate behavioral and mental health problems via SGM-specific incarceration-related trauma (e.g., showering, housing) as well as reentry challenges (e.g., family rejection, non-SGM reentry services). It is important to note that while the current study highlighted increased odds of experiencing past-year suicide attempt or self-harm among SGM incarcerated adolescents (regardless of REM status), depressive symptoms and suicidal ideation were comparable across groups. This pattern suggests that disparities may be more pronounced in self-harming behaviors than in ideation. In carceral settings, this finding raises critical concern about the potential lack of observable warning signs, such as reported low mood, prior to self-injurious behaviors among high-risk SGM adolescents. Given the limited mental health resources in juvenile correctional facilities and reentry programs particularly for SGM adolescents, these results underscore the need for safe and affirming environments (e.g., gender neutral bathrooms, inclusive pronoun options), staff training on the intersectional quality of stressors faced by SGM adolescents, and a concrete process for reporting experiences of discrimination (e.g., misgendering, victimization).¹⁹

These findings may have important implications for interventions targeting adolescent mental health before and during juvenile detention. At the policy level, state-wide and system-wide reforms can enhance workforce capacity through targeted training, trauma-informed screening protocols, and secondary traumatic stress support for staff. Such efforts are critical for addressing the compounded and intersectional stressors experienced by SGM and REM adolescents in the juvenile justice system.^20–22 Additionally, these findings highlight the need for more tailored prevention and intervention strategies for SGM adolescents at risk of self-harm and suicide. Researchers have called for expanding the implementation of evidence-based approaches before and after justice system involvement, such as early identification of risk factors for victimization related to SGM status, confidential spaces for care, and collaborations with pediatricians, schools, and family members.^23,24 Safety planning is one evidence-based intervention that shows particular promise for reducing self-harm within criminal-legal contexts.²⁵ In a recent randomized clinical trial, adults in U.S. jails who received a safety planning intervention had 55% fewer suicide attempts in the year following release compared with those in the control condition, suggesting potential relevance for adaptation to adolescent populations.

Several limitations should be considered when interpreting results. First, small sample sizes, cross-sectional nature, and the geographic focus on Minnesota may limit generalizability and causal inference. This limitation highlights the need for the collection of sexual orientation and gender identity data in carceral settings to be able to explore these issues in well-powered analyses. In addition, the MSS does not assess information about incarceration, including reason for incarceration, duration of stay, security level, disciplinary action, and other information that has important implications for the health of incarcerated adolescents.²⁶ Future prospective research is needed to replicate these findings in a longitudinal dataset and study the influence of carceral contact on mental health after release.

Conclusions

In a sample of incarcerated adolescents, this study identifies mental health disparities across intersectional identities shaped by SGM and REM statuses. Findings point to high risk for self-harm in all four groups (−SGM/−REM, −SGM/+REM, +SGM/−REM, +SGM/+REM), and particular concern among SGM-identifying adolescents, calling for focused public mental health responses. SGM adolescents, regardless of REM status, demonstrated elevated odds of suicide attempt and self-harm after adjusting for sociodemographic covariates and receipt of behavioral health care. In summary, SGM status is a key risk marker for poor mental health among incarcerated adolescents, underscoring the need for interventions—both before and during incarceration—that are culturally responsive and tailored to the unique challenges SGM adolescents face across REM statuses.

Authors’ Contributions

C.B.: Conceptualization, visualization, formal analysis, writing—original draft, writing—review and editing. J.A.W.: Conceptualization, writing—review and editing. K.A.C.: Conceptualization, resources, supervision, funding acquisition, writing—review and editing.

Footnotes

Acknowledgments

The authors thank members of the LGBTQ+ Policy Lab at Vanderbilt University for support and feedback on this work. The authors also thank the Vanderbilt University Medicine, Health, and Society Honors Program for their undergraduate enrichment opportunities. The authors gratefully acknowledge the students in public schools and juvenile detention facilities across Minnesota who participated in the 2019 Minnesota Student Survey (MSS). The authors also appreciate the efforts of local public-school districts and correctional facilities in facilitating data collection. The MSS dataset is managed by the Minnesota Student Survey Interagency Team, whose work ensures the availability of this valuable data for research and policy development. The authors would also like to thank the participants of the 2024 Southeastern Medical Scientist Symposium held in Nashville, TN, on September 22, 2024, for their valuable feedback on an earlier version of this work.

Author Disclosure Statement

The authors have no competing interests to declare.

Funding Information

K.C.’s time on this project was supported by the National Institute of Mental Health of the National Institutes of Health under award number K01 MH125073. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. C.B, was supported through the Association of Clinical Research Professionals (ACRP) Access for Students to Clinical Research Training (ASCRT) Scholarship.

Supplemental Material

Abbreviations

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