Few Mental Health, Violence Interventions for LGBTQ Youth

Batya Swift Yasgur, MA, LSW

August 29, 2019

Although sexual and gender–minority youth (SGMY) experience inequities in substance abuse, mental health conditions, and violence victimization compared with cisgender (nontransgender) heterosexual youth, there are only a limited number of effective, SGMY-inclusive interventions, new research suggests.

In a systematic review study, researchers analyzed interventions for overall mental health, including substance use and violence victimization, in more than 1 million participants. They found that five sexual minority–specific interventions, one therapist-administered family-based intervention, a computer-based intervention, and an online intervention all improved mental health outcomes.

Despite these promising findings, however, only one study was of strong methodologic quality. The quality of the other studies was deemed "suboptimal."

"We found that there were only nine evidence-based interventions for addressing mental health, substance use, or violence victimization among sexual and gender–minority youth, [and] only one of these had strong methodological quality, suggesting that we have to cautiously interpret the findings from the existing interventions," Robert W. S. Coulter, PhD, MPH, assistant professor, University of Pittsburgh Graduate School of Public Health, Pennsylvania, told Medscape Medical News.

"More interventions are needed," he added.

The findings were published online August 19 in Pediatrics.

Priority Population

"Decades of research show that sexual and gender–minority youth experience great disparities in mental health, substance use, and violence victimization," Coulter said.

For this reason, SGMY are a "priority population" for research into preventing, reducing, and treating these problems, the investigators write.

They conducted their review because "we did not have a paper detailing the state of the field for interventions to address these issues among this vulnerable population," Coulter said.

Selected studies were published from January 2000 to 2019 and included randomized controlled trials as well as nonrandomized studies.

To limit potential bias in the nonrandomized studies, the researchers included only studies for which both preintervention and postintervention data were available for participants.

Cross-sectional and case report studies were excluded.

Studies were required to examine participants younger than 18 years at baseline. For studies that enrolled both younger and older persons, only those in which no more than 25% of participants were aged 18 years or older at baseline were included in the review.

Studies were required to include assessment of sexual or gender minority status.

More Than 1 Million Participants

The researchers defined "sexual minority populations" as persons who identify as lesbian, gay, bisexual, queer, or as being of other sexual minority, as well as youth who have same-gender sexual behavior or attractions.

They defined "gender minority populations" as transgender people — those who identify as transgender or whose current gender identity does not match their assigned sex at birth; or people with other gender-nonconforming identities, such as genderqueer.

Included studies examined substance use, including licit and illicit drug use, alcohol, and tobacco; mental health problems, such as stress, anxiety, depressive symptoms, internalized homo-bi- and/or transphobia, and nonsuicidal self-injury; and violence victimization. The latter included experiences/threats of bullying, cyberbullying, aggression, violence with weapons, sexual assault, harassment, discrimination, physical abuse, and emotional abuse.

Of 6598 unique studies that were identified, 424 were potentially relevant for inclusion. However, only nine studies met the inclusion criteria.

Of these, the researchers found nine interventions that covered general mental health, including two that also covered substance use and one that also covered violence victimization.

The studies selected by the researchers included 1,050,339 total participants (median, 20,127 participants; range 1030 – 762,768 participants; average age, 15.95 years).

More Interventions Needed

All studies reported gender identity or assigned natal sex; some studies reported only sexual orientation or sexual attractions or sexual identities (n = 3 studies for each).

The only study that included all SGMY was the Comprehensive Community Mental Health Services for Children With Serious Emotional Disturbances Program, more commonly known as the Children's Mental Health Study. It provides "coordinated networks of community-based services tailored to the local needs of youth."

Specific interventions in the study included individual therapy, medication, treatment, case management, group therapy, recreational activities, inpatient hospitalization, vocational training, family support, and residential treatment — all tailored to local participants as well as to their individual needs.

These interventions reduced symptoms of anxiety, depression, global functioning impairment, internalizing and externalizing symptoms, and substance abuse and dependence symptoms among those with SGMY.

However, the researchers gave the study a global rating of "weak," owing to selection bias, confounders, and withdrawals/dropouts. On the other hand, the study design and blinding were "moderate," and the data collection was "strong."

Five studies were tailored specifically to sexual minority youth (SMY); other studies evaluated interventions specifically tailored to SMY.

SMY-specific interventions included the following:

  • A therapist-administered, family-based intervention to reduce mental health problems

  • A self-administered computer-based intervention to reduce mental health problems

  • A self-administered online intervention to reduce substance use and stress

  • A state-level policy granting same-sex marriage

  • State-level general and enumerated antibullying laws

The GMY-specific studies examined transition-related gender-affirming care interventions, including puberty suppression, use of cross-gender hormones, gender affirmation surgery, and psychological support.

Although all interventions improved mental health outcomes, a therapist-administered family-based intervention, a computer-based intervention, and an online intervention were found to be especially beneficial.

One study, deemed to have "strong" methodologic quality, showed that state-level marriage equality laws significantly reduced suicide attempts among SMY. Another study with "moderate" methodologic quality showed that state-level general and enumerated antibullying laws significantly reduced bullying victimization for SMY.

Although the other seven interventions were associated with significant improvements in mental health problems and substance use, results of these "must be interpreted cautiously because of suboptimal methodologic quality," the investigators write.

"More interventions are needed, and we need a larger and stronger evidence base of interventions for sexual and gender minority youth," Coulter said.

He added that "if clinicians believe they have techniques that improve the health of sexual and gender minority youth, I'd ask that they please partner with researchers to evaluate them using rigorous methodologies."

Screen All Adolescents?

Commenting for Medscape Medical News, Donald Greydanus, MD, founding chair and professor in the Department of Pediatric and Adolescent Medicine, Western Michigan University, Kalamazoo, said this was an "interesting review that concluded, as most do, that we need more research and don't have a lot of good studies of interventions."

In addition, "Lumping these kids together doesn't help because there are issues going on that ought to be separated out, particularly with regard to transgender youngsters," said Greydanus, who was not involved with the research.

Transgender youth face unique challenges and seem to be more unhappy than other sexual minority because they "need to change," he added. It is important for clinicians to point out that the youth's need to change "isn't abnormal, it's how you were born and how your brain is functioning; so let's get you some psychological evaluation and take it from there."

Greydanus pointed out that the needs of sexual minority youth differ widely, depending on community and family culture, religion, and region.

"Every case needs to be addressed in any teenager who comes into your office or clinical practice, whatever their sexual orientation," he said.

"Even though this group may be more abused than others and have increased risk, every child and teen might be abused, could be depressed, or could have violence or substance use," Greydanus noted. "All should be screened, and treatment individualized to help that person."

The authors of an accompanying editorial agree.

"Clinicians who routinely ask all adolescents about gender identity, preferred pronouns, and sexual orientation in a nonjudgmental and developmentally sensitive way during annual visits are more likely to identify SGMY and better meet their health needs," write Nadia Dowshen, MD, and Carol A. Ford, MD, both from Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania.

The study was funded by the National Institute on Drug Abuse, the National Center for Advancing Translational Sciences, the National Institute on Alcohol Abuse and Alcoholism, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The study authors, the editorialists, and Greydanus have reported no relevant financial relationships.

Pediatrics. Published online August 19, 2019. Abstract, Editorial

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