The Promise of Digital Mental Health for LGBTQ+ Youths

Despite improvements in psychiatric treatment, lesbian, gay, bisexual, transgender, queer, plus (LGBTQ+) youths experience disproportionate psychiatric morbidity compared with their peers. The stress of being in a minoritized group (“minority stress”) drives this health disparity (1, 2). Adaptations of evidence-based treatments that target minority stress and affirm LGBTQ+ identities can improve psychiatric outcomes (3). The field of psychiatry has treated the LGBTQ+ community in harmful ways, such as with the diagnoses of ego-dystonic homosexuality and gender identity disorder. Therefore, treatments that are explicitly affirming are critical to engaging and supporting LGBTQ+ youths.

Nearly half of LGBTQ+ youths desire psychotherapy but cannot access it (4). They face numerous identity-specific barriers, such as a lack of providers trained in affirmative evidence-based interventions and fears of being “outed,” in addition to general barriers, such as cost, access to care, and parental permission. With the potential to overcome these barriers, digital mental health (DMH) provides an opportunity to address some of the unmet mental health needs of LGBTQ+ youths. However, as of February 2022, only one of the high-value DMH applications (apps) with automatable content available in app stores offered programming specifically for LGBTQ+ people. A review (5) of research-based digital health interventions for LGBTQ+ youths found that only five focused on mental health. Thus, insufficient attention has been devoted to LGBTQ+ youths in both DMH research and practice.

Mental health start-ups are based on the principle of scaling quickly to reach the most users, often resulting in products that cater to heterosexual and cisgender people and potentially exacerbating existing mental health disparities. These start-ups are missing an opportunity, given the size of the LGBTQ+ population, which continues to grow, and because LGBTQ+ youths are more likely than their peers to use DMH (6). Moreover, this situation stands in contrast to user-centered design principles, which call for considering the end users in order to maximize engagement.

Engaging the end user from the outset is a fundamental principle of user-centered design. Focus groups have revealed that isolated LGBTQ+ youths look online for support and for information about identity and gender-affirming care (6). LGBTQ+ youths desire communities that are validating and provide accurate information (6). DMH could include opportunities for interpersonal connection, foster a sense of belonging, and provide information about sexuality and gender to facilitate positive identity development (6).

Focus groups provide a starting place for DMH, but, consistent with user-centered design principles, it is critical to continually collect data from users to understand whether DMH content meets users’ needs and to revise content as needed. In this column, we describe ways to move toward inclusive and equitable DMH for LGBTQ+ youths, on the basis of documented feedback from users and affirmative practice principles. We begin with how to increase inclusivity through updates to existing content. We then describe ways to move toward mental health care equity by developing new content to address minority stress and resilience. Throughout, we offer illustrative examples for how content could look in DMH practice.

Updating Existing Content

DMH offers advantages for access to services yet faces drops in use and retention. LGBTQ+ youths who do not see their experiences represented may intuit that interventions are not relevant to them and will be less likely to engage (7). Given that attending to diversity factors increases engagement (7), we suggest taking steps to increase inclusivity by updating language and models of mental illness.

In considering language, developers should keep in mind that there are more than two genders, gender is not determined by sex assigned at birth, heterosexuality is not the default, and many family structures exist (3). Language can be updated accordingly. The words “men” and “women” can be replaced with “people” when gender is irrelevant. When gender is relevant, genders beyond the binary can be included. Instead of referencing “boyfriends” or “girlfriends,” or assuming that people are attracted to one gender and only engage in monogamous relationships, language can be used to refer to romantic interests, including the potential for multiple partners, attraction to multiple genders, and no attraction at all. Gender-neutral pronouns can be used, such as “they,” in addition to “he” and “she.” Ensuring that the user can select the appropriate pronouns provides a first step toward inclusion. Allowing users to share and update their gender and sexual identity could also increase LGBTQ+ identity affirmation.

DMH tools often explain psychiatric morbidity as caused by biology or by the interaction of biology and stress, without inclusion of minority stress. For LGBTQ+ youths, stressors that occur on the basis of identity play a large role (3). DMH tools could acknowledge that stress for LGBTQ+ youths includes familial rejection, misgendering, and lack of bathroom access and that these experiences increase risk for psychopathology (1, 2). Avoidance of these topics ignores the documented associations between minority stress and mental health, which could contribute to feelings of shame and self-blame among LGBTQ+ youths.

Developing Content to Address Minority Stress

To move toward equity, new content could address the unique concerns, such as those related to discrimination and disclosure, that lead LGBTQ+ youths to seek out DMH (7) and could target the stressors that drive psychiatric morbidity among this population. Next, we discuss how DMH can leverage existing strategies to address identity-specific stressors.

Coming Out

Many youths have not disclosed their identities to important people in their lives and find it stressful to navigate decisions about disclosure (1, 2). “Coming out” is often viewed as a universal goal and as a reflection of self-acceptance. However, youths have valid reasons for concealing, such as maintaining relationships and avoiding violence. Coming out can have negative consequences, and it can lead to receiving support and building community.

DMH is well suited to help youths who are contemplating disclosure and may provide a way to practice disclosing prior to actually doing so. In addressing coming out, DMH tools could be developed to help youths weigh the potential risks and benefits of disclosure, to offer tips for assessing whether it is safe to disclose, to encourage youths to develop a safety plan in case of negative reactions, and to guide youths through exercises to identify their values to help inform their decisions.

Chatbots could be programmed to respond to entries about coming out with something like the following: “There are lots of reasons to come out, and it’s important to think about whether it’s safe to do so.” Users could describe pros and cons, and tools could be designed to help users decide what is best for them and to plan accordingly (e.g., “It sounds like coming out to your mom is important to you, and you think she’ll be accepting. Do you want to practice what you’re going to say? What can you do if she doesn’t react the way you think she will?”).

For youths who are exploring their identities, DMH could include educational content that distinguishes sex, gender expression and identity, and sexual orientations. Users could be prompted to imagine how they might like to present themselves and to create avatars to virtually experiment with gender expression, as has been suggested by user feedback (8).

Internalized Stigma

The internalization of invalidating messages about one’s identity (“internalized stigma”) can contribute to self-invalidation, which contributes to psychiatric morbidity among LGBTQ+ people (1, 2). LGBTQ+ users of DMH have reported a desire for content to address this stigma (8). Online interventions that challenge stereotypes, identify sources of negative beliefs, and acknowledge positive aspects of being LGBTQ+ (9) could be leveraged by DMH to combat internalized stigma. To translate this research into practice, developers could consider including modules that present common stereotypes (followed by information busting these myths) and that prompt users to reflect on negative messages they have received and to identify the sources of those messages. Chatbots could respond to comments such as “I wish I wasn’t LGBTQ+” by offering “It can be hard to feel good about yourself when you receive negative messages about your identity. What messages have you received and where have they come from? What evidence do you have that those messages are true?” Relatedly, users have identified a desire for self-compassion skills to combat shame (6).

Expectations of Rejection

Rejection sensitivity (i.e., expecting and fearing rejection on the basis of identity) is another risk factor for psychiatric morbidity among LGBTQ+ youths (1, 2). From their rejection experiences, some LGBTQ+ people are understandably rejection sensitive. Coping strategies from affirmative versions of evidence-based therapies (3) could address this need digitally. First, users could be encouraged to check the facts to assess the likelihood of rejection. Chatbots can be designed to respond to worries about rejection with, “Have you observed that person make negative comments about LGBTQ+ people? If you don’t know how they feel, try mentioning an LGBTQ+ celebrity and see how they respond.”

In a case where the mention of an LGBTQ+ topic is met with a negative response, a chatbot could suggest problem-solving strategies, such as identifying alternative support people and avoiding harmful people. If checking the facts does not prompt a negative response, the chatbot could be designed to acknowledge that the fears do not seem to fit, and it may be safe to engage. Regardless, it can be helpful to offer cope-ahead plans, because none of us have crystal balls, and rejection can occur. This concept could be illustrated graphically with a crystal ball and a measuring stick, accompanied with messaging, such as “Someone else’s reaction to you is not a measure of your worth.”

Intraminority Stress

Psychiatric morbidity can also be driven by intraminority stress from within the LGBTQ+ community (10). Those who identify with multiple minority groups are particularly vulnerable. DMH can be helpful here too; artificial intelligence responds to the concerns a user enters. A person who enters text about experiencing racism at a Pride event could be supported with content about coping with racism within the LGBTQ+ community.

Amplifying Resilience

Protective factors mitigate psychiatric morbidity among LGBTQ+ people (2); therefore, we suggest amplifying resilience by increasing pride and fostering community connections, as well as by facilitating access to gender-affirming resources, all of which are aligned with feedback from users of DMH (5, 6).

Pride

Representation is important; when LGBTQ+ youths see role models who share their identities, this conveys that they too can lead fulfilling lives (2). Developers of DMH technologies can collaborate with LGBTQ+ celebrities to provide models of proud LGBTQ+ people. Developers of DMH tools could also create playlists featuring LGBTQ+ artists to foster pride. Chatbots could be designed to prompt users to enter text focused on positive aspects of being LGBTQ+. Apps featuring celebrities could include stories describing how being LGBTQ+ is a strength.

For some people, expressions of pride may include advocating for social justice. To acknowledge how exhausting advocacy work can be and to encourage self-care, chatbots could offer “We think about advocacy as a relay race, not a sprint or a marathon” and “What can you do to take care of yourself so that you don’t burn out?” Finally, affirmative mindfulness practices that explicitly amplify LGBTQ+ resilience can be incorporated into mindfulness-based DMH.

Community

The well-being of LGBTQ+ youths depends on who surrounds them not only physically but also virtually (2). DMH can foster connections among individuals who lack local communities or support. For instance, some apps include a public mode, which allows users to be visible to each other. Given that LGBTQ+ identities are often invisible, DMH can offer ways for users to visibly self-identify to increase opportunities to connect.

Gender-Affirming Resources

Gender-diverse youths who express their authentic gender and those with access to affirming health care show improvements in psychiatric outcomes following access to care (11). By using location-based services, DMH could connect users with local affirming health care providers. When not locally available, connections could be made to providers virtually. Educational content on how to change legal documentation, such as name changes, could also be included in DMH.

Conclusions

LGBTQ+ youths are overrepresented among users of DMH; however, there is a lack of content targeting minority stress reactions, and most apps do not collect sufficient diversity-, equity-, and inclusion-related user feedback (7). The recommendations in this column offer a blueprint for moving toward inclusive and equitable care for LGBTQ+ youths.

Developers of DMH technologies could also consider collecting data and engaging users on how to modify DMH tools in subsequent versions. We urge DMH companies to start building content for diverse users brick by brick and to engage with users in an iterative way, because DMH has the promise to help reduce the mental health disparities affecting LGBTQ+ youths.