Exploration of Experiences and Perpetration of Identity-Based Bullying Among Adolescents by Race/Ethnicity and Other Marginalized Identities

Key Points Question How are experiences of bullying based on race/ethnicity/national origin and other marginalized identities associated with outcomes for health, mental health, and violence among adolescents? Findings In this cross-sectional study of 3939 high school youth, the highest rates of experiencing and perpetrating identity-based bullying were demonstrated by youth with multiple marginalized identities. Experiences with and perpetration of bullying based on race/ethnicity were associated with all health, mental health, and violence outcomes examined; experiencing multiple forms of identity-based bullying was associated with worse adjustment. Meaning These results suggest that policies that address experiences of race/ethnicity-based bullying and co-occurring mental and physical health outcomes must also attend to other aspects of youths’ social identity.


Introduction
Race-based discrimination is an ongoing public health crisis in the US, manifested by wide-ranging disparities in health care access and health outcomes, exposure to community and interpersonal violence, and inequitable criminal justice interactions.Black adolescents experience an average of 5 instances of racial discrimination per day, 1 underscoring the extent to which anti-Blackness is woven into societal fabric.While Black youth report the highest rates of racial discrimination in the US, 2 other racial/ethnic minority groups, including Latinx youth, are also frequent targets of race-based discrimination and bullying. 3Such experiences during adolescence have been linked to multiple negative emotional, behavioral, and physical health problems, [4][5][6] which often persist into adulthood. 7,8Targeting and responding to adolescents' experiences with discrimination has the potential to prevent further widening of inequities into adulthood. 9though many racial-ethnic minority youth demonstrate extraordinary resilience by drawing on cultural and familial strengths, repeated encounters with racial discrimination can lead to significant emotional and psychological injury, also known as racial trauma. 10,11Other forms of discrimination and identity-based bullying (IBB), including gender-based and ableist bullying, carry similar negative health consequences. 12,13IBB can be a form of interpersonal trauma that threatens an individual's self-esteem and sense of safety, resulting in variable socioemotional responses, including heightened depressive and other internalizing symptoms or increased violence and aggression. 12For some adolescents, these expressions of anger may take the form of bullying or harassing others, a behavior conceptualized as the bully-victim. 14While bully-victims exhibit higher levels of depression, anxiety, and suicidality, 15,16 the complex mechanisms through which identity affects bullying behaviors remain poorly understood.In particular, traditional models of IBB may neglect broader, interacting systems of oppression that drive these responses.
While studies of single-identity discrimination, including race-based discrimination, have proliferated, research considering IBB based on multiple stigmatized identities is needed.According to intersectionality theory, dynamic structures of power and inequality (eg, racism, sexism, heterosexism) constrain access to resources and shape our lived experience. 17,18Thus, other aspects of youths' sociocultural contexts, such as gender identity, sexual orientation, and immigration status may interact with their race to inform the frequency and types of racial discrimination they experience.In addition, broader societal structures may drive other forms of intersectional oppression, including exposure to interpersonal and community violence. 18Together, these identitybased phenomena may factor into how multiply marginalized youth navigate encounters with health care and mental health systems. 9Thus, without considering multiple forms of IBB, our ability to meet the diverse needs of racial/ethnic minority youth is limited.
To address this gap, the current study adopted an intersectional approach by jointly considering experiences of discrimination based on race, sexual orientation, gender identity, religion, immigration status, and physical or mental disability.Using a cross-sectional sample of youth, this investigation sought to clarify how different types of IBB independently and collectively affect health, mental health, and violence-related outcomes.Patterns of IBB were examined to elucidate how youth adjustment may differ across various combinations of experiences (ie, experiences of IBB, IBB perpetration, involvement in both).

JAMA Network Open | Pediatrics
Identity-Based Bullying Among Adolescents by Race/Ethnicity and Other Marginalized Identities

Methods
This study sampled 4207 students in grades 9 through 12 at 13 high schools within Pittsburgh Public Schools (PPS), who completed anonymous school-based surveys of health risk and protective behaviors.An informational letter sent to parents/guardians provided an opportunity to opt out of their child's participation by signing and returning the form.All students who were present in school on the day of survey administration and whose parents/guardians had not opted out were eligible to participate.Students were also given the opportunity to opt out of participation.Questions were modeled on the US Centers for Disease Control and Prevention Youth Risk Behavior Survey (YRBS) 19 and were administered as a paper-pencil survey during a class period between October 15 and October 19, 2018.Among 6306 students enrolled across all 13 schools, 4487 surveys were collected (a response rate of 71.2%).A total of 280 surveys (6.2%) were excluded-37 surveys were unreadable and 243 were judged too incomplete for analysis.Because data collection was anonymous, we were unable to ascertain demographics of students not completing the survey.This survey was a partnership among PPS, Allegheny County Health Department, and UPMC Children's Hospital of Pittsburgh.The PPS School Board approved this assessment, and the University of Pittsburgh's institutional review board deemed this cross-sectional analysis exempt from review because it used deidentified data.No remuneration was provided.This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Measures Racial/Ethnic Identity
Participants were given the following race options and instructed to mark all that apply: White, Black or African American, Asian, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and other.A separate question queried Hispanic/Latino origins.Based on the race and ethnicity prevalence in the sample, we created a race/ethnicity variable with 4 categories that included Non-Hispanic White, Non-Hispanic Black, Hispanic, and multiracial/other.

Gender Identity
Gender was assessed with 2 questions about current gender identity and sex assigned at birth.Youth who endorsed their gender identity as transgender, genderqueer, nonbinary, or another identity, and youth whose gender identity differed from their sex assigned at birth were categorized as gender diverse. 20,21

Sexual Orientation
Participants indicated which of the following best describes them by marking yes or no: heterosexual, mostly heterosexual, gay or lesbian, bisexual, queer, asexual, and not sure.Youth who endorsed any response other than heterosexual were coded as sexual minorities.

Discrimination and IBB
An experience of IBB was defined as answering affirmatively to being bullied on school property during the past 12 months.To assess experiences of IBB, youth were then asked whether they had been harassed or bullied on school property during the past 12 months for any of the following reasons (yes/no responses): race/ethnicity/national origin, religion, gender, sexual orientation, physical or mental disability, immigration status, and/or other reason.
To assess IBB perpetration, youth indicated whether they had harassed or bullied others based on each of the aforementioned 7 identity categories.In addition to looking at endorsement rates for each identity, we also summed participants' responses to obtain a total number of stigmatized [0.8%], respectively), total scores were rescored so that more than 2 identities were scored as 2 (ie, 0 indicates 0 identities; 1 indicates 1 identity; 2 indicates Ն2 social identities).

Health and Health Care Outcomes
Well-child care was assessed by asking, "When was the last time you saw a doctor or nurse for a check-up or physical exam when you were not sick or injured?"Responses were recoded so that 0 equaled 2 years or less since routine well visit and 1 equaled more than 2 years since routine well visit.
Forgone health care was assessed with a single yes or no question: "In the past 12 months, have you ever thought you needed to go see a doctor, nurse, or go to the emergency room BUT did NOT go?" Participants also indicated whether they "are limited in any way in any activities because of physical, mental, or emotional problems" in a yes or no question.

Mental Health Outcomes
Nonsuicidal self-injury (NSSI) and suicidal ideation in the past 12 months were assessed using validated items from the YRBS.NSSI was defined as answering affirmatively (1 time or more) to the question: "How many times have you ever hurt yourself on purpose without wanting to die, such as cutting, pinching, scratching, or burning yourself?"Suicidal ideation was assessed with 1 binary item: "Did you ever seriously consider attempting suicide?"

Violence Outcomes
Five YRBS items assessed violence-related outcomes within the past 12 months, operationalized as any or none: violence perpetration (threatened or injured someone else with a weapon), exposure to violence (someone threatened or injured you with a weapon), physical fighting, sexual assault (forced to do sexual things you did not want to do), and adolescent relationship abuse (someone you were dating or going out with forced you to do sexual things or physically hurt you on purpose). 19fetime homicide survivorship was defined as answering affirmatively (ie, 1 or greater) to the question, "How many of your friends and/or family members have been murdered?"

Statistical Analysis
Analyses were performed using Stata version 16.Of the 4207 youth who completed surveys, 2950 youth did not respond to the IBB items.
Closer examination of the data revealed that 2448 of these participants responded no when asked if they had been bullied on school property within the past 12 months, suggesting that these participants interpreted the subsequent IBB subtype questions as inapplicable to them.This is further corroborated by the fact that these 2448 youth responded to the other items immediately before and after the IBB questions.Thus, IBB items were coded as no if youth did not respond and   violence outcomes.When comparing joint involvement in both experiences of IBB and IBB perpetration with no involvement, there were fewer significant differences that emerged, with the exception of greater suicidal ideation and exposure to violence (Table 5).

Discussion
Among a school-based sample of youth in urban neighborhoods, the present study examined experiences of IBB and IBB perpetration based on race/ethnicity/national origin and other stigmatized identities.Examining types of IBB provided key insights into the complex interplay between intersecting identities and highlighted the pervasive exposure to race/ethnicity/national origin IBB among youth, particularly among Black and Hispanic youth who identify as gender diverse. 227][28] We extend these findings by examining the types of both experiences of IBB and IBB perpetration (eg, racial/ethnic/national origin, sexual orientation, gender identity) experienced by youth, and find higher endorsed prevalence across multiple types of IBB in using this approach.
Experiences of IBB and IBB perpetration were both associated with all health, mental health, and violence outcomes examined; experiencing multiple forms of IBB was associated with worse adjustment.Notably, compared with uninvolved youth, youth experiencing IBB due to race/ ethnicity/national origin were at increased risk for NSSI, suicidal ideation, exposure to violence, sexual assault, and adolescent relationship abuse.These same youth were also more likely to forego medical care (ie, not go to the emergency department when needed) and go more than 2 years since their last routine well visit.Similar results emerged for youth in the race/ethnicity/national origin IBB perpetration only group.
Follow-up studies are needed to elucidate specific barriers to health care utilization among youth who have experienced race/ethnicity/national origin IBB.However, it is reasonable to expect that an important barrier includes the historical and continued mistreatment of Black (eg, Tuskegee syphilis study) and Hispanic communities, which have led to warranted mistrust of health care systems. 29,30Although associations between IBB and service utilization may be driven by additional factors, such as family income, parents' experiences of discrimination, or insurance status, it is critical to recognize how histories of oppression in the medical system and adolescents' experiences of discrimination may contribute to these disparities.[33][34][35][36] Data for the present study were collected in 2018, a time in which we saw increases in racist political rhetoric, racial hate crimes, 37 and the introduction of antitransgender legislation restricting access to health care and reversing protections prohibiting discrimination in health care based on gender identity.These examples highlight how sociocultural and political contexts may shape experiences of IBB among youth.Efforts to address IBB-associated health outcomes among Black transgender individuals must consider the multiple layers of oppression due to racism and transphobia.Furthermore, as data reflect the experiences of youth of race-based bullying in schools, prevention efforts should empower young people to engage in prosocial, antiracist behaviors with their peers, and schools should incorporate healing-centered practices that recognize racial trauma.

Limitations
Our findings must be interpreted within the context of several study limitations.Data collection took place in urban neighborhoods in a single city; thus, findings may not generalize to adolescents in other geographic contexts.Missing data due to both survey opt-out and/or school absence and nonresponse to IBB questions could have biased findings.While youth have firsthand knowledge of IBB that may be unknown to others, the stigma of bullying may make youth reluctant to disclose being their experiences with IBB or IBB perpetration.Both forms of IBB were examined with single yes/no items for each stigmatized identity.More detailed assessment of these experiences, including of the frequency, severity, and perpetrator of IBB, is needed.Small subsample sizes required us to collapse across categories (eg, other collapsed a number of racial/ethnic identities) and precluded us from examining specific combinations of IBB.Future examinations incorporating larger samples are needed for a more nuanced intersectional examination of experiences of IBB and IBB perpetration.
Finally, because of this study's cross-sectional design, we are unable to draw directional conclusions from these data.While IBB itself may not directly lead to violence exposure or negative health or

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12 the preceding question inquiring about being bullied on school property.Prior work using similar items from the YRBS have used this approach to handle missing data on IBB questions.12This yielded a total sample size of 3939 out of 4207 youth (6.3% missing IBB data).There were no significant differences in demographics (age, race/ethnicity, sex assigned at birth, gender identity, and sexual orientation) between individuals who completed vs did not complete the IBB items.Analyses were limited to the 3939 participants with IBB data.

Table 1 .
Prevalence of Demographic Characteristics, IBB, and Health, Mental Health, and Violence Outcomes b Transgender, genderqueer, nonbinary, or other gender identity and youth whose gender identity differed from their sex assigned at birth.c Lifetime homicide survivorship was defined as answering affirmatively (ie, 1 or greater) to the question, "How many of your friends and/or family members have been murdered?"

Table 5
reports adjusted associations between the race/ethnicity/national origin IBB involvement types (ie, experiences of IBB only, IBB perpetration only, involvement in both) and health, mental health, and violence outcomes, with no involvement treated as the reference.

Table 3 .
Associations Between Experiences of Bullying Based on Race/Ethnicity and IBB Perpetration

Table 4 .
Associations of IBB With Youth Health, Mental Health, and Violence

Table 5 .
Associations Between IBB Groupings and Health, Mental Health, and Violence a Odds ratio from mixed-effects logistic regression model adjusted for youth age and accounting for school-level clustering.Data in each row come from a single model, with each column representing the aOR for experiences of IBB with or without perpetration involvement compared with the reference group.