SPECIAL REPORT: SEXUAL AND GENDER MINORITIES
Despite rapid social progress, including the landmark United States Supreme Court ruling on same-sex marriage in 2015, challenges remain for young individuals who are lesbian, gay, bisexual, transgender/trans, or queer (also known as sexual and gender minority or SGM youth). Fortunately, since the start of this century, online environments have revolutionized the lives of young SGM individuals, so even those in the most remote of locations can access discrete and timely supports. While the internet has generated many benefits for SGM communities, it has also created new problems, such as the rise of internet-based homo-, bi- and trans-phobic bullying, online sexual exploitation, as well as worrying conversion tactics.
Given the diversity implicit under the wider SGM umbrella, it is important to briefly define these unique subpopulations and their mental health needs before delving into the impacts of online environments for these young people.
ALSO IN THIS SPECIAL REPORT
To identify as lesbian, gay, or bisexual (LGB) is to claim a certain, often politicized, sexual identity label. However, sexual attractions and sexual behaviors are other important dimensions of human sexuality.1 Depending on the dimension of sexuality assessed, estimates of nonheterosexual prevalence varies considerably, even when estimates are derived from population-based studies.
Assuming questions related to sexuality are included in these large-scale studies, researchers have consistently reported that a substantial proportion of youth identify as being a sexual minority individual. For instance, up to 8% of youth identify as bisexual, and up to 3% of youth identify as lesbian or gay.1 Meanwhile, although being LGB is related to sexuality, being transgender/trans pertains to one’s gender identity. (See What Constitutes a SGM Community for more information.)
Mental Health Challenges
Robust population-based data have demonstrated SGM youth are at an elevated risk of a range of mental health problems, including suicide attempts, depression, anxiety, and addiction issues.9,10 Unfortunately, there is limited population-based data focused on the mental health of transgender adolescents.
For instance, a systematic literature review and meta-analysis of suicide attempts among SGM young individuals identified only a single study in which the results for transgender adolescents were presented separately, and not combined together with SGM youth.11 Based on the meta- analysis, transgender adolescents were nearly 6 times more likely to attempt suicide when compared to their cisgender peers.11
The increased rates of mental health problems are hypothesized to be caused by minority stress, whereby the mistreatment associated with the high levels of stress these youth encounter is thought to place them at an increased risk for emotional problems.12 Experiencing this mistreatment also results in internalizing the negativity associated with anti-SGM messages, which can lead to mental health issues.
Opportunities for Affirmation and Community
The internet has initiated a revolution for SGM youth because geographic boundaries are no longer limiting; these young people can now connect online with others like themselves. As such, the internet has exerted a powerful influence, with numerous advantages. For instance, those in rural or more socially hostile environments can obtain support via online groups as well as from charitable organizations that provide free online services 24 hours a day, 7 days a week (Table 1). This is a huge advantage. SGM-specific information on relationships and sexual health is also freely available online.
Table 1. Resources for SGM Youth, Families, and Professionals
Risks of Online Conversion Efforts
SGM youth in high-income countries are thought to be coming out at younger ages.13 Consequently, many will still be living at home and will be dependent on their families when they first come out. Unfortunately, not all families will be supportive, and some will actively attempt to secure services and information—either online or face-to-face—aimed at “converting” or “correcting” the SGM youth. This practice still occurs, despite the disapproval of professional bodies toward reparative or conversion therapy, including strong opposition from the American Psychiatric Association14 as well as the American Academy of Child and Adolescent Psychiatry.15
Bullying, Harassment, and Exploitation Risks
Bullying behaviors and trolling via social media platforms are concerning issues in general and especially for SGM youth. It is worth noting that some of this mistreatment can take the form of horizontal violence in which one SGM youth bullies another SGM youth. Both young individuals as well as health professionals have previously identified internet safety and security issues being important considerations.16 Specific examples include the risk of SGM youth being outed against their will on social media and youth being targeted for sexual exploitation online.16,17 The United Kingdom-based SGM charity, Stonewall, has recently made recommendations to support the safety of youth online.18 Selected top tips from this report are summarised in Table 2.
Table 2. Tips Communicating With Young Patients
Mental Health Services
The online context is a valuable milieu in which to deliver psychotherapy at the present time, especially for SGM youth because this population has previously indicated a preference for web-based support for mental health issues.16 Yet few evidence-informed interventions have been developed for these youth. Two systematic reviews of psychosocial treatments in the peer-reviewed literature found only a single tested online tool—Rainbow SPARX—to support the mental wellbeing of SGM adolescents.19-21
Rainbow SPARX, a cognitive behavioral therapy program for adolescent depression, has been specially adapted for SGM youth, but it has not been made available to prospective users outside of a research context. The mainstream version of SPARX has been freely available to all youth in New Zealand since 2014. However, SPARX was less effective for transgender adolescents in comparison with other users who did not identify as transgender.22 The results suggest targeted efforts are needed to address the mental health needs of SGM youth.
The internet is both ubiquitous and influential. SGM youth have grown up with modern technologies in a way that their caregivers and clinicians have not. As such, it is important that clinicians defer to their expertise as digital natives and remain open-minded about online environments as they proffer many benefits. Clinicians also need to be nonjudgemental and aware of the considerable challenges facing SGM youth online, so that SGM youth will discuss their concerns with their clinicians as these arise. In addition, treatment providers should encourage their SGM youth patients to maximize the benefits from their online experiences while managing the potential risks or challenges. We anticipate more work will be undertaken in the fields of cognitive-behavioral therapy and e-therapies for SGM youths.
Dr Lucassen is a researcher and an educator in the Department of Health and Social Care at The Open University (United Kingdom) and an honorary academic in the Department of Psychological Medicine at the University of Auckland (New Zealand). Dr Ugueto is a child psychologist and an assistant professor in the department of Psychiatry and Behavioral Sciences at the University of Texas Health Science Center at Houston.
References 2-8 can be found in the sidebar to this article, What Constitutes a SGM Community?
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3. Johns MM, Lowry R, Andrzejewski J, et al. Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students — 19 states and large urban school districts, 2017. Centers for Disease Control and Prevention. January 25, 2019. Accessed March 19, 2021. https://www.cdc.gov/mmwr/volumes/68/wr/mm6803a3.htm
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7. Australian and New Zealand Intersex Organisations. Darlington Statement: A joint statement by the Australia and Aotearoa/New Zealand intersex community organisations and independent advocates. March 2017. Accessed March 17, 2021. https://ihra.org.au/wp-content/uploads/key/Darlington-Statement.pdf
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13. Lucassen MFG, Clark TC, Denny SJ, et al. What has changed from 2001 to 2012 for sexual minority youth in New Zealand? J Paediatr Child Health. 2015;51(4):410-418.
14. American Psychiatric Association. APA reiterates strong opposition to conversion therapy. November 15, 2018. Accessed March 17, 2021. https://www.psychiatry.org/newsroom/news-releases/apa-reiterates-strong-opposition-to-conversion-therapy
15. American Academy of Child & Adolescent Psychiatry. Conversion Therapy. February 2018. Accessed March 19, 2021. https://www.aacap.org/aacap/policy_statements/2018/Conversion_Therapy.aspx
16. Lucassen MFG, Samra R, Iacovides I, et al. How LGBT+ young people use the internet in relation to their mental health and envisage the use of e-therapy: Exploratory study. JMIR Serious Games. 2018;6(4):e11249.
17. Suto DJ, Macapagal K, Turban, JL. Geosocial networking application use among sexual minority adolescents. J Am Acad Child Adolesc Psychiatry. 2021; S0890-8567(20)32214-0.
18. Stonewall. Staying safe online: Practical strategies to best support all children and young people online, including those who identify as LGBT. February 2020. Accessed March 19, 2021. https://www.youngstonewall.org.uk/system/files/staying_safe_online_-_stonewall_childnet_1.pdf
19. Hobaica S, Alman A, Jackowich S, Kwon P. Empirically based psychological interventions with sexual minority youth: A systematic review. Psychol Sex Orientat Gend Divers. 2018;5(3):313-323.
20. Van Der Pol-Harney E, McAloon J. Psychosocial interventions for mental illness among LGBTQIA youth: A PRISMA-based systematic review. Adolescent Research Review. 2019;4 (2):149-168.
21. Lucassen MFG, Merry SN, Hatcher S, Frampton C. Rainbow SPARX: A novel approach to addressing depression in sexual minority youth. Cognitive and Behavioral Practice. 2015;22(2):203-216.
22. Lucassen MFG, Stasiak K, Fleming T, et al. Computerized cognitive behavioural therapy for gender minority adolescents: Analysis of the real-world implementation of SPARX in New Zealand. Aust N Z J Psychiatry. 2020. ePub ahead of press:1-9. ❒