Fostering connections and lessening stigma

Factors shaping LGBTQ+ youth mental health

The LGBTQ+ youth community is one of the most marginalized and underserved groups in the United States when it comes to healthcare. Fifty-six percent of LGBTQ+ youth cannot access mental health services. Even when LGBTQ+ youth can access the care they need, their experiences are often less than ideal – 32% of transgender youth report that their provider has intentionally misgendered them.

LGBTQ+ youth often endure risk factors to their mental health such as bullying, discrimination, lack of family or school support, and physical harm.

Due to these factors, LGBTQ+ youth are at greater risk of developing mental health issues and substance use disorders.

“Historically, LGBTQ+ youth have experienced more bullying and stigma than their non-LGBTQ+ peers,” says Caroline Geelan, DO, Medical Director, Carelon Behavioral Health. “As a result, LGBTQ+ youth often experience more depression and suicidal ideation.”

 

 

Barriers LGBTQ+ youth experience when accessing mental healthcare

LGBTQ+ youth endure unique barriers to healthcare access:

• Stigma – LGBTQ+ youth tend to experience greater stigma when seeking behavioral healthcare, due to pressure to withhold their sexuality. When they do receive care, it is often inadequate.  
• A limited supply of LGBTQ+ culturally competent providers currently exists, especially providers trained in treating youth. Overall, many providers tend to have limited LGBTQ+ healthcare training, at times exhibiting discriminatory behavior.
• Socioeconomic and geographic factors cause further barriers. As a result, the distribution of behavioral health clinicians is uneven throughout the country.
• Further systemic challenges include prejudice within medical institutions and anti-LGBTQ+ legislation.

“It’s challenging finding mental health providers with a niche in serving LGBTQ+ youth, especially those who can provide that care with sensitivity,” says Dr. Geelan. “LGBTQ+ kids have unique needs. Providers need to understand those needs. Because of that, a lot of LGBTQ+ kids want a provider who identifies with and is part of the LGBTQ+ community.”

Dr. Geelan also highlights a shortage of providers available. “In general, we are currently experiencing a shortage of physicians, including that of child and adolescent psychiatrists,” says Dr. Geelan. “It’s also difficult for individuals find mental health providers, including therapists and psychiatrists, who accept health insurance, particularly depending on where individuals live. All these issues present further challenges in adequately delivering mental health care to LGBTQ+ youth.”

 

 

The impact of COVID-19 on LGBTQ+ youth mental health

 

COVID-19 amplified many preexisting behavioral health inequities and created new ones in the LGBTQ+ youth community.

Behavioral health issues and substance use disorders increased during the pandemic. Physical distancing, as well as community spaces closing, caused LGBTQ+ youth to lose significant safe spaces and support systems. Many LGBTQ+ youth had to return to their parents’ homes, some of which were unsupportive of their community and lifestyle.

“In general, there’s been an increase in antidepressants prescribed to kids because of the social isolation and resulting depression in those two years. People seeking services increased overall. The pandemic exacerbated youth mental health challenges, especially those of LGBTQ+ youth,” says Dr. Geelan.

Additionally, since COVID-19 began, the country has seen a significant uptick in efforts to pass anti-LGBTQ+ legislation. From 2021 to 2022, state lawmakers introduced over 306 anti-transgender bills. The ACLU tracked 452 anti-LGBTQ+ bills.

“The increasingly polarization of the political landscape has presented unique challenges for LGBTQ+ youth, as many now worry about their safety,” says Dr. Geelan.

 

 

How telebehavioral health helps to fill the LGBTQ+ youth mental health treatment gap

 

LGBTQ+ youth who choose telebehavioral health (TBH) often find several advantages over in-person therapy.

• People with social anxiety or PTSD may feel far more comfortable with TBH, experiencing a greater ease of communication than they have experienced in-person. They may also experience less stigma.
• TBH also allows people to choose from a greater variety of providers, since geographic boundaries are not an issue. Individuals opting for TBH have a much greater chance of connecting with providers experienced in treating LGBTQ+ people.
• TBH can be more efficient for clinicians, and less costly for patients. Both clinicians and patients often find TBH more convenient and comfortable. Patients can minimize the risk of potential harassment and negativity when accessing treatment.

“TBH is a good thing in that it helps to fill treatment gaps. We do not yet have enough in-person providers available, as clinics are oversaturated. TBH also helps to increase patient compliance, as it’s convenient, it’s not limited by geographic location or time zone, and more providers are available to deliver mental health care virtually. COVID helped to significantly expand the acceptance of TBH,” says Dr. Geelan.

 

 

Limitations in treating LGBTQ+ youth mental health with TBH

 

As with other treatment options, TBH comes with its own set of advantages and limitations. TBH offers privacy and comfort, and due to the variety of options available, an LGBTQ+ youth incurs a lesser risk of working with an unsupportive provider.

However, TBH may offer limitations. LGBTQ+ youth who struggle with TBH may have difficulty accessing technology or unreliable internet service. Some youth may feel the interactions with their provider are too impersonal, due to the lack of an in-person presence. Others may have privacy and confidentiality concerns, due to cybersecurity, or fear of being overheard on a TBH session.

“Nothing replaces in-person therapy,” says Dr. Geelan. “In-person therapy provides one on one interactions that result in an energy exchange and transference. In TBH, therapists risk missing patient mannerisms and body language.  Simply by being in the same room and space as a patient, a therapist can provide in-person treatment that creates a stronger therapeutic alliance between the therapist and patient in ways that telehealth cannot.” 

Dr. Geelan underscores how a strong therapeutic alliance is key to a provider successfully helping a patient to reach their treatment goals. “An in-person visit is often the first time an adolescent engages in mental health treatment. When the adolescent has a positive first experience, that goes a long way in terms of reducing or eliminating any hesitation or resistance towards the adolescent seeking future mental health treatment.”

She emphasizes how LGBTQ+ youth in particular benefit from in-person therapy, as anxiety is a main prevalent mental disorder that youth experience. “Kids who were avoidant, for example, loved being at home during the pandemic, and had a hard time returning to school. Kids experiencing challenges with avoidance benefit the most from in-person therapy because they are forced to leave the house and sit in a waiting room with others. 

“All of these issues are much more pronounced for LGBTQ+ kids and the unique challenges they struggle with. In-person therapy enables us to address these challenges one on one more directly,” says Dr. Geelan.

 

 

How to improve LGBTQ+ youth mental health treatment

 

By raising awareness and educating the LGBTQ+ youth community on affirming in-person care and TBH treatment options, as well as the benefits, mental health care providers can earn the community’s trust and provide better overall experiences.

When providers receive training on LGBTQ+ youth affirming care and cultural competency integrated with TBH, they can improve the quality of care they deliver. They can then improve patient outcomes.

By incorporating LGBTQ+-inclusive guidelines into in-person care and TBH, providers can help to elevate care systemwide. By working with policy makers and LGBTQ+ organizations to combat discrimination and marginalization, providers can substantially help to improve LGBTQ+ youth mental health overall.

“We need to broaden the number of providers sensitive to the LGBTQ+ youth population, who understand the nuances and challenges that the community experiences,” says Dr. Geelan. “Providers need to receive more LGBTQ+ focused training and take advantage of educational opportunities. Medical practices need to bring in experts who are willing to give their time to educate the provider community.”

She also points out the importance of treating LGBTQ+ youth as individuals. “In psychiatry, especially, providers need to look at LGBTQ+ youth patients as unique individuals. Their psyches are going to be dealing with stigma and marginalization in various ways, so providers need to be sensitive towards that. It’s even more complex for transgender youth.”

Overall, Dr. Geelan believes that providers need to educate themselves on best practices in LGBTQ+ youth mental health care rather than deciding they are not the right fit for an LGBTQ+ youth. “Everyone needs and deserves access to quality mental health care. It’s our responsibility as mental health professionals to learn and grow with the changing needs of our communities and society.”