5

Promising Interventions in Mental, Emotional, and Physical Health

On the third day of the workshop, speakers and participants discussed the mental, emotional, and physical health of LGBTQ youth and identified promising interventions in these areas.

LANDSCAPE: OUTCOMES, INEQUALITIES, AND KNOWN INTERVENTIONS

The health disparities between LGBTQ youth and their cisgender, heterosexual peers are well documented, said Margaret Rosario (The Graduate Center, CUNY). However, there are interventions that can help reduce these disparities and allow LGBTQ youth to develop their sexual and gender identities in a safe, supportive environment, she said. One approach for improving the health of LGBTQ youth is increasing positive societal attitudes toward sexual-minority and gender-diverse individuals. Empirical data support this approach, said Rosario. Positive attitudes toward LGBTQ individuals steadily increased between 1988 and 2014, and after the Supreme Court ruled in favor of same-sex marriage in Obergefell v. Hodges in 2015, positive attitudes increased dramatically. Other drivers of the increase in positive attitudes include increasing contact with LGB individuals, decreasing religiosity, and increasing education. These attitudes are related to health outcomes among both heterosexuals and LGBTQ individuals. For example, in communities with more positive attitudes toward gay marriage, LGBTQ individuals are less likely to smoke or to report poor or fair health. In states that passed constitutional bans against gay marriage prior to Obergefell, LGB individuals experienced an increase in

psychiatric morbidity once the ban was in place. LGB individuals living in states without a gay marriage ban had no change in psychiatric morbidity, said Rosario. Finally, she said, negative attitudes toward “homosexuality” are related to higher mortality among heterosexual individuals.

There are, of course, more direct interventions for improving the health of LGBTQ youth, said Rosario. These include interventions in school settings (see Chapter 6), interventions with parents (see Chapter 4), and interventions designed to educate, support, and affirm LGBTQ youth. This chapter focuses on how these types of interventions can improve mental and physical health in the LGBTQ community and reduce disparities between these youths and their cisgender, heterosexual peers.

In his day-one presentation, Jose Bauermeister offered several suggestions for future research on the mental and physical health of LGBTQ youth. First, he highlighted the value of involving youths as appraisers of systems and services. Bauermeister developed a project in which young people from the LGBTQ community acted as mystery shoppers for HIV testing and counseling services and graded the services based on their experiences (Bauermeister et al., 2019). He suggested that, rather than placing the onus for change on youth, we should focus on ensuring that existing systems are operating at their highest levels. Second, developmental theory should be integrated into interventions for sexual- and gender-minority (SGM) youth, according to Bauermeister. For example, the IREACH app contains developmental content across 16 life-skill domains, including goal-setting activities. Third, he noted the need for interventions that are culturally relevant and that address geospatial variations, including the wide variation in access to LGBTQ-affirming providers across the country. Fourth, Bauermeister offered a word of warning about the use of technology and reminded the audience that building an app is not enough to create behavioral changes. Impactful technology must be integrated with the lived reality of young people and with the availability of trained providers, particularly if the technology is encouraging youths to receive services. Finally, he emphasized that his team’s interventions are created “for, by, and with youth.” He noted the crucial importance of programs that include opportunities for youths to participate and engage, particularly youth of color. Youths can help think about problems, think about solutions, implement solutions, and help ensure that interventions are used in the “real world,” outside of clinical trials.

PROMISING INTERVENTIONS

In this session of the workshop, a panel of speakers presented information about interventions that are designed improve the mental, emotional, and physical health and well-being of LGBTQ youth.

Mental Health Interventions: EQuIP

John Pachankis (Yale School of Public Health) began his presentation by pointing out the substantial mental health inequities facing LGBTQ youth. Sexual- and gender-minority youth are at greater risk for depressive disorder, post-traumatic stress disorder, lifetime mental disorders, suicidal ideation, and suicide attempts than are their cisgender, heterosexual peers (Clark et al., 2020; Johns et al., 2020; Lipson et al., 2019; Day, et al., 2017). These mental health inequalities begin early in life, said Pachankis, with disparities in depression becoming significantly pronounced by middle school (Pachankis et al., 2021). The most studied sources of these disparities are structural stigma, bullying, and family rejection, said Pachankis. Structural stigma include laws and policies that do not support LGBTQ youth (e.g., bathroom bills, lack of bans on conversion therapy, and lack of anti-bullying policies). Associations between mental health disparities and structural stigma, bullying, and family rejection have been found in population-based, prospective, longitudinal studies (Clark et al., 2020; la Roi et al., 2016; Hatzenbuehler et al., 2015a). These upstream factors, said Pachankis, could serve as promising intervention targets. For example, sexual-minority youth in school districts with anti-bullying policies have a lower likelihood of attempting suicide (Meyer et al., 2019; Hatzenbuehler et al., 2015b, 2014). The data are less clear on the association between mental health and conversion therapy bans (Turban et al., 2020; Ryan et al., 2018) and bathroom access (Horne et al., 2021; Murchison et al., 2019). Some interventions addressing bullying have been evaluated, but few were randomized trials, and few specifically examined the impact of these interventions on SGM mental health (Poteat et al., 2020; Earnshaw et al., 2018; NASEM, 2016; Espelage et al., 2015). Although parental rejection is one of the most prominent sources of SGM mental health disparities, Pachankis noted the lack of widely disseminated and evaluated parenting interventions. Huebner noted that psychotherapy and psychoeducational interventions have shown promise in this area (Goodman and Israel, 2020; Huebner et al., 2013; Diamond et al., 2012; Ryan et al., 2010).

Interventions targeted at changing the stressors associated with poor mental health are one approach to improving LGBTQ mental health, said Pachankis; another approach is changing how SGM youth react to these stressors. For example, stressors like structural stigma are associated with stress adaptations including identity concealment, internalized stigma, and social isolation, all of which are associated with poorer mental health (Pachankis et al., 2020a; Hatzenbuehler, 2009; Meyer, 2003). Pachankis explained that because these reactions are cognitive, affective, and behavioral, they can be addressed through mental health services. There are a number of mental health services available to LGBTQ youth, some of which have

been shown to be promising, he said. Crisis services, like those provided by The Trevor Project, offer support via phone, chat, or text (see below). A 2017 evaluation found that youths found the service supportive and would seek it again, and for over 90 percent of respondents, it de-escalated suicidality (The Trevor Project, 2017). Online support groups, such as Q Chat Space, offer live chat for support and community building in noncrisis times, and youths have reported positive experiences with this modality (Fish et al., 2021). There are online cognitive behavioral therapy (CBT) games (e.g., Rainbow Sparx) that showed promising results for reducing psychological symptoms in a small pilot study (Lucassen et al., 2015). Finally, said Pachankis, group CBT therapy has been evaluated, and one intervention called AFFIRM showed promise in reducing depression and building coping skills (Craig et al., 2021; see below). However, none of these interventions has been tested in a randomized controlled trial (RCT). Pachankis explained that RCTs are important for ruling out confounding factors and for comparing the efficacy of various interventions, and he noted that this is an important area for future research.

Pachankis shared the results of his work evaluating the efficacy of LGBTQ-affirmative CBT. One intervention, Empowering Queer Identities in Psychotherapy (EQuIP), specifically addresses an individual’s reactions to stressors. It is delivered in 10 one-on-one sessions; the therapist helps the young person become aware of potential stressors, overcome engrained emotion-avoidance patterns such as drinking or self-harm, learn effective communication skills, rework the internalization of anti-LGBTQ messages, and build a supportive community. Two waitlist-controlled trials found that the treatment worked significantly better than the waitlist in terms of improving mental health outcomes for both sexual-minority men and SGM young women (Pachankis, 2020b, 2015). Pachankis and colleagues (2021b) also conducted the only known RCT comparing an LGBTQ-affirmative mental health intervention to an active control. In a population of 254 young gay and bisexual men, the study compared EQuIP to a single session of community-delivered HIV testing and counseling. EQuIP was comparatively more efficacious at reducing measures of depression, suicidality, anxiety, substance use, alcohol abuse, and HIV risk transmission behavior. One of the most robust findings from these studies, said Pachankis, is that LGBTQ-affirmative CBT is more efficacious than existing mental health treatments for Black, Latinx, and Asian participants compared to White participants (Keefe et al., 2021). Pachankis said these results suggest that a focus on stressors may have particular benefit for young men of color, perhaps due to their experiences of racial and minority stressors.

While it is concerning that mental health interventions are not as advanced as they could be, Pachankis concluded, this gap presents enormous

opportunity for the future. Pachankis identified several questions that future research could address:

• How are LGBTQ youth already supporting their mental health and building resilience?
• How can LGBTQ-affirmative mental health services best address the needs of transgender youth and LGBTQ youth of color?
• Are existing LGBTQ-affirmative mental health services efficacious?
• How can we best match LGBTQ youth to proper treatment approaches?
• How can effective LGBTQ-affirmative models be implemented widely and efficiently?

Pachankis said that research addressing these questions is needed to better utilize limited mental health resources and to address the specific mental health needs of LGBTQ youth. For example, a future RCT could identify ways to match individuals to the appropriate treatments so that youths who could benefit from brief interventions can do so, while other youths can receive appropriate in-depth treatments such as CBT.

Mental Health Intervention: AFFIRM

Shelley Craig (University of Toronto) described her work on AFFIRM, an affirmative cognitive behavioral intervention to improve mental health of SGM youth. AFFIRM is an eight-session CBT intervention that focuses on promoting positive change and healthy coping through a safe, affirming, and collaborative group therapy experience. It was created, Craig said, to counter “conversion therapy” and its associated harmful narratives. The goals of AFFIRM are to help youths to decrease unhelpful thoughts that may have roots in stigma and homo/bi/transphobia, to feel better about themselves and their lives, and to cope in ways that affirm their identities and support healthy behaviors and actions. AFFIRM was developed using community-member and youth input, with the intention of ensuring an inclusive and affirming stance; recognizing SGM-specific sources of stress (e.g., heterosexism); focusing on the unique experiences of navigating SGM identities during adolescence and young adulthood; and delivering CBT content within an affirming framework that attends to the intersectionality of identity-based experiences (Austin and Craig, 2015; Craig et al., 2013). The program was systematically developed using the adapt-and-evaluate framework, and it is grounded in the realities of mental health service delivery, said Craig. For example, AFFIRM can be delivered in natural settings such as schools, and it can be easily integrated into existing programs. Craig noted that this is important, as it avoids placing an added burden on

community-based organizations that are often doing a great deal of work with limited resources.

The implementation of AFFIRM began in 2014 with an open pilot feasibility study in an LGBTQ center in Toronto. Since 2017, AFFIRM has been delivered to 461 participants in 16 sites and online, as part of a clinical trial. Over half of the participants had an immigrant or newcomer parent, 35 percent had moderate to severe depression, and 31 percent had previously attempted suicide. Young people participating in AFFIRM identified as a range of gender identities and sexual orientations, including queer, pansexual, asexual, nonbinary, and two-spirit. Results have shown significant impacts in several areas, including reduction in depression, increases in coping and support, increase in hope, and increases in healthy stress and resource appraisal (Craig et al., 2021). Craig noted that hope is a particularly critical outcome, particularly in terms of increasing “pathway” and “agency.” Pathway reflects an individual’s ability to see a future in which they are successful, happy, and authentic, while agency reflects their self-efficacy in terms of following that path. Participants reported high rates of satisfaction with the program, indicated that they could apply what they learned, and said that they would recommend AFFIRM to others (Craig et al., 2021). One participant said, “This program has had a profound impact on the way that I think and has given me hope that I thought I’d never find.”

Craig also shared information about a new intervention that has grown out of AFFIRM, called AFFIRM Caregiver. As others have discussed, said Craig, caregivers and families are essential to the mental health of queer youth. AFFIRM Caregiver is a seven-session intervention that helps caregivers move away from rejecting behaviors, including behaviors that they think are affirming but are not. The program has been implemented in three states with 103 foster parents; researchers found significant improvement in caregiver attitudes, behaviors, and confidence in implementing the skills they learned (Austin et al., 2021). One foster father stated, “I am not the same man that I was.” He described a transformation of some of his core beliefs and shared that the intervention impacted his life beyond the skills he learned about caring for LGBTQ youth.

Craig concluded by explaining that she and her colleagues are collecting and analyzing more data on both programs, looking at longer-term outcomes, and launching AFFIRM in new sites.

Mental Health Interventions: The Trevor Project

LGBTQ youth face increased risk of mental health challenges, yet they often face many barriers to accessing mental health services, said Myeshia Price (The Trevor Project). A recent survey (The Trevor Project, 2021b) found that, over the course of a year, nearly half of surveyed LGBTQ youth

wanted counseling from a mental health professional but did not receive it. This problem is even more severe for LGBTQ youth of color, with over half the survey respondents in each racial/ethnic group being unable to access desired care, said Price. The most common barrier that youths report is inability to pay for care. Other common barriers include previous negative experiences with care, not wanting to get a parent’s permission, and fear of being outed (Green et al., 2020). LGBTQ youth also reported cultural barriers to care and concerns about whether providers are competent to discuss LGBTQ issues. These data, said Price, indicate that there is incredible need for access to LGBTQ-centered mental health services. When preventive mental healthcare is not available, she said, LGBTQ youth often end up in crisis. The Trevor Project was created because there was no crisis service specific to LGBTQ youth, despite their higher rates of suicide, said Price.

The Trevor Project takes a comprehensive approach to suicide prevention and crisis intervention, said Price. The Trevor Project recognizes the role that factors ranging from the macro- to the individual level can have on mental health, said Price. At the macro level, The Trevor Project advocates for LGBTQ-inclusive policies through legislation and litigation. At the exosystem or community level, The Trevor Project’s education department provides information and training on how to best support LGBTQ youth and help prevent suicide, and The Trevor Project research department evaluates and disseminates evidence-based approaches for reducing suicide risk for LGBTQ youth. At the micro-, or individual, level, The Trevor Project provides a safe social-networking community for LGBTQ youth, their friends, and their allies. Price noted that this online platform was even more critical during the pandemic because it allowed youths to find affirming connections even when physically isolated. Finally, The Trevor Project offers direct suicide and crisis-intervention services for LGBTQ youth by phone, text, or chat. The Trevor Project’s crisis intervention services are critical for LGBTQ youth, said Price, because these youths strongly prefer an LGBTQ-specific approach. A national survey found that 80 percent of LGBTQ youth said that if they needed to contact a crisis line, it was important that the crisis line include a focus on LGBTQ youth (The Trevor Project, 2021a). Further, said Price, 74 percent of youths who have used The Trevor Project crisis services said they would not contact, or were unsure if they would have contacted, another service if The Trevor Project did not exist. Last year, The Trevor Project directly served over 200,000 LGBTQ youths who reached out for support. During their interactions with The Trevor Project, over 90 percent of youths with suicide risk were successfully de-escalated and sustained at the 1-month follow-up contact, Price said.

The Trevor Project is essential for youths in crisis, said Price, but there is also a need to reach young people before they enter crisis. Changes to

the mental healthcare system are necessary to meet the needs of the most vulnerable, including LGBTQ youth, Price said. Many LGBTQ youth have challenges finding accessible, affirming care. The COVID-19 pandemic, said Price, provided many technological adaptations that can now be used to address these challenges. For example, mental healthcare can be provided by telephone or videoconferencing; permitting cross-state licensures may also be beneficial for improving access. Platforms that allow asynchronous provision of mental healthcare can make care more accessible, more flexible, and less expensive, and can give youths the potential for privacy if their parents are not supportive.

Concluding her remarks, Price suggested that work to address the mental health needs of LGBTQ youth should apply an intentional, intersectional perspective. LGBTQ youth with multiple identities often face additional stressors such as bias, racism, anti-immigration attitudes, fear of deportation, and stigma, both within and outside the LGBTQ community; these stressors further compound the everyday stresses of being LGBTQ. For example, she said, Black LGBTQ youth have similar rates of mental health issues as non-Black LGBTQ youth, but they tend to have less access to care, more risk factors, and are often targeted for multiple identities. Price said that it is critical that intersectionality and unique factors are specifically addressed as these youths try to navigate the larger society.

Physical Health Intervention: HIV Prevention

There were over 37,000 new diagnoses of HIV in the U.S. in 2018, said Renata Sanders (Johns Hopkins School of Medicine). Two out of ten diagnoses were among youths ages 13–24, and more than 90 percent were among men, particularly Black men who have sex with men (MSM). There are multiple barriers that young people face in accessing HIV testing, prevention, and treatment, she said. Sanders discussed several multilevel strategies to address these barriers that are based in a socioecological framework. This framework recognizes the ability of individuals to make decisions but also acknowledges that individuals exist within interpersonal relationships, within institutions, and within a culture with laws and policies (Figure 5-1).

Sanders described how interventions work at each level, using HIV and PrEP (pre-exposure prophylaxis that people can take to prevent getting HIV) as an example. At the individual level, a person’s knowledge, perceived risk, and enabling factors impact whether they seek care, said Sanders. One intervention on this level is community messaging, using sex-positive messages and bright, visually appealing designs to encourage youths to seek out services (Arrington-Sanders et al., 2016). Echoing other presenters, Sanders noted that it can be valuable to “meet youth where they are”; this is often in virtual spaces, she said. At the interpersonal level, youth are impacted

by and in relationships with peers, parents, providers, partners, and others. One intervention that works on this level is Providing Unique Support for Health (PUSH), which is a coach-based intervention to engage Black and Latinx MSM and transgender women in HIV treatment and PrEP use. The program is focused on life skills and goal setting; participants reported that health coaches helped them to identify and reach goals, as well as to feel accepted. Parents are also an important interpersonal influence on youths, said Sanders. One promising intervention seeks to help parents and youths talk about sexuality, with a focus on PrEP, through videos and in-person counseling. Sanders noted that these types of interventions can be used not just with parents, but also with other trusted adult figures in a youth’s life.

Sanders explained that, at the structural level, HIV and PrEP interventions may include strategies to ensure access to safe housing and employment. A quarter of PUSH participants reported engaging in transactional sex due to housing and job instability; these structural-level interventions are critical for reducing HIV, said Sanders. At the policy level, comprehensive sexual and reproductive health education is essential for reducing HIV infection, said Sanders, yet sexual education varies by state, and eight states restrict teachers from providing LGBTQ-focused education (Raifman et al., 2018).

In his day-one presentation, Bauermeister mirrored Sanders’ assessment that interventions on multiple levels are necessary to address HIV in the LGBTQ community. There are a number of HIV interventions, said Bauermeister, some of which are biomedically oriented (e.g., HIV testing)

and some of which are more socially oriented (e.g., behavior change strategies). The Prevention Research Synthesis has a searchable compendium¹ of best practices or interventions that have been used by key populations. While there are many interventions for youths, said Bauermeister, many of the evidence-based strategies are “quite old.” Bauermeister suggested that there has been a slowing of new evidence that could promote new strategies for LGBTQ youth and that could help re-imagine how older evidence-based practices could be adapted for today’s youth. When considering interventions, it is critical that “we’re not doing a plug-and-play,” said Bauermeister. There is no one-size-fits-all intervention; implementation science can be used to customize, adapt, and scale programs. He noted that technology is an important tool for reaching young people, particularly for SGM youth who may be unable to access information or connection in other ways.

REFLECTIONS

Following the panel presentations, planning committee member Errol Fields (Johns Hopkins School of Medicine) led speakers and participants in a reflective discussion. Workshop audience members were invited to submit questions for panelists via the virtual livestream. Fields opened by noting that the inequities faced by LGBTQ youth, particularly those of color, are the result of intersecting social disadvantages, marginalizations, and oppressions. He asked panelists to comment on whether and how the interventions they described contribute to dismantling those oppressions. Sanders agreed with Field’s assessment and said that there is a need for multilevel, comprehensive interventions to address the intersecting identities, disparities, and marginalizations of many LGBTQ youth. Youth have many needs—affirming care providers, comprehensive health education, safe schools—which need to be approached in a culturally congruent way that incorporates intersecting identities and lived experiences. Price added that a multilevel approach is critical to address the multiple factors that impact youth well-being; for example, youths experiencing homelessness are unlikely to be able to adequately treat their anxiety or depression in the absence of stable housing. Price highlighted cost as a primary barrier to mental healthcare access and emphasized that impactful work for youth mental health is already being done in communities of color and could be adapted to become more LGBTQ-affirming. Craig agreed and said that, when implementing individual-level interventions, staff should also be trained to help participants with wraparound services, such as finding housing. She added that implementing interventions within organizations

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¹ See https://www.cdc.gov/hiv/research/interventionresearch/compendium/index.html.

can help shift the organizational culture and help dismantle oppressions and disadvantages. For example, integrating a caregiver intervention within the foster system can help dismantle transphobia and homophobia, and can “challenge the system in interesting ways.” Sanders added that utilizing a peer navigator approach is one way to address multilevel needs while supporting youth. For example, a young person paired with a similar but older peer navigator can get support with navigating internalized homophobia, addressing structural issues such as housing, and seeking physical and mental healthcare. Most importantly, she said, peers can simply “sit with them in that space” and listen to their concerns and worries. She noted that person-to-person engagement is particularly important when interventions are being conducted remotely (e.g., via Zoom).

In concluding her remarks, Price said that improving the mental and physical health of LGBTQ youth cannot be accomplished without addressing the lack of access to affordable physical and mental healthcare. Disparities in access to care “trickle down” to disparities in outcomes for LGBTQ youth of color, said Price. She emphasized that there are many existing interventions—particularly in communities of color—that can be adapted to be inclusive and affirming for LGBTQ populations.

A workshop participant asked speakers to share insights on engaging youth digitally during the COVID-19 pandemic while avoiding “Zoom fatigue.” Craig summarized some of AFFIRM’s techniques for engaging virtually, including taking frequent breaks during virtual sessions (sometimes involving a walk outdoors), integrating icebreakers and games, and working with co-facilitators so that one facilitator can be active in chat. She also noted that having young people involved in designing digital programming has been essential to engagement. Craig shared that there have been more youths interested in AFFIRM online than offline, and that the virtual format has allowed AFFIRM to provide services to young people who previously experienced barriers to access.

Fields closed the session by asking Price to speak about research on differences in suicide rates among Black youth. Price explained that in her work, she sees the fastest increases in youth suicide rates among Black youth. She also noted that, even when Black and White LGBTQ youth have similar rates of suicide attempts and depression/anxiety, Black LGBTQ youth have less access to care and experience more risk factors. She suggested that this is a vital area for further research.

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