Ann Marie Rakovic on the 2019 LGBTQ Youth and Substance Use Prevention Report for Region 1

Ann Marie Rakovic (uses pronouns she/her/hers) has over 25 years of leadership experience in community, state, and national program design, implementation, and evaluation. She has directed federal and state programs addressing the implementation of behavioral health systems change models focusing on HIV, mental health, and substance/tobacco use disorders, and has managed training and technical assistance and public health communications contracts. She has directed the Tri-state Tobacco Resource Centers of Massachusetts, Rhode Island, and New Hampshire Departments of Public Health, where she provided strategic direction for multi-faceted tobacco control initiatives. Ann Marie co-leads JSI’s Tobacco Resource Network and is currently working on COVID-19, LGBTQ and health equity related projects. Ann Marie has an MSW from the Silberman School of Social Work at Hunter College and a Postgraduate Certificate in Integrated Holistic Health Studies from Lesley University.

In late 2018, JSI conducted a needs assessment on the impact of substance use within the Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (LGBTQ) student community (ages 12-17) in five Rhode Island (RI) cities and towns (Cranston, Johnston, North Providence, Scituate and Smithfield) that make up the catchment area for the Region 1 Southern Providence County Youth Substance Use Prevention Coalition. JSI, under contract to the Tri-County Community Action Agency with funding provided by the RI Department of Behavioral Health, Developmental Disabilities, and Hospitals (BHDDH), conducted the study and reported on the results. In this interview, Ann Marie Rakovic, lead researcher, discusses some of the report findings as well as the significance of these findings, and shares some strategies for supporting students who identify as LGBTQ.

Could you start by telling us a bit about yourself and your role at JSI?

My work at JSI, a Providence-based public health and health care research and consulting firm, has been mainly concentrated in areas related to behavioral health. I’ve overseen the delivery of tobacco and nicotine cessation services to tobacco users in multiple states as well as supported infrastructure development for state and national government programs to enhance their medical, substance use and mental health services. I began my work in Rhode Island over 15 years ago through my role as the Project Director for the JSI managed Smoker’s Quitline/QuitWorks Program, which offers free support to RI residents to address nicotine addiction in all its forms. I also had the opportunity to routinely collaborate with Tobacco Free Rhode Island, the state’s network of organizations that help to reduce tobacco and nicotine usage. I currently serve as a Rhode Island Prevention Resource Center (RIPRC) trainer.

Can you provide a brief introduction to the 2019 LGBTQ Youth and Substance Use Prevention Report for five Rhode Island towns?

The idea to conduct the needs assessment of LGBTQ students was born out of a discussion between Patti Sweet, the Region 1 Youth Substance Use Prevention Coalition Coordinator, and Dr. Will Giordano, MD, who is an Assistant Professor of Family Medicine at the Warren Alpert Medical School of Brown University, and a Family Practice Physician for the Tri-County Community Action Agency Health Center. They each understood that this small and mostly hidden LGBTQ subgroup of youth has the greatest need for substance use prevention support, messaging, and resources, which to date, has largely gone unattended. Patti engaged JSI and I assembled a research team to conduct this first of its kind initiative in RI from September – October 2018. The mixed methods study design involved both qualitative and quantitative research approaches.

Who did you work with on this needs assessment and the associated report and what did the process entail? What was the incentive for this work?

The research team at JSI consisted of three staff members and myself. I served as the lead researcher and report writer. My colleagues, Hannah Chidekel and Connor Emmert, served as research assistants, were involved in the study design and implementation, and managed the in-person interview logistics with schools and key informants. Allison Hackbarth was the lead writer and report editor. Patti Sweet also served as a strategic advisor, connecting the team with various schools and key informants as well as facilitating our access to the Rhode Island Student Assessment Survey (RISS) data – which had just begun to include LGBTQ related survey questions. And of course, it is important to give credit to the students and teachers from the five focus groups that we conducted at local schools, and the ten key informants that we talked to from a wide variety of fields representing: high school education, youth substance use recovery, behavioral health, family medicine, community health, community education/support/advocacy programs, and health research.

Many research initiatives have only recently started to ask about sexual orientation and gender identity in their data collections. Thus far nationally, evidence continues to show that LGBTQ youth are twice as likely to use substances (alcohol, marijuana, tobacco, prescription drugs, opiates, and vaping products) compared to their straight and non-transgender peers. Given this research had not previously been done for RI students, we set out to examine whether or not this statistic was also true for students in Region 1 and statewide. In addition, we wanted to learn what could be done to support LGBTQ students if in fact local findings were consistent with national trends. We were driven by the knowledge that we would be providing a great service to the prevention community by increasing awareness of the need to support LGBTQ youth among the Youth Substance Use Prevention Coalitions both in Region 1 and statewide.

Rhode Island is deeply concerned about health equity and the racial, ethnic, cultural, and socio-economic health disparities, which affect social determinants of health. The LGBTQ population often faces social stigma, discrimination, harassment, violence, and other challenges not encountered by heterosexual and cisgender populations, and these issues are exacerbated in adolescence. LGBTQ youth are at greater risk of not successfully completing developmental milestones associated with substance use/misuse protective factors including developing a positive self and social identity, having peer acceptance, and developing healthy relationships with adult role models and family members. Because of these and other stressors, LGBTQ youth are at increased risk for various physical, mental and behavioral health issues including substance use and misuse. We held every hope that through our study and report – teachers, local health care providers, and community advocates as well as the state departments of health and education would have the information needed to help reduce the risk factors which increase LGBTQ youth substance use, addiction and mental health disorders. Our hope was that the results of this work would impact the right people and the right organizations that would be in the position to make a positive difference to support LGBTQ youth.

What were some of the most pertinent findings of this needs assessment/report?

One of the challenges we faced was that the RISS data available was limited given small sample sizes, so caution should be exercised in making generalizable assumptions about the LGBTQ student population. With this caveat in mind, 15% (n=643) of students who responded to the RISS survey identified as LGBQ, and 3.4% (n=144) identified as transgender. Both of these variables are thought to be underreported given not all students openly identify on surveys. The most significant data showed that in Region 1 and statewide, students who identified as LGBTQ were in fact twice as likely to use substances compared to their straight or cisgender peers (those that identify with the gender that they were assigned at birth) in the prior 30 days. We also found out that LGBTQ youth were more likely to bully and be bullied, experience violence, be the victim of mean peer behavior, and face school disciplinary action.

It was also very disappointing to learn that across all focus groups, students who identified as LGBTQ indicated that they feel misunderstood and rejected by peers, adults, and support systems – which has led to a perception that they are not seen or heard. They also reported feeling isolation due to race, geography, and sexual orientation. Additionally, these main themes emerged from the analysis of the interviews – the need for: family and home support; safe spaces and a protective community; LGBTQ role models; representation of the LGBTQ community through the use of language, messaging and communication.

Despite its limitations, the analysis provided the best possible insights into this important youth subgroup. Based on the sample size and data to which we had access, we learned that youth in Region 1 and RI who identify as LGBTQ are using substances twice as much as their peers, and to date, they have not been prioritized for prevention messaging and services.

What were some of the recommendations made?

The report recommendations were divided into 4 sections: 1. Awareness, Education and Training, 2. Welcoming and Safe Spaces, 3. Communication Channels and Strategies, and 4. Protective Policies. Some of the more encompassing recommendations included: 1. Providing training to increase understanding and awareness of the LGBTQ youth community to help change biases and discrimination faced by this community. 2. Funding and creating more safe spaces for youth to socialize and have access to identity affirming adults, caregivers and educators. 3. Developing curricula focusing on supporting youth in their first year of coming out. 4. Involving youth who identify as LGBTQ in substance use/misuse prevention message planning and campaigns by allowing them to review and provide input on content, images and display planning.

The report has now been presented to wider audiences throughout RI, and some of the recommendations are under consideration. The students and teachers with whom we met were committed to addressing substance use in their Gender Sexuality Alliances (GSA’s) and to developing a better understanding of the general experience of youth and adults throughout the country who identify as LGBTQ. I look forward to seeing these interests come to fruition.

You recently presented the findings of this report for a webinar in the RIPRC’s RIDE Distance Learning Series for educators. Can you tell us why you think it is important for educators to understand this information? What were some of the strategies that you shared for supporting students who identify as LGBTQ, particularly in the context of COVID-19?

During the session, it was clear that the teachers who attended were genuinely interested in learning more about the needs of youth who identify as LGBTQ and were committed to learning about how to create safer classroom environments for this student population. However, many of the teachers also expressed that they need help in doing so. The smaller group discussion portion of the RIDE Distance Learning session was particularly helpful in that it allowed me and co-facilitator, Arman Lorz, to address specific questions raised by teachers, which included how to support their transgender students. The teachers were completely unaware of the 2016 RIDE Guidance for Rhode Island Schools on Transgender and Gender Nonconforming Students, which is available to teachers and their schools. We were able to share this resource as well as explain that it is the school’s responsibility to implement the guidance and that teachers should be able to rely on the school’s support to provide accommodations to transgender students as needed to create a safe and nurturing environment.

COVID-19 has created physical distancing, but that does not have to mean social isolation. Nonetheless, teachers and health professionals should be aware of how a new online environment may lead to more instances of bullying or cyberbullying, and they should try to find ways to let students who identify as LGBTQ know that they are not alone. For example within a virtual setting, educators can let students know that they are welcoming and supportive by adding their pronouns to their screen names and also by making online office hours available to provide support to students. Social support groups such as GSAs could hold virtual meetings. It is also OK to encourage students who identify as LGBTQ to maintain social connections through online interactions like FaceTime and online gaming.

How do you think prevention providers can use this information to inform the work they do around substance use prevention and mental health promotion?

The report is full of excellent suggestions and recommendations including the idea to plan a statewide or regional LGBTQ Youth Substance Use Prevention Summit and enlist consultation from programs like Youth Pride, the Thundermist Trans Health Access Program, GSA student leadership, the Jim Gillen Teen Center and Tri-Town Community Action Agency to provide LGBTQ training programs for key stakeholders and to assist them in furthering the work of developing safe spaces for youth as well as customized prevention strategies. Additionally, it has been over four years since the RIDE Guidance on Transgender and Non-conforming Youth has been updated, and a lot has changed, so it would be instrumental for policy makers and educators to focus on bringing the guidance into current day reality. Overall, the findings of this report should help prevention providers to understand that RI-based prevention efforts should aim to focus on youth who identify as LGBTQ both in and out of school, and especially those who are experiencing homelessness. The work to support and protect LGBTQ youth is essential, and I do hope that the report will be used as a resource and reference to help guide those efforts.

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