摘要：This article explicates a vision for social change throughout multiple levels of society necessary to eliminate sexual orientation health disparities in youths. We utilized the framework of Bronfenbrenner’s ecological theory of development, a multisystemic model of development that considers direct and indirect influences of multiple levels of the environment. Within this multisystem model we discuss societal and political influences, educational systems, neighborhoods and communities, romantic relationships, families, and individuals. We stress that continued change toward equity in the treatment of lesbian, gay, and bisexual youths across these levels will break down the barriers for these youths to achieve healthy development on par with their heterosexual peers. The articles that we have assembled in this special issue join a host of others documenting that lesbian, gay, and bisexual (LGB) adolescents experience health inequities that are driven by social determinants at multiple levels of influence. 1–4 Rather than taking this further evidence as cause for increased pessimism, we share our vision for social change that we believe would create an America where LGB adolescents are given the same opportunity for healthy development as their heterosexual peers. We are not naive in believing that such change will come effortlessly or instantly, but we do believe in the value of sharing these aspirations as a way of illustrating the profound benefits they would engender. We begin by acknowledging that although transgender youths are not enumerated in the articles in this issue, health inequities have been described in a small number of studies with these youths. 5,6 As Youth Risk Behavior Surveillance (YRBS) data do not assess gender identity, the focus of our discussion here is on LGB youths. We believe many of the social changes we articulate in this commentary would be of tremendous value to transgender youths, but at the same time recognize that they have additional needs that may not be sufficiently met by the changes we advocate here for their cisgendered LGB peers (e.g., medical care related to gender transitions). We also point out that sexual orientation is a multidimensional construct including sexual and romantic orientations, identity labels, and the gender of sexual partners 7 ; our use of “LGB” is meant to be inclusive of the both- and same-sex oriented parts of these distributions. Among youths, these dimensions are correlated but not perfectly overlapping, 8 and only recently have researchers begun to investigate how these multiple dimensions may be differentially related to health outcomes for LGB youths—a focus area of several of the articles in this special issue. As an organizational framework for considering the multilevel determinants of health disparities between LGB and heterosexual youths, we utilized Bronfenbrenner’s 9 ecological theory of development. This theory describes a multisystemic model of development that nests youths within increasingly broad systems that act either directly or indirectly, by shaping the environment. This model has been applied widely in prevention research with youths 10 and is consistent with the socioecological perspective espoused in the recent report of the Institute of Medicine (IOM) on the health of LGB and transgender (LGBT) people. 11 At the broadest level, Bronfenbrenner describes the macrosystem, or the overarching structural or societal norms. These norms are described as “blueprints” that influence multiple aspects of the individual’s life and may be expressed at the ideological level or via written laws. The mesosystem includes the interrelations between the major settings in which the youths find themselves, and subsequently the impact of these interrelations upon the youths. Major settings in the mesosystem include local economy and work environment, government, religion, neighborhood, and mass media. The microsystem is composed of the relationships or contexts with which the child has direct contact, including romantic relationships, friendships and peer groups, and family relationships. Bronfenbrenner describes the relationships at this level as bidirectional (i.e., the child simultaneously has an influence on and is influenced by the individuals in his or her microsystem). Finally, the chronosystem reflects the effects of the passage of time, both for the individual and society at large. As it reflects the cumulative experiences a person has over the course of his or her lifetime, it is consistent with the life-course perspective articulated as 1 of the 4 guiding frameworks of the IOM report. 11 The chronosystem also reflects sociohistorical changes, such as the passage of laws regarding same-sex marriage. Envisioning a future with thriving and healthy LGB youths will require change at all of these levels. Because of the dynamic interplay among these multiple levels, it is likely that changes at one level may alter determinants at other levels. For instance, institutional (e.g., discriminatory policies) and interpersonal (e.g., victimization) stressors engender maladaptive psychological responses (e.g., rumination, hypervigilance) that in turn predict negative mental health outcomes among LGB individuals. 12,13 Thus, preventing social forms of stress would eliminate the need to change individual coping behaviors. However, it is also possible that change in some contexts may be profound, even if the improvements do not resonate to other levels. For example, having supportive and accepting parents promotes resilient development across a variety of adverse contexts. At the same time, our research 14,15 and experience show that family support is not enough to overcome the deleterious effects of LGB-focused bullying and victimization. We cannot just seek to buffer LGB youths against victimization because resilience in the face of adversity is not the same thing as health equality. Teaching LGB youths how to cope and adapt to adversity should not be the goal of fair-minded people who want the best for all children. Rather we need to directly address determinants at multiple levels if we want true health equity. To explicate this vision, we begin by articulating change at the broadest macrosystem level and then honing down to individual factors.
