Interpretations and Implications

The two-year Project SPARK findings show that LGBTQ+ young people continued to experience substantial and persistent mental health challenges across the study period. Anxiety and depression increased from baseline to follow-up and remained elevated, while suicidal ideation stayed consistently high, indicating that overall mental health concerns did not improve over the two-year study period. At the same time, self-harm and suicide attempts decreased from baseline. This contrast may be attributable to the fact that protective factors helped some participants manage periods of acute risk more safely, even as chronic distress remained high. Indeed, the study’s longitudinal models show that family support, affirming home environments, and gender euphoria were each associated with lower likelihood of self-harm over time. Several protective factors — including perceived helpfulness of mental health care, gender euphoria, and helpline use during suicidal crises — also strengthened during the first year of the study, the same period in which self-harm and suicide attempts declined. This interpretation is consistent with research showing that social support, family support, and affirming environments can buffer suicide-related risk among LGBTQ+ youth, even in the context of ongoing mental health challenges (DelFerro et al., 2024; Russell & Fish, 2016; Ryan et al., 2010). Because the study experienced attrition over time, changes in self-harm and suicide attempts may also partly reflect changes in the composition of the analytic sample.

The divergence between sustained suicidal ideation and declining self-harm and attempts is itself noteworthy. Research within the “ideation-to-action” framework indicates that the factors driving suicidal ideation often differ from those governing the progression from ideation to suicidal behavior (Klonsky & May, 2015; Klonsky et al., 2016). It suggests that the pathway from suicidal thoughts to suicidal behavior may be where protective factors and supports exerted the most influence during the study period, and it reinforces that ideation-focused measures alone do not capture the full picture of risk.

Stigma-Related Stressors

One likely reason that anxiety, depression, and suicidal ideation remained high is that many participants continued to face stigma-related stressors throughout the study. More than half of participants reported discrimination based on sexual orientation or gender identity at every time point, showing how persistent these experiences were across the two years. Sexual orientation-based discrimination changed significantly over time, while physical threats based on sexual orientation remained stable. Among TGNB participants, gender identity-based discrimination increased significantly, while physical threats based on gender identity did not change significantly. Overall, the clearest worsening was in gender identity-based discrimination among TGNB young people. In addition, threats of and exposure to conversion therapy continued to accumulate over the study period, indicating that some participants continued to face direct attempts to change, suppress, or invalidate their sexual orientation or gender identity. This is especially concerning given evidence that conversion therapy and related sexual orientation or gender identity change efforts are associated with serious mental health harms, including suicidal thoughts and behaviors among LGBTQ+ young people (Forsythe et al., 2022; Green et al., 2020). These findings suggest that stigma, exclusion, threats to safety, and identity-based invalidation remained common and consequential experiences for many LGBTQ+ young people, particularly TGNB youth.

Economic Insecurity

Economic insecurity remained a concern across the study period. Past-year houselessness increased significantly from the one-year to the two-year follow-up, while unmet basic needs remained high at both follow-up points. This increase may reflect, in part, participants aging into more independent living situations, and losing access to family housing — a transition that carries particular risk for LGBTQ+ young people, who experience disproportionate rates of family rejection and housing instability (DeChants et al., 2021). These findings underscore that mental health is closely tied to the conditions of young people’s daily lives, including whether they have stable housing, enough food, and access to basic resources. Improving mental health for LGBTQ+ young people therefore requires attention not only to clinical care, but also to the social and economic conditions that shape their safety and well-being.

Gender Affirmation: Progress and Barriers

The findings related to transgender health care and gender affirmation show both progress and ongoing barriers. Among TGNB participants, desire for hormones increased over the study period, and access to desired hormones also increased substantially. This increase should be interpreted in the context of participants aging over the course of the study. As participants moved from adolescence into young adulthood, some may have gained more control over health care decisions, had fewer consent-related barriers, or become better positioned to find and navigate transgender health care. The wide gap in access at the two-year follow-up between participants ages 18 and older (73%) and those under 18 (33%) is consistent with this interpretation, and also reflects the restrictive legal landscape governing transgender health care for minors in many states. Prior research has similarly identified caregiver involvement, provider availability, long wait times, and lack of affirming or knowledgeable care as key barriers to transgender health care for TGNB youth (Gridley et al., 2016; Pullen Sansfaçon et al., 2019; Sequeira et al., 2023). Reports of gender-related surgery also occurred primarily among older participants: nearly all participants who reported surgery in the past year were ages 18 or older at the time of the survey, and among those who reported surgery during the second year of the study, the median age was 23. This pattern is consistent with prior evidence that gender-related surgeries are uncommon in adolescence and, when they do occur among TGNB young people, they more often take place in young adulthood (Fazal et al., 2023).

Beyond medical care, access to tools related to gender expression or transition also increased, particularly among younger participants, suggesting some gains in social and practical forms of gender affirmation. At the same time, many TGNB participants continued to report barriers to gender affirmation, including bathroom access barriers and difficulty changing identification documents. This distinction is critical: some forms of gender affirmation became more accessible as participants gained autonomy with age, including hormones and tools related to gender expression. Other forms of gender affirmation that were tied to laws and policies, such as updating identification documents and accessing bathrooms that aligned with their genders, did not show progress over time.

Affirming Environments and Relationships

Affirming environments and supportive relationships showed encouraging but uneven patterns. LGBTQ+-affirming home environments increased by the two-year follow-up, suggesting that some participants may have experienced greater acceptance, support, or safety in their immediate living environments over time.  This increase may also reflect participants gaining greater control over their living situations as they aged into adulthood, including moving into homes of their own choosing.

Gender euphoria also increased steadily among both the full sample and TGNB participants. The increase in gender euphoria is especially important because it highlights positive identity-related experiences — not only distress, dysphoria, or risk — as a meaningful dimension of LGBTQ+ youth well-being (Bauer et al., 2021). The concurrent rise in gender euphoria alongside worsening gender identity-based discrimination is striking: even in a more hostile external climate, TGNB participants reported growing comfort and affirmation in their gender, which may reflect gains in access to hormones, gender-expression tools, and affirming homes.

In contrast, affirming school environments increased at the one-year follow-up before decreasing by the two-year follow-up. This fluctuation may reflect changes in the composition of the in-school subsample as participants aged — by the two-year follow-up the median age was 21, so fewer participants remained in school and those who did were disproportionately in college and university settings — as well as school transitions, differences in school climate across settings, or changes in the broader social and policy environment affecting LGBTQ+ students.

There were mixed findings related to participants’ online behaviors and experiences. LGBTQ-related cyberbullying was low at both the one-year and two-year follow-ups, and LGBTQ+ young people reported slightly fewer cyberbullying experiences at the two-year follow-up. At the same time, at the two-year follow-up, participants reported lower comfort using social media for identity exploration and disclosure, and lower use of social media to seek LGBTQ+-related support and connection. However, these findings demonstrated that many LGBTQ+ young people consistently used social media – through all stages of the study – for information, support, and connection. Ultimately, these results suggest that online spaces play an important role in helping young people find understanding and belonging, while at the same time,  respondents have become somewhat less comfortable using social media as a source of identity-related support during the second year.

Mental Health Care: Access, Quality, and Help-Seeking

Mental health care findings point to both strengths and gaps in current systems of support. By the two-year follow-up, most participants who wanted mental health care were receiving it, and among participants who received care, perceived helpfulness increased substantially over the study period. These improvements may partly reflect participants aging over the course of the study, gaining more autonomy to seek care, becoming better able to identify care that meets their needs, or feeling more comfortable participating in services over time. They may also reflect continued or increasing need for mental health support, as anxiety and depression remained high across the study period.  However, barriers to care persisted, including cost, parent or caregiver permission, fear of discussing mental health, fear of not being taken seriously, and concerns that providers would not understand their LGBTQ+ identities. According to these findings, access to care alone is not sufficient; care must also be affordable, affirming, developmentally appropriate, and responsive to LGBTQ+ young people’s intersecting identities and needs.

Help-seeking patterns during suicidal crises further show the central role of informal and peer-based support. Friends were the most common source of support across the study period, followed by mental health professionals and intimate partners. Helpline use increased significantly, while help-seeking from parents, caregivers, doctors, and religious leaders remained less common. The consistently low rates of help-seeking from doctors (4–6%) represent a missed opportunity, given that primary care is often young people’s most regular point of contact with the health system. Moreover, nearly one-third of participants who experienced suicidal thoughts reported seeking help from no one, and this remained consistent across the study period. This is deeply concerning because it suggests that many LGBTQ+ young people may be navigating moments of crisis without any safety net, including support from family, friends, professionals, or crisis services. Improving crisis response therefore requires more than making services accessible; young people need to feel that support is safe, trustworthy, and accessible before a crisis escalates.

Temporal Relationships and Causal Insights

Across the two-year study, LGBTQ+ young people’s mental health was closely tied to the social, material, and policy environments in which young people were living. Across models, victimization, discrimination, economic insecurity, and barriers to gender affirmation consistently predicted poorer mental health over time, while affirming relationships, supportive home environments, gender euphoria, and access to gender-affirming resources were associated with better outcomes. This pattern is consistent with minority stress theory and prior research documenting the protective role of affirming environments and relationships (Meyer, 2003; Russell & Fish, 2016; Ryan et al., 2010). Statistical models examining suicide attempts did not reliably converge because attempts were relatively rare events, so suicide attempts are described descriptively earlier in the report rather than interpreted as modeled outcomes.

Victimization and discrimination stood out as some of the strongest and most consistent predictors of poor mental health across the models, suggesting that stigma-related harm may have lasting implications for mental health trajectories, not only immediate effects on safety and well-being. Economic insecurity also emerged as a consistent predictor: houselessness and unmet basic needs were predictive of anxiety, depression, self-harm, and suicidal ideation. Together, these findings suggest that anxiety, depression, self-harm, and suicidal ideation were closely tied to ongoing social and material stressors, rather than simply reflecting individual vulnerability.

Recent mental health-related hospitalization was also associated with higher likelihood of anxiety, self-harm, and suicidal ideation over time, with a particularly strong association for self-harm. This should not be taken to mean that hospitalization itself causes poorer mental health. More likely, hospitalization is a marker of acute clinical severity, identifying young people who were already at higher risk.  It does, however, underscore the importance of robust post-discharge support and continuity of care for LGBTQ+ young people following psychiatric hospitalization, a period known to carry heightened risk.

For TGNB participants, barriers to gender affirmation were closely linked with mental health risk. Being prevented from using a bathroom that corresponded with one’s gender identity was predictive of all four adverse outcomes, while being able to change identification documents and access desired hormones were predictive of better mental health outcomes. Taken together, these findings reinforce that gender affirmation across social, legal, and medical settings is closely tied to better mental health among TGNB young people.

Conversion therapy threats or exposure remained among the most concerning risk factors, particularly for suicidal ideation. Participants who had been threatened with or subjected to conversion therapy were more likely to experience anxiety, depression, self-harm, and suicidal ideation over time. Seeing these associations repeatedly across multiple waves of data collection strengthens concern that conversion therapy may contribute to later mental health harms, rather than simply occurring alongside existing distress. These findings add to a growing body of evidence documenting the harms associated with conversion therapy (Forsythe et al., 2022).

Just as importantly, the models identified several factors associated with better mental health. Affirming home environments, family support, and gender euphoria were each predictive of lower likelihood of anxiety, depression, self-harm, and suicidal ideation. These findings suggest that support is more than simply the absence of rejection; it appears to actively promote better mental health. Gender euphoria, in particular, highlights the importance of promoting positive identity-related experiences, not only reducing distress or risk (Bauer et al., 2021). Gender euphoria also showed among the strongest protective associations of any factor in the models, suggesting that interventions and environments that actively cultivate gender positivity — not only those that reduce harm — may be especially promising.

Overall, these findings reinforce that LGBTQ+ young people’s mental health does not develop in isolation. Experiences of victimization, discrimination, conversion therapy, economic insecurity, and barriers to gender affirmation were linked to poorer mental health over time, while affirming family, home, and gender-related supports were consistently associated with better outcomes. Although these observational data cannot establish causality, the consistency of these patterns across two years provides strong evidence that social environments matter for LGBTQ+ young people’s mental health.

Broader Context and Policy Implications

This report was conducted during a period when LGBTQ+ young people were navigating persistent stigma, economic insecurity, and uneven access to affirming care and support. Across the U.S., recent policy debates and state-level legislation have focused heavily on transgender youth, including restrictions on transgender health care, participation in school activities, bathroom access, and legal recognition of gender identity (KFF, 2026; Movement Advancement Project, 2026a, 2026b, 2026c; Arrayales & Redfield, 2026). The pattern of findings in this report — increasing gender identity-based discrimination, persistently high physical threats, continued bathroom access barriers, and little progress on identification document changes, particularly among TGNB participants and during the second study year —is consistent with the pressures TGNB young people may face in a restrictive policy environment.  This interpretation also aligns with prior evidence linking anti-transgender legislation to increased suicide attempts among TGNB young people (Lee et al., 2024). Notably, even as access to desired hormones and gender-expression tools increased over time, bathroom restrictions and difficulties changing identification documents remained common. In light of the longitudinal associations between discrimination, victimization, economic insecurity, and later adverse mental health outcomes, these barriers are not peripheral concerns; they may help create and sustain the conditions that make it harder for young people to feel safe, recognized, and supported.

Conversion therapy is also particularly important to name in this policy context because protections against conversion therapy for minors remain legally contested following the U.S. Supreme Court’s decision in Chiles v. Salazar (Chiles v. Salazar, 2026; Movement Advancement Project, 2026d). Improving LGBTQ+ youth mental health therefore requires attention to both affirming access and the broader policy and structural environments in which young people live.

Limitations

Despite its strengths, this study has several limitations. First, all measures were self-reported. Self-reported data are appropriate for understanding young people’s lived experiences, but it can also introduce recall bias or social-desirability bias, especially for sensitive topics such as suicide, self-harm, hospitalization, and conversion therapy. Although the study used validated screeners and standardized items where possible, administrative or clinical data would be needed to confirm hospitalization and treatment histories.

Second, some measures used different recall windows at baseline and follow-up. For example, some baseline questions asked about lifetime or current experiences, while follow-up questions asked about experiences in the past year. These differences make some estimates harder to compare directly over time and should be considered when interpreting changes across the study period.

Attrition is another important limitation. Generalized linear mixed models allowed participants to contribute data even if they missed one or more follow-up surveys. However, these models rely on the assumption that missing data can be explained by factors measured in the study, such as age, identity, or baseline symptoms. If participants who stopped participating differed from those who remained in ways the study did not measure, the results may be biased. In addition, descriptive analyses in this report are restricted to participants with sufficient data across the two-year study period for a given variable. As a result, some baseline and one-year follow-up estimates may differ from those presented in the interim one-year report.

The sample, though large and diverse, is not nationally representative. Recruitment occurred primarily online through paid social media advertisements, which may exclude youth without reliable internet access or those who are less connected to online LGBTQ+ spaces. This is especially important for interpreting findings related to social media, online safety, and cyberbullying, as participants recruited online may differ from LGBTQ+ young people who do not use social media as often or who have limited internet access. The current socio-political context may also have influenced who chose to participate in the study, as LGBTQ+ young people’s willingness to engage in research may be shaped by safety concerns.  For this reason, point estimates should not be generalized to all LGBTQ+ young people in the U.S. Instead, the study is most useful for understanding how risk and protective factors are associated with mental health and suicide-related outcomes over time within this large and diverse longitudinal sample.

Finally, while the longitudinal design allows for examination of associations over time, causal inferences remain limited due to possible unmeasured confounding variables and the observational nature of the study. The broader sociopolitical context — including anti-LGBTQ+ legislation, policy debates, and rhetoric during the study period — likely influenced participants’ experiences and mental health, but the study was not designed to isolate the effects of specific external events or policies. These limitations highlight the need for cautious interpretation and underscore the importance of continued data collection and analysis in future waves.