Early mental health intervention and supported self-care for LGBTQ+ young people in the UK: a mixed-methods study

Scoping review

An initial scoping review conducted by the research team confirmed the nascent nature of existing research on early intervention support for mental health of LGBTQ+ youth. The primary aim of the scoping review was to assess the size of the available published literature on LGBTQ+ youth mental health early intervention services/support research. Scoping review methodology can be used to identify knowledge gaps, scope a body of literature and provide a roadmap for a subsequent full systematic review. 84 We searched four main databases, from 2005, for research examining LGBTQ+ youth and mental health services, and research on mental health interventions aimed at LGBTQ+ youth. We located 55 relevant studies and no systematic reviews on the topic. The scoping review revealed a body of literature from divergent research paradigms such as medicine, clinical psychology, psychiatry, sociology, cultural studies, education, youth studies, social work and queer theory.

For this reason, a configuring systematic review methodology68,85 was utilised rather than hypothesis testing systematic review methodology. A configuring approach is suitable as our scoping review did not find any randomised control trials and very few large-scale studies that are used to test causal hypotheses and ask ‘what works’?86 Use of a configuring rather than aggregative approach to the systematic review87,88 is appropriate for reviews with heterogenic literature, and it specifically aims to broaden understanding of particular services/interventions, asking instead, ‘what happens?’. 86 This discovery informed our decision to utilise the MNR method because it offers a strategy to make use of a conflicting body of research from diverse research paradigms. 89

Meta-narrative review rationale

Research on LGBTQ+ youth mental health early intervention services and self-care support is an emerging field of investigation. The nascent nature of existing literature, and limited theoretical explanations of why existing interventions and services are inappropriate for LGBTQ+ young people, guided our view that a theory-led systematic review methodology will be more fruitful than the traditional Cochrane and Campbell collaborations approach which are typically focused on forms of a meta-analysis. 90 Theory-driven approaches seek to detail the underlying logic or theory of how, why and in what contexts a service or intervention may work,63,68 which is necessary to ensure they are effective, sustainable and scalable. This underlying theoretical explanation is often overlooked but is, in fact, crucial to ensure that interventions that have been successful in their original contexts can be ‘meaningfully replicated’68 in other settings.

We chose to utilise the MNR method rather than other theory-led review methods (e.g. realist review, meta-ethnography, thematic synthesis) for two reasons. First, the scoping review revealed a heterogeneous body of literature consisting of disparate research paradigms with different epistemological and ontological perspectives that have produced a disjointed empirical evidence base. Second, our aim was to produce a theoretical explanation of mental health early intervention support for LGBTQ+ youth that could be tested within a case study evaluation methodology. A MNR is a distinct systematic theory-driven technique developed by Greenhalgh et al. 91 that is used to generate understanding from heterogeneous, complex, often contradictory evidence across diverse disciplines. 89,92

There are six guiding principles that inform MNR, and these were incorporated into each step of the review process from the outset. These are listed below (taken from Greenhalgh and Wong;93 Wong et al. 85):

• Pragmatism – being guided by evidence most likely to promote sense-making.

• Pluralism – explored from multiple perspectives and the quality appraised according to the discipline of origin.

• Historicity – attention to how the tradition within which the research evidence was generated has unfolded over time.

• Contestation – analysis and sense-making about conflicting evidence.

• Reflexivity – individual and team of reviewers continually reflect on emerging findings.

• Peer review – testing findings with external reviewers.

In addition to the six guiding principles, quality standards and training materials92,93 have been developed to ensure MNR are conducted in a systematic way ‘according to an explicit, rigorous and transparent method’91 (p. 418).

Specifically, MNRs make sense of complex interventions/services by exploring the implications of different conceptualisations of a given topic across a range of research paradigms over time. The underlying assumption is that key constructs, in our case ‘sexual orientation’, ‘gender identity’, ‘mental health’, ‘youth’ and ‘help-seeking’, are conceptualised, theorised and empirically studied differently among research paradigms. A MNR is premised upon a constructivist epistemological approach that suggests that knowledge is produced within particular research traditions (e.g. sociological, psychological, biomedical). Consequently, a MNR aims to make sense of heterogeneous bodies of literature by identifying, comparing and analysing the belief systems that exist within different research paradigms. The aim of this MNR was to obtain a theoretical understanding of how early intervention mental health services can support LGBTQ+ youth with common mental health problems. The review questions addressed were:

1. What empirical studies have been undertaken on mental health early intervention services and self-care support for LGBTQ+ young people?

2. What are the theoretical propositions for how and why these services may work?

Multidisciplinary team

Consultation throughout the review process with a wider team for the purposes of reflexivity and peer review of findings are central principles in a MNR. 93 A multidisciplinary research team is important to conducting MNR because it enables pluralism of approaches and an appreciation of distinct research traditions. 89 The Queer Futures Research Team included people from a variety of disciplines (such as clinicians, mental health nursing, psychology, public health, health economics, health science, sociology) and were involved throughout the MNR.

We also took the view that user involvement is key to conducting systematic reviews to ensure they will produce meaningful outcomes for all stakeholders. 90 The Queer Futures 2 study Project Advisory Group was consulted about the review at regular intervals. The Project Advisory Group comprised health service staff and commissioners; clinicians; voluntary sector practitioners who work with the population group; and a service user representative. We also conducted extensive PPI with LGBTQ+ young people recruited from different sites across the UK.

Search strategy

The aim of the search strategy, consistent with the MNR, is to identify documents that are conceptually or empirically relevant to the research questions. 85 Using the RAMESES85 standards for MNRs the protocol was registered with PROSPERO (CRD42019135722). The search terms (Table 1) were developed in four domain categories: (1) sexual orientation and gender identity, (2) age, (3) mental health and (4) intervention/service. Searching was then undertaken via relevant electronic databases including both discipline-specific databases and multidisciplinary databases to increase the scope. These included, for example, MEDLINE, CINAHL, PsycInfo, Academic Search Ultimate, Web of Science, British Education Index, NHS Evidence, Social Care Online (see Appendix 1, Tables 17 and 18). The electronic database search was supplemented by expert informants, journal hand searching, citation tracking, and informant-led grey literature online searches. All identified papers were then subject to the review procedure.

Inclusion/exclusion criteria

The inclusion/exclusion criteria (Table 2) were based upon the Population, Intervention, Comparison, Outcomes, Study (PICOS) framework. However, in comparison to other forms of systematic reviews, MNR does not pre-define a ‘preferred’ study design. This is consistent with the principle of pragmatism, that is, that evidence most likely to promote sense-making about the phenomenon (LGBTQ+ youth mental health support) and be most useful to the ‘intended audience’, is selected. 93 Thus, Table 2 represents PICOS criteria adapted to capture the diversity of possible search results that is acceptable for inclusion within a MNR.

The selection of papers for a MNR is an interpretative process that attempts to make sense of the literature to produce an account of how the research traditions develop over time. This MNR selection process was iterative, that is, it required a series of judgements within the research team about the relevance of particular research within that tradition. Papers published before 1990 were excluded because research published before this date were unlikely to be relevant given substantial changes in attitudes, policies and laws towards LGBTQ+ populations. The United Nations94 defines ‘youth’ as referring to people aged 15–24 years, but the age definition of youth varies across nations, disciplines and policies. Research written in English, Spanish, Portuguese, Italian and French were included because these languages are spoken within the research team. The inclusion/exclusion criteria were applied independently by two members of the research team.

Quality assessment

The systematic review methodology does not have a standard quality appraisal framework. We drew on the EPPI-Centre ‘Weight of Evidence Framework’95 and recommendations for theory-led systematic reviews96 to devise a quality appraisal tool (Table 3) that focused on the relevance to the review question and the quality standard in relation to the discipline of origin. The tool was applied by two members of the research team.

Data extraction

Data extraction and synthesis were simultaneously conducted using the data analysis software Atlas.ti. Three members of the research team developed a data extraction and synthesis coding schema (Table 4), and this was applied to the included studies. The use of Atlas.ti enabled easy comparison and contrast of the extracted data across the included studies for the synthesis of the literature.

Data synthesis

It is usual in the synthesis stage of a MNR to have two interpretative phases. In the first phase, reviewers aim to identify and map out specific meta-narratives for each research tradition, focusing in particular on the concepts, theories, methods and instruments, which have characterised the tradition. The second stage involves comparing the meta-narratives asking what insights can be drawn by combining and contrasting findings from different traditions. 85 We outline the two phases below.

In stage one of the synthesis, multiple research team members used the extracted data to identify the research paradigms and map each meta-narrative. In this way, the different research traditions ‘become the unit of analysis’. 89 For each research paradigm, we asked key questions:

1. How has each tradition conceptualised the topic?

2. What theoretical approaches and methods did they use?

3. What are the main empirical findings?85

The synthesis process was informed ‘a priori’ by the research team’s familiarity with the key concept areas of the research project: (1) LGBTQ+ identities, (2) youth, (3) mental health and (4) help-seeking. Therefore, theoretical understandings of these concept areas were used analytically to inform an interpretive reading of all the research tradition meta-narratives created. Emergent theories were recorded transparently as with other stages of the MNR process. 85

Stage 2 of the synthesis compared the key dimensions across the research paradigms to generate a higher-order theoretical understanding of how and why interventions/services might work. In particular, we attended to the conflicts that arise between the theories, concepts and findings underpinning research from different traditions. This is consistent with the principle of ‘contestation’ – the commitment of MNR ‘to engage in disagreements’97 (p. 732). This second phase of the synthesis was conducted iteratively, using five distinct analytical steps that were guided by the principles of a MNR: pragmatism, pluralism, historicity, contestation, reflexivity, and peer review91 (Table 5). We moved between these five steps and the key question we asked across the research paradigms was ‘what are the implications of the contested concepts for developing early intervention mental health support for LGBTQ+ youth?’

The multidisciplinary research team developed a robust theory68 consistent with the pluralism and peer review principles of MNR. 93 The theoretical explanation of mental health early intervention services and self-care support for LGBTQ+ young people with common mental health problems derived from the MNR was then ‘tested’ during the case study data analysis in stage 3 of the overall study design.

Method overview

This stage of the study drew on the successful mapping methods used in Pryjmachuk et al. ’s children and young people mental health self-care research. 98 Between February 2019 and February 2020, we employed systematic online and offline search strategies to identify services of various types for example self-care, peer-support, digital support, clinical; in a range of service settings for example health, local authority, third sector. Data collection was desk based and basic details (e.g. target population, mode of delivery, theoretical approach) of potential services obtained from any source were extracted and entered into an Excel spreadsheet. The service mapping data were tested against inclusion criteria in the information extraction phase and a final typology was generated to describe service provision across the UK. A full summary of the mapping data then produced a typology of services which was used to inform the selection of the CSS in stage 3 evaluation.

Search strategy

The search strategy was devised as both online and offline to identify services in the UK where youth, sexuality or gender identity, and mental health were a focus.

Inclusion/exclusion of services

The identified services were considered against inclusion and exclusion criteria. Determining whether services meet the inclusion criteria was an iterative process, dependent on the information available through the website and informal conversations with expert informants and the services directly. This was applied by two research team members. The inclusion/exclusion criteria are detailed in Table 6.

Data extraction

Detailed information (Table 7) about the operation of the eligible mental health services was collected using the service website, online resources, key contacts, and direct contact with the service via telephone or e-mail and entered into an Excel spreadsheet by two members of the study team.

Frequently it was difficult to determine from the information available during the searching phase (e.g. via websites) whether a service definitely met the inclusion criteria. In these cases, services were contacted via telephone or e-mail by the researchers for further information. Thus, the searching and information extraction was more of an iterative than linear activity and these activities overlapped considerably in practice. To assist in determining if services were relevant for inclusion, a flow chart was created in consultation with the Project Advisory Group (see Appendix 2).

Once services were deemed to meet the inclusion criteria, detailed information was collected about their operation. This information was extracted either from materials available in the public domain such as service websites and promotional materials or by requesting the information via telephone, e-mail or by asking a service representative to complete an online form. All information extracted was inputted into a spreadsheet for each of the categories in Table 7.

Typology generation

The typology of early intervention mental health service/support for LGBTQ+ young people was developed by five members of the research team. Framework analysis was used to create the typology of services from the information extracted during the mapping process. 98,99 Framework analysis consists of five processes: familiarisation, identification of thematic framework, indexing, charting, followed by interpretation. 100

During the familiarisation process, the researchers highlighted themes and similarities between the services. These initial observations along with the findings of the MNR informed the creation of the thematic framework, which provided the basis of the indexing and charting. A matrix format was utilised for the indexing and charting processes to a group of services. 98 The grouping of services informed the development of the service typology. Finally, the research team along with the wider project advisory group discussed the criteria for the service typology and produced a simple typology that identified the type of service provision available in the UK.

Case study selection

Case study sites were selected from each category of the service typology. The case study selection criteria were developed by five members of the research team and are outlined in Table 8. The criteria were developed to reflect the capacity of the service to participate in the research and to include a diversity of service models in a range of settings at a variety of geographical sites. The CSS were determined in consultation with the project advisory group and LGBTQ+ young people. Twelve CSS were selected.

Methods overview

The third stage of the project comprised a collective case study evaluation of mental health early intervention and self-care support services for LGBTQ+ youth across 12 case studies. A case study is an empirical enquiry that focuses on a single phenomenon in its real-life context, especially useful (as in our circumstances) when a description or explanation is required. 101 Collective case studies are those in which multiple cases are studied simultaneously or sequentially in an attempt to generate a broad appreciation of a particular issue. 69 Yin62,101 defines a ‘case’ as a ‘bounded entity’, a broad and flexible definition that allows the case to be as varied as an event, an individual, a service or a policy. In this project, we have defined the case as ‘mental health early intervention and self-care support service for LGBTQ+ young people in the UK’.

The 12 case studies were purposively102 selected from services identified in stage 2 (service mapping) to reflect the different dimensions of the stage 2 service typology. We estimated that 12 would be an adequate number of cases to capture the range of services identified in stage 2. Data were collected from key stakeholders in each of the CSS (n = 12) to examine factors such as service acceptability, gaps in provision, barriers/facilitators to access, views on service improvement and encouraging access/engagement. At each case study site, data were collected via:

1. Online interviews with LGBTQ+ young people, family members and service staff (n = 10)

2. Documentary review

3. Non-participant observation

4. Data were collected on service cost.

Case study evaluation is a theory-driven evaluation methodology and therefore the data analysis strategy is theoretical using the ‘explanation-building’ (EB) analytical technique. 62 The findings from each case study site were used to gradually refine the theoretical model developed in stage 1 of the study to produce an overarching theoretical understanding of how, why and in what context mental health early intervention services and self-care support work for LGBTQ+ young people. 69

Sampling and recruitment

A purposive sampling strategy64 was used to select participants within the case study sites to ensure that a diverse range of appropriate stakeholders (LGBTQ+ youth, parents and carers, health, social care and education professionals, and volunteers) were invited to participate.

For service staff, the inclusion criteria were that they worked for the case study service and had experience supporting the mental health of LGBTQ+ young people. For parent/carers inclusion criteria were that they had experience caring for an LGBTQ+ young person with common mental health difficulties who had sought mental health support. For LGBTQ+ young people, the eligibility criteria were as follows:

• 12–25 years old

• Identifies as LGBTQ+

• Experience of seeking support for a common mental health difficulty

• Currently engaged with the case study service

• Not in crisis.

Recruitment of LGBTQ+ young people was via digital flyers and posters circulated by the service staff. In some cases, research staff went along to online youth group sessions to introduce Queer Futures 2 and invite participation. In other cases, support workers passed the digital flyers directly to individuals they thought may be interested and safe to take part. Individual LGBTQ+ young people were selected purposively to ensure we involved a diverse range of LGBTQ+ young people including in relation to gender and sexual identity, ethnicity, poverty and disability. Recruitment of service staff was also purposive to gain diverse insights into LGBTQ+ youth mental health support depending on job role. Parents/carers were recruited only where there was a specific parent/carer support group.

In total 93 participants took part in the study: 45 LGBTQ+ young people, 42 service staff, 6 parents/carers (see Table 9 for demographic characteristics of participants).

Data collection

Data analysis

First, the data sets – interview transcripts, non-participant observation and documentary evidence – from each individual case study site were imported into Atlas.ti.9 computer software designed to assist in the organisation and analysis of qualitative and multi-methods data (the service cost data were not included).

The resulting data set was extensive and diverse as is characteristic of case study research. This volume of data needs to be managed systematically62,101,111 with a clear analytical data strategy in place prior to data collection. 111 Case study evaluation is a theory-driven evaluation methodology, and therefore, we drew on Yin’s EB data analysis strategy that is designed for case studies with multiple case sites (like ours) and aims to build a general explanation that fits each individual case.

Yin111 (p. 142) states this is ‘analogous to creating overall explanation, in science, for findings from multiple experiments’. EB is used where ‘how’ and ‘why’ questions (i.e. causal questions) are regarding complex topics that are difficult to measure. The explanation is therefore narrative and more robust if there is a central theoretical proposition. The theoretical framework/model developed from stage 1 MNR provided this and a coherent orientation for our case study data analysis. Generally, this approach has been poorly operationalised and described by other studies and therefore we relied upon insights from Yin. 111 There are three fundamental aspects of case study data analysis that informed our strategy:

1. This is a deductive and inductive approach

Explanation building is partly deductive because we had a theoretical model from stage 1 that we proposed explains early intervention mental health support for LGBTQ+ youth. This model came from the literature/evidence, and we were ‘testing this’ with our 12 case study sites. EB is also partly inductive because we suspected the model was inadequate and we were using data from the case study sites to revise and improve the model.

1. Includes within-case analysis and cross-case synthesis

What is important to case study analysis is a whole-case approach. In a sense, the case study site is the unit of analysis. This means for each case study site we conducted a ‘within-case’ analysis, followed by cross-case synthesis comparing whole-case study sites. The aim was to retain the integrity of each entire case study site. In this way, the findings from each case study site data analysis were used to gradually refine the theoretical model developed in stage 1 to produce an overarching theoretical understanding of the mechanisms by which mental health early intervention services can support LGBTQ+ young people with common mental health problems.

1. Uses a series of iterations

The iterative nature of EB is central to the approach of a case study with multiple case study sites. Eventual explanation results from a series of iterations, and if done in relation to a theoretical proposition increases the trustworthiness of the findings. The findings from each case study site were examined and compared to the theoretical model from stage 1 which was then revised, and the evidence examined again. This iterative process was important to ensure other plausible explanations were considered in the process. 62

In this way, the findings from each case study site data analysis were used to gradually refine the theoretical model developed in stage 1 to produce an overarching theoretical understanding of the mechanisms by which mental health early intervention services and self-care can support LGBTQ+ young people with common mental health problems.

Operationalising EB data analysis in a case study evaluation with multiple case study sites is difficult because we had a large amount of complex data. Our analysis was conducted on each site only when all data had been collected for that individual case study site. The iterations of analysis were in four phases as follows:

1. Deductive within-case analysis Revision of model

2. Deductive/inductive cross-case analysis Revision of model

3. Inductive within-case analysis Revision of model

4. Inductive cross-case analysis Final revision of the model.

The four phases of the case study analysis process are represented in Figure 1.

FIGURE 1.

Four-phase case study analysis.

Intersectionality, including factors that were ‘missing’ or privileged, was held at the forefront of the analytical process throughout.

Coding took place in Phase 1 using a coding framework developed from the theoretical model from stage 1: MNR. As this coding was deductive, these were referred to as ‘D-codes’. Inductive codes (‘I-codes’) deduced from the data through this initial coding process were then applied in Phase 3 (see Appendix 3 for coding frameworks).

Informed consent

For participants in online interviews, informed consent was gained through an electronic signature on a data-secure form before taking part in the interview. Informed consent is an ongoing process, with participants being reminded of their right to withdraw at intervals throughout the study. LGBTQ+ young people aged 12–15 years were afforded the right to give consent without the need to involve their parents/guardians. Requiring parental consent may have placed the young person at risk of hostility, abuse and rejection if their parents were previously unaware of their sexual orientation or gender diversity. 86 There is evidence that disclosure of LGBTQ+ identity to some parents and carers can have potentially harmful consequences and risks familial rejection, abuse, homelessness, and violence. 42,115–118

It is increasingly recognised that young people under 16 years of age are able, and should, give consent for taking part in research as long as they are judged as competent. 119–121 In the UK and globally it is recognised that children’s opinions should be considered in all matters that affect them, and this is ratified by the UN Convention on the Rights of the Child as a fundamental right. 122 It is now common practice for research studies examining LGBTQ+ young people and health to waive parental consent. 123–128 Studies suggest that the majority of parents agree that parental consent should not be required for LGBTQ+ young people to participate in research because of the risk of harm. 129 In addition, studies show that LGBTQ+ young people are less likely to participate in research if parental consent was required. 130 The LGBTQ+ Young People’s Advisory Group for this study confirmed that it was important that parental consent was waived to encourage young people to participate in research and contribute their views and experiences.

Research guidelines for recruiting and protecting LGBTQ+ young people suggest that waiving parental consent is warranted if the research involves only minimum risk, the rights and welfare of the participants will not be adversely affected and the research could not be conducted without a parental waiver. 131,132 The three main components of informed consent are as follows: the information is presented in an understandable way; consent is voluntary; and the participant has capacity to provide consent. 120 In Medical Research Council ethics guidance on research with children, competency is considered not to depend primarily on age, but rather on the ability to understand and weigh up options. 133 Competency can be influenced by the way information is presented and many young people will be competent if information is presented in an appropriate way and they are supported through the decision-making process. 133 We worked alongside the LGBTQ+ Young People’s Advisory Group to ensure the informed consent process was appropriate and the study took the following steps to obtain informed consent:

• Informed consent was gained through a digital signature for all participants (young people, key/youth/education workers, parents/carers). Participation in the study was discussed with a study researcher who was independent and not involved in any services the young person was receiving, or staff were delivering. The project information sheet and consent form were available before an interview was conducted to ensure participants had time to consider the material, ask questions and seek any further information.

• The study materials for LGBTQ+ young people were presented in an accessible way and in an age-appropriate format to help ensure those who may have literacy problems, are younger or have language barriers were able to provide informed consent. The participant information sheet (PIS) for young people was presented in three formats (see Report Supplementary Material 3): (1) accessible language written PIS; (2) visual infographic abbreviated PIS; and (3) PIS video with voiceover audio description. The PIS materials were co-produced in collaboration with the study LGBTQ+ Young People’s Advisory Group to ensure they used appropriate language, at an appropriate level of comprehension and address the correct issues and concerns that young people may have about participating in the study.

• To facilitate the informed consent process, study materials were available on the study website (www.queerfutures2.co.uk). The Chief Investigator’s previous studies have shown that online content about the research study enables LGBTQ+ young people to learn more about the study, who is involved, why it is happening and what will actually happen if they participate in an interview. 42 Online content allows potential participants to read the information in their own time, in a format that is familiar. The project website had been designed in collaboration with the study’s LGBTQ+ Young People’s Advisory Group, in an accessible format with safety features such as a quick exit button to ensure they can leave the webpage quickly if necessary and maintain their privacy.

• Participants were advised of their right to withdraw from the study at any stage and the right to request their data to be deleted from the study dataset.

• Young people aged 12–15 years gave informed consent if they were deemed competent. For a young person to be deemed competent, they had to have study information presented in an understandable way; understand consent is voluntary; and have the capacity to provide consent. 134 In line with guidelines for researching children’s mental health,120 four criteria were used to assess capacity to consent:

  1. Can the individual understand the information given to them?

  2. Can the individual retain that information long enough to be able to make a decision?

  3. Can the individual weigh up the information available to make a decision?

  4. Can the individual communicate their decision to you?

Risks, burden and benefits

Confidentiality, data handling and record keeping

Key to ensuring that LGBTQ+ young people participated safely in the research was confidentiality and anonymity. The study was compliant with Lancaster University GDPR full policy. Data were handled and stored in three universities (Lancaster, Leeds and Brighton) during the active data collection phase. We took the following measures to protect participants’ confidentiality and secure the study data:

• The three study researchers each maintained an electronic file of potential participants to be contacted to discuss the study and obtain informed consent. This file was a general record of the study recruitment process and will include names for the purpose of contacting potential participants to obtain consent and to arrange an interview and focus group date and location (where appropriate). Once the interview had taken place, these details were deleted from the register. The names and contact details of people who did not provide informed consent were deleted from the register, but a numeric count was kept to record the number of people who were unable to or unwilling to take part. Each University (Lancaster, Leeds, Brighton) stored its files on the Lancaster University secure encrypted cloud storage – OneDrive. Only the immediate research team undertaking fieldwork had access to this folder.

• Online interviews were recorded direct using Teams or Zoom and immediately converted to audio-only files for transcription (to remove the video component to protect anonymity) and stored in OneDrive. WhatsApp interview chat was exported direct to OneDrive. Only the research team undertaking the fieldwork had access to the drive.

• The signed participants’ consent sheets were completed online, and copies were exported and stored with other data in the secure OneDrive filestore.

• Transcribers signed a confidentiality agreement when transcribing and accessed the recordings direct from OneDrive. A specific folder was set up to share with the transcribers, so they only had access to these files. Transcriber(s) were requested where possible to stream the audio direct (rather than download it to their own computer). Audio files were deleted immediately when the transcription was complete.

• The complete anonymised study dataset was electronically stored in the encrypted Lancaster University OneDrive and accessible only to the Chief Investigator, two co-applicants and three study researchers.

• Following the end of the study period (December 2021), all anonymised study data will be stored for 10 years in a secure network drive on the Lancaster University secure server and access restricted to the Chief Investigator. This is compliant with Lancaster University’s Research Ethics and Governance code of practice.

Reporting procedures for risk and adverse events

We employed a two-tier approach to responding and reporting concerns of risk or adverse events. If the participant became upset during the interview, it was planned to be addressed by taking a break or ending the interview if they become upset. All participants were provided with details of local support services and encouraged to seek support from their regular service provider. In addition, interviews with LGBTQ+ young people were all arranged with a check-in follow-up meeting with their support worker at the case study service immediately after the interview.

We obtained copies of each case study service’s safeguarding policy and in the event that a participant disclosed or presented with major concern or significant risk to themselves or others, we had an agreement with the case study service to follow this procedure. There were no reported risks or adverse events throughout the data collection period.

Search results

The search was conducted between March and June 2019. In total, 2951 titles and abstracts were screened, and 200 full papers reviewed. Eighty-one studies were excluded due to not meeting the inclusion criteria and 31 studies were excluded for quality reasons. Eighty-eight papers remained for inclusion in the final analysis (see Figure 2 for PRISMA flow chart).

FIGURE 2.

PRISMA flow chart.

Stage 2. Synthesis: developing a theoretical framework

The framework we have produced is ‘theoretical’ (Figure 3) and it is not a blueprint for a mental health support service. The framework contains the key dimensions, derived from the literature, of a service for successfully supporting, at an early stage, LGBTQ+ youth with common mental health problems. It draws on models found in the literature that attempt to capture the multilevel (macro, meso, micro) interacting complex factors required to support the mental health of LGBTQ+ youth. 172 Our framework has a critical approach to LGBTQ+ youth mental health support, paying attention to three key contestations across the meta-narratives: (1) the conceptualisation of adolescence/youth; (2) theorisations of mental health; and (3) the theoretical propositions for why LGBTQ+ populations have elevated rates of poor mental health.

FIGURE 3.

Theoretical non-pathologising framework for providing mental health support to LGBTQ+ young people.

Explaining the theoretical framework

Youth rights

Our analysis suggests that youth rights should underpin the delivery of all early mental health support for LGBTQ+ young people. It is crucial that LGBTQ+ young people are enabled to make informed independent decisions about their own bodies and lives, and for the right to freedom of self-expression to be upheld so they can explore their LGBTQ+ identities safely. The UK is a signatory to the UNCRC which describes both youth rights and the right to good mental health but a rights-based approach to mental health service provision is not prominent or mainstream.

The ability of LGBTQ+ young people to make decisions about their mental health is often compromised by discrimination due to their LGBTQ+ identity and age often leaving them powerless compared to adults. This means they are less able to make decisions for themselves about their own lives and less able to be in control of the circumstances around them, for example what services they can access, opportunities to earn money, etc. 212 Where services enable LGBTQ+ youth rights, we found this had an impact on their mental health. Sandy, a staff member, stated:

I think confidence in being able to say: ‘actually, my rights are this, I can wear this uniform’ or ‘I can use the toilet that is assigned to my gender’ because that confusion, can create unease and anxiety. We’ve had young people who won’t use their school toilet for the whole day, all of these affect a young person’s mental health and wellbeing.

The analysis suggested that where typically the youth-rights discourse in the UK context is silent, in the services provided by the case study sites, there was frequently explicitly communicated commitment to upholding the rights of LGBTQ+ young people. This was especially apparent in relation to confidentiality and seeking healthcare services, for example for gender identity and transition support. When providing good mental health support, services made LGBTQ+ young people aware of safeguarding processes and the limits to their confidentiality in circumstances where there is a safeguarding concern.

Our findings indicate that the rights to non-discrimination are also key for LGBTQ+ young people who are at high risk for marginalisation, victimisation and harassment. LGBTQ+ young people must be supported in their right to safely explore and express their sexual and/or gender. UNCRC (1996) also highlights how LGBTQ+ young people have the right to know about rights. Being supported through advocacy and education to understand and express rights in different areas of life and feeling safe to express identity was imperative. In the case study sites, service staff were advocates for LGBTQ+ young people and they were helped to uphold their rights in health services and institutions such as schools, for example toilets and changing rooms and uniforms. Bryn, a service staff member, stated:

I think education of rights, psycho education, so LGBTQ+ people can understand that what they’re going through doesn’t mean that they’re crazy or insane or they should be judged or rejected or feel shame.

Intersectionality

The experience and impacts of oppression and identity categories are often conceived as discrete from each other and static. LGBTQ+ identities are often represented in homogeneous ways, structured by homo- and trans norms that centre whiteness, heterosexuality, class privilege and being non-disabled in relation to the ‘right’ ways to be LGBTQ+. 79,80 These norms can and do assert themselves in LGBTQ+ spaces. 213,214 In our findings, the impact of services being structured around such norms is that LGBTQ+ young people feel the need to minimise or hide some parts of their experience, or to assume the burden of educating those providing them with support.

Yeah, being a trans person of colour is extra difficult and it’s another one of those things that you have to either censor yourself about or give people a crash course on racism and either try to convince them that the whole ‘I don’t see race’ thing is part of the problem or just give up and pretend they’ve got it. And aside from just skin colour there’s lots of cultural differences and challenges to navigate with parents from other cultures or who speak other languages etc that British people don’t understand.

Blue, young person

Doing intersectionality in mental health support services requires critical reflexive practice to support the identification of how to work in appropriate anti-oppressive ways, and the identification of intersections as they pertain to privilege. Intersectional mental health support needs to operate at multiple levels: interpersonal, disciplinary, cultural and structural. Services must consider the systems of operation; the culture and norms reproduced (or marginalised) by the service; and structural aspects such as location, opening times and financial support. Central in these considerations must be the questions of which LGBTQ+ young people are privileged and excluded, and how.

I think it’s about acknowledging the layers of stigma and prejudice that people carry and hold and the impact of all those are. I think we definitely need to have a [POC] LGBT+ worker, who personally understands that intersection because I think you can have all of the compassion in the world and the intent and the want to know and understand and that’s essential to being a good human, I think – but not understanding first hand is very different.

Alex, staff member

In practice, this means the service should ensure that ‘intersectionality’ is understood thoroughly, and that robust staff training is available to support understanding. Across our case studies, intersectional considerations related to age, different LGBTQ+ identities, chronic illness, disabilities, racism and colourism, neurodiversity, homelessness and poverty and experiences of the care system. Our analysis highlights the centrality of racism, colourism and white privilege in considerations around intersectional practice, and the need to shift positioning away from recognition of any ‘absence’ of LGBTQ+ young people of colour to the awareness that this represents dominance of whiteness in LGBTQ+ spaces. ‘Intersectionality’ does not only apply to marginalisation but also reflects intersections of privilege. Service providers and practitioners must be cognisant of power imbalances in relation to privilege and marginalisation and awareness that individuals can and do experience both.

Ensuring that practice is anti-oppressive and reflexive includes attending to the suitability of staff to deliver support for LGBTQ+ young people, by ensuring for example that targeted groups are run by adults who are also LGBTQ+ people of colour, or trans and non-binary people. Awareness of the benefits of lived experience of staff must be accompanied by adequate support for staff well-being, as multiply marginalised staff will also be managing the impact of experiences of racism, transphobia, classism, or ableism. Examples of practical support and inclusion for intersectional identities across the case studies included projects foregrounding specific experiences of marginalisation and offering support accordingly, such as groups for young LGBTQ+ people of colour, and the provision of time-out space(s) to support access related to neurodiversity.

Time

Our analysis highlighted the importance of time in relation to young people’s access to and experience of mental health support. The analysis clearly indicated that time poverty impacted individuals and services. 215 Waiting times for accessing mental health support in the UK are well documented, as are the limitations in frequency and duration of mental health support provision through CAMHS and AMHS. 216,217 When the time to engage arrives it is often rushed and limited, with the duration of support being pre-defined and limited. Our analysis found that this had a damaging impact on LGBTQ+ young people:

Lack of time, access, trying to get an appointment. It’s really difficult for anyone but particularly for the young person if you’re holding stuff around identity and you really don’t want to discuss that with someone. So feelings around being rushed. Fears around being closed down.

Laurel, staff member

Time is crucial to support trusting relationships between support staff and LGBTQ+ young people. Having sufficient time to build trust with service practitioners made it easier for young people to open up about their feelings and experiences and reduced the risk of LGBTQ+ young people feeling frustrated and not cared for within support.

Having the ability to see the same staff member is very helpful as it gives a sense of continuation. You don’t have to explain yourself over and over again to a new person.

Jamie, young person

Our analysis also indicates that delivering support that works with the LGBTQ+ young people’s pace and direction will enable LGBTQ+ young people’s autonomy because they are afforded the time necessary to ensure that decisions they make about their care are fully informed, that is, time to ask questions, think and change their minds. In addition to the practical impact of waiting for support, our analysis demonstrated that services needed to understand that waiting resonates in specific ways within LGBTQ+ young people’s lives. Waiting to leave home or move away to be more ‘fully’ oneself, for example, is an experience many LGBTQ+ young people share. For trans and gender-diverse young people looking to transition, long waiting times to access Gender Identity Development Service (GIDS) or Gender Identity Clinic (GIC) care have a particularly burdensome impact. 218,219 Isla (staff member) highlighted the importance of offsetting the problem of waiting:

It’s more about the, yeah, the kind of social support, emotional support. Because I think that, yeah, I guess with medical transition there’s so much waiting that the social support really holds up your mental health throughout that time.

While time as a resource may be limited or constrained in ways that are beyond an individual services’ control, for example due to waiting lists for other services that young people may be referred to, our case studies highlighted that services can address and incorporate consideration of time. A rapid response to initial contact and ‘while you wait’ support reduced the possibility of LGBTQ+ young people falling through gaps in provision. In practice, this included ensuring that the service was available for some kind of engagement ‘any time’, for example, there being someone to talk to, or offering remote access via phone or Internet. ‘While you wait’ support included providing bridging support (e.g. online and face-face activities and ‘drop ins’) to ensure there are multiple pathways into support for LGBTQ+ young people.

People

Trusting relationships with adults can be complicated for LGBTQ+ young people due to fear and past prejudicial experiences from adults (e.g. teachers, parents and carers) about their sexual and gender identity, and LGBTQ+ young people often do not ask for help from adults even when they need it. 42 The analysis suggests that mental health support services should not presume that LGBTQ+ young people trust adults or have a trusted adult in their lives. Our research indicates that LGBTQ+ young people may feel unsafe in relationships with adults including authority figures and institutions such as social workers and the police. This distrust may be exacerbated due to multiple marginalisation and discrimination, for example institutional racism and how this intersects with being LGBTQ+ and navigating healthcare services. 220

We’re a mental health service, so we sometimes suffer from that lack of trust that young people might have in professionals, if they’ve been burnt before where someone has handled something in the wrong way, someone’s betrayed their trust, that’s quite a common problem.

Billie, staff member

Our findings demonstrate that important relationships for LGBTQ+ young people may include: support staff; peers; LGBTQ+ adults; family and school. Our analysis shows that services should actively seek to build trust between LGBTQ+ young people and adults in their lives. This is distinct from the presumption that their relationships are already (or should be) trusting ones. ‘Adult’ or cis/heteronormative assumptions about relationship hierarchies should also be avoided, for example parents and family as ‘most important’. For many, familial relationships could be the source of distress, harm or violence. Instead, the diversity of different relationships in an LGBTQ+ young person’s life should be celebrated and supported. Where relevant, supporting LGBTQ+ young people to navigate their relationships with their family/carers or teachers/school may be helpful. However, awareness that family and school relationships are important for some but may have little relevance for others, is imperative.

Being introduced to diverse LGBTQ+ adults is one way that trust in adults can be (re)built as this limits fear about being judged due to being LGBTQ+. Active facilitation of peer–peer relationship building through group work and sharing space, fun and activity is another important dimension that facilitates belonging. Relationships with support staff should have boundaries but also be reciprocal, for example listening and talking on both sides. This reciprocity helps address power imbalances inherent in this dynamic between an adult and a young person and fosters trust and security. In all instances, support to navigate relationships must prioritise the needs of the LGBTQ+ young person.

The service has helped me open up more although I do believe this is because of the human connection and experiences that my support practitioner has had, it makes me see the person as another human rather than well I guess a machine just doing their job if that makes sense, I’ve opened up due to that connection and the safety I feel.

Bea, young person

Body

Physical health and well-being are interrelated with mental health outcomes; physical illness, activity levels, nutrition and sleep all impact on mental health. 221–224 The body is also a crucial site for self and gender expression, in terms of how people present and express themselves through appearance and comportment. Cis-heteronormative expectations around gender expression impact LGBTQ+ young people’s mental health, especially trans and gender-diverse young people. 225 In the case study sites we evaluated, LGBTQ+ young people reflected on experiences of inappropriate interest in and scrutiny of their bodies when accessing mental health support, as well as policing or invalidation of their gendered presentation and expression. Aspects of their distress that relate to the body were left unaddressed at best or exacerbated at worst.

[…] health services finding out I’m trans and ‘oh just out of personal curiosity’ a million inappropriate questions they didn’t need to ask me because ‘oo let’s ask the medical curiosity some stuff while they’re here’ attitude?

Kai, young person

Experiencing scrutiny, policing and the undermining of autonomous decisions in relation to the body not only detracts from the potential benefits of mental support for LGBTQ+ young people but actively contributes to distress. Isobel (young person) stated, ‘I had a counsellor that didn’t believe me being trans [...] like “I see a confused man in front of me who’s very lost with their identity” [...] it really doesn’t help especially when I’m feeling vulnerable’.

These experiences erode LGBTQ+ young people’s trust in services, contributing to their underuse of mental health services more broadly. Across the case study sites, we found that spaces and resources to explore self-expression were invaluable for the validation of LGBTQ+ identities and supporting mental health. Our analysis indicates that providing support around the body enables LGBTQ+ young people to build confidence in self-expression, attend to their physical health and well-being needs, and make informed decisions about their own bodies. Sophie (staff member) explained:

Offering the practical support alongside that emotional support is really important and being able to discuss topics or issues if there is something that maybe we don’t know, can say alright I’ll find that out for you; access to resources. […] the knowledge base is just the most important because if a young person wants to speak to us about binders for example, just the fact that we know about binders removes the barriers. And because […] it’s not a massive issue, and we understand and know about what binders are, check that they’re being safe with binders, and because I suppose we’ve got that knowledge base, it instantly removes barriers.

In practice, we found that services supported the body by upholding and advocating for the bodily autonomy of LGBTQ+ young people; providing practical, emotional and affirming support for gender exploration, expression and transition, including in relation to GIDS/GIC referrals; validating and including diverse trans and non-binary bodies through visibility and representation; and supporting LGBTQ+ young people’s physical health while avoiding reductive assumptions that exercise or weight loss represented ‘cures’ for mental health difficulties.

Space

The spaces in which mental health support is delivered are not benign for LGBTQ+ young people. The analysis of the case study data suggests that the space in which mental health support is provided needs to be (re)defined, owned, and occupied by LGBTQ+ young people and their needs. Our analysis found that LGBTQ+ young people felt that typically all spaces they inhabited were owned, controlled, surveilled and designed by adults. 212 As a consequence, they were contained and controlled by the demands of these adult and/or cis-heteronormative spaces. In our model ‘space’ is conceptualised as not only a physical factor but has emotional and social dimensions too.

I’ve written a lot about space in my practice, because it is something that is defined by other people and owned by other people and it’s problematic. People don’t give trans people any space without asking them to say why they’re taking it up.

Harper, staff member

Being comfortable and feeling powerful in the space is invaluable for LGBTQ+ young people’s mental health as this allows for freedom to explore and express LGBTQ+ identities. Services should prioritise building familiarity and ownership of space by LGBTQ+ young people including awareness that the space is not for parents/carers and uninvited adults. Meeting with other adults/professionals in spaces that are considered the ‘territory’ of LGBTQ+ young people can help address power imbalances between LGBTQ+ young people and adults. Laurel (staff member) elucidates:

We’ve set up an appointment to share with the psychiatrist, a community psychiatric nurse and the young person and that’s worked really well when we’ve been able to have that onsite that’s familiar to the young person. They’ve come in beforehand and we’ve laid out the chairs. It’s trying to think about their empowerment, to help them and to have their voice heard in a place where they feel that they’re already listened to, it’s not medical.

Our findings also demonstrated that orientation in the space can ensure services are navigable and not confusing or dis-orientating which can be intimidating and isolating. If possible, mental health services should ideally consult and co-design the space with LGBTQ+ young people to ensure it is safe on their own terms, for example time-out space or systems, trans and non-binary specific space.

Safety

Lesbian, gay, bisexual, trans, queer/questioning, plus young people often feel unsafe or insecure in areas of their lives such as with family, at school, or on the street due to bullying and harassment in relation to their gender or sexuality,37,226,227 and feelings of powerlessness due to their age. 13,212 The fear experienced as a result creates widespread uncertainty for LGBTQ+ young people about what may happen to them, including within mental health support services, with fears arising around the possibility of being judged or being outed to parents or carers by services. 42,51 In this context, safety does not only pertain to being safe from physical harm but also extends to emotional, social, and material safety. Where being LGBTQ+ places young people at risk of harassment and violence, this is exacerbated in the case of people who are multiply marginalised, such as LGBTQ+ young people who are black or people of colour, trans or gender diverse, or disabled. 37

They’re so scared that somebody will find out, and somebody will judge, and all that sort of thing. So when the young person comes to talk to us, we need to open up those layers that they find frightening.

Jasmine, staff member

Fostering safety in mental health support settings for LGBTQ+ young people involves active reassurance around confidentiality and anonymity. Our analysis demonstrated that services must ensure LGBTQ+ young people understand that nothing will happen ‘to them’ as a young person without either informed consent and agreement, or at least with knowledge about what is going to happen in the case of safeguarding interventions that necessitate confidence breaking. Transparent and honest communication between mental health support services and LGBTQ+ young people is essential to ensure young people feel trust and safety.

Experiencing emotions was beneficial, the service was just the only place where I felt safe to do so. So my sometimes having strong negative feelings in group was a result of me feeling safe.

Blue, young person

In practice, the service should understand that inadequate support services can be exclusionary and harmful, which can exacerbate mental health challenges. Our analysis highlights the importance of avoiding normative adult assumptions that the police and other authority figures represent safety for LGBTQ+ young people. In line with intersectional considerations, services must be aware that factors such as institutional racism increase the burden of risk and exclusion from mental health support services for LGBTQ+ young people of colour.

The young people were like: you should have warned us, you should have let us know they were going to be in our space, what are you thinking of bringing police here?

Leni, staff member

Some of the practicalities of creating safety for LGBTQ+ young people across the case study sites included the provision of all-gender toilets and using an online presence to manage expectations about ‘what will happen when you visit’ such as video service walk-throughs and offering ‘taster’ sessions. Service staff moderation of both in-person and online support was essential to ensure that support was welcoming and non-threatening. Across the case studies, safety was enacted via, for example, responding to and supporting those experiencing bullying, offering non ‘scene’ spaces away from alcohol and drugs, and sharing policy and practice to address bullying and victimisation.

Agency

Due to legislative, policy and developmental norms, LGBTQ+ young people have limited autonomy and agency compared to their adult counterparts. 212 The conditions created in mainstream mental health support services frequently reinforce this disadvantage, for example when parent or carer consent is required for treatment decisions. 51,107 This ‘adult knows best’ standard frequently acts to minimise LGBTQ+ young people’s distress and experience.

I have only ever heard negative feedback, young people not feeling like they are being support or heard by CAMHS. Young people feel like their care plans aren’t being updated as they should, feel like they aren’t being listened to when suggesting what is not working for them or with regards to assessments/medications.

Service document

The analysis of the case study data demonstrated that to best support LGBTQ+ young people’s mental health, services need to facilitate and encourage autonomous decision-making and position LGBTQ+ young people as experts of their own experience. Supporting LGBTQ+ young people where they may be inexperienced due to, for example, their age requires a respectful option-based (not directive) approach which better enables LGBTQ+ young people to feel more powerful and confident in relation to their own lives and help-seeking.

They gave me a list of things and what those types of support would do and let me choose, they didn’t really keep anything from me or make me feel like I wasn’t in control of the decision but if I didn’t know what I needed they would advise me in what they think might be best but still let me choose.

Devon, young person

Our analysis highlights the importance of services integrating an awareness of the power imbalances between young people and adults into practice. The service should be young person-led wherever possible, through inclusive and accessible feedback mechanisms for example. In the case studies, support was delivered collaboratively with LGBTQ+ young people, to ensure that young people felt actively involved in provision and not as though things were being done to rather than with them. Services were transparent around confidentiality, privacy and safeguarding processes, and supported non-directive and options-based decision-making including the option for young people to say ‘no’. Ellie (young person) stated ‘[w]‌e were given a chance to explore ourselves and discover what we need. As well as being given the independence to make our own choices’.

Our findings suggest that upholding agency and autonomy requires taking seriously LGBTQ+ young people. Advocacy for LGBTQ+ young people should uphold their decisions where autonomous, agentic decision-making power may be limited due to multiple marginalisation on the basis of racism or ableism, for example.

Belonging

Social isolation and marginalisation are common for many LGBTQ+ young people and have a direct impact on mental health. 13,72 Socioeconomic and material limitations experienced due to being young, living in care and/or poverty exacerbate the situation, for example restricted funds or technology to access social spaces. 228 Furthermore, dominant cultural norms and assumptions related to LGBTQ+ young people as white, middle class etc. 79,229 mean that many may be excluded from ‘mainstream’ LGBTQ+ support. This is particularly the case for LGBTQ+ young people of colour, those living in poverty and trans or non-binary young people. 213,230

Being in the queer community and having mental health issues is one thing, but I feel being trans adds another layer. You can begin to feel ostracised and alone even in your own community (especially in the current political climate).

Harri, young person

Our analysis found that supporting LGBTQ+ young people’s mental health required services that foster belonging through active LGBTQ+ community building and group work to address social isolation while validating LGBTQ+ identity. If this is not available in a service signposting to trusted experienced providers of LGBTQ+ specific support should be available.

In practice, the case studies developed ‘community building’ in a multitude of ways that cultivated togetherness and unification through sharing, for example space, food, time, experience, identity characteristics and memories. This LGBTQ+ community building, our analysis suggests, nurtures individual relationships while raising awareness of the ‘wider world’ which unites LGBTQ+ young people through their shared experience of cis-heteronormativity. The case study site analysis indicated that there is no ‘one size fits all’ and that LGBTQ+ communities are multiple and diverse not homogeneous. Protected spaces to foster these communities, for example annual residentials or specific identity groups foster an understanding that everyone there ‘shares’ certain characteristics and experiences without that being the totality of their identity.

It enables trans youth to connect with each other which allows people to explore their identities more and just exist with other trans people. which I think in itself is very empowering and good for my mental health.

Sammy, young person

Our findings highlight how support should be offered in a way that promotes comfort and care for LGBTQ+ young people including in language (of care) and practices that actively support the young person to sustain a meaningful engagement with the service. These ‘care practices’ included helping a young person to ‘settle in’ to a group through checking in, reassurance, and buddying with another LGBTQ+ young person. The analysis also suggested that support can foster LGBTQ+ belonging in the service’s resources by presenting diverse LGBTQ+ identities in service promotion materials.

Recognition

Our analysis demonstrated that, within mental health services, LGBTQ+ young people were often presumed to be cisgender and/or heterosexual and this can damage mental health. 13,231 A strong and consistent finding in the study showed that effective mental health support must actively recognise or affirm LGBTQ+ identities in the wider context that undermines them. Cal (staff member) described the importance of service affirmation of sexual and gender identity:

I may be the only adult in that young person’s life that celebrates their queer identity openly and unashamedly, unabashedly. Most of the stories they tell us, not all, but most of the stories they tell are of ignorant adults in their lives and I think it weighs on them.

Our analysis indicated that recognition of LGBTQ+ identity is concerned with the fundamental sense of being valued, respected and affirmed within a service. Our findings demonstrate that services should make it clear across in-service and promotional materials that diverse LGBTQ+ identities are respected, affirmed and valued. Across many case study sites, staff worked collaboratively with LGBTQ+ young people to ensure that the service was inclusive and safe for them.

This recognition and validation requires deep understanding and nuance. The findings suggested that a service needs to balance the ‘normalisation’ of LGBTQ+ identities that does not stray into the territory of fetishising or othering and an understanding that identities are fluid, not linear and becoming LGBTQ+ (or anything else) has no fixed destination. There is also the navigation of homo/trans-norms to consider whereby there exist assumptions and expectations about how LGBTQ+ young people become LGBTQ+ adults, for example medical transition pathways. Narrow conceptualisations of LGBTQ+ identities are problematic and understanding that one person’s (st)age does not map onto that of another is imperative. There is no singular version of an LGBTQ+ young person or who they will become, and early mental health support must be cognisant of this.

You don’t have to be a stereotypically masculine trans man or feminine trans woman, you can be whoever you are without judgement. You can use whatever name and pronouns. For many, it’s the only space they can use the name and pronouns they identify with.

Val, young person

Our findings show that affirming and validating LGBTQ+ identities can be facilitated through supporting access to LGBTQ+ affirmative resources (e.g. clothes, make-up, gender-neutral toilets) and opportunities including intergenerational relationships and queer cultural events that facilitate the validation and exploration of identity on their own terms. Pronoun sharing and re-checking as a standard is helpful but there should be no pressure to explain, disclose or ‘decide’ gender. Being ‘unsure’ is also a valid option and should be included in forms and conversations about LGBTQ+ identities.

I feel safe, welcomed, appreciated. The service is very inclusive. You don’t need to have anything figured out. They make sure they always include ‘unsure’ options. This is very welcoming and makes you feel like you can get support even if you don’t know.

Stevie, a young person

(Re)checking pronouns at each encounter respects fluidity of gender and upholds their safety, for example pronouns may be different with parent/carers. Staff should also share/display pronouns, for example on badges, online. Explicit and proactive validation of LGBTQ+ identities helps support inclusion and communication that ‘everyone is welcome’. Practical support and resources that are LGBTQ+ specific including gender-neutral toilets; LGBTQ+ sex education; binding and packing workshops; coming out support; transition support; safe space to explore and experiment with body, dress, pronouns also matter in terms of recognition and validation.

Possibility

The principle of possibility relates to LGBTQ+ young people’s ability to imagine happy and fulfilled futures for themselves on their own terms. This works to counteract the feeling of ‘failing’ to meet expectations around what or who they ‘should’ be (which they may face in other areas of their lives). Expectations and norms of becoming a future citizen make socially desirable a white, cis-heterosexual, educated future232–234 that LGBTQ+ are excluded from and can seem unattainable. 13,40,76 This contributes to a sense of hopelessness which itself is a risk factor for poor mental health.

I’d say hope and aspiration are key to LGBTQ+ mental health. A lot of young people feel that because you’re LGBT there’s a lot of limits put on you about goals and achievement and so on. It’s like, ‘oh, well you could go to university but you’re LGBT so that will be really hard for you’. You know it sort of labours that stuff.

Jem, staff member

Our findings suggest services can make sure LGBTQ+ young people can see their own experiences reflected in the adults providing support and enable LGBTQ+ young people to explore their passions and interests. (Psycho)education (including direct education about normative ideals and pressures, privilege, and power) to support LGBTQ+ young people’s understanding of these norms alongside support to act and resist is important to allow LGBTQ+ young people to build confidence and experience hope for their futures on their own terms.

As an LGBTQ person in a particularly homophobic school to be welcomed with such open arms was so good. I remember after my first session feeling like I could do anything I wanted to because I knew who I am isn’t a bad thing it’s something to be celebrated.

Tomi, a young person

Across our case study sites, services upheld possibility by nurturing and uplifting LGBTQ+ young people’s futures on their own terms and taking care not to assume or enforce ‘desirable’ social norms. In practice, this included facilitating access to training opportunities and support with education, fulfilling ambitions or goals, volunteering opportunities both inside and outside of services, and involving LGBTQ+ young people in producing content such as websites and podcasts. Services also supported community building and modelling of diverse LGBTQ+ futures through mixed age group work, employing diverse ‘out’ staff and hosting LGBTQ+ adult guests to talk about careers, family building, or other aspects of adult life.

Emotion

Our findings indicate that mental health support must validate LGBTQ+ young people’s distress as a logical response to marginalisation and stigma; and support the development of emotional resilience. We found that the most effective mental health support centred on the young person’s emotions and moved away from the usual position of deficit in which something is ‘wrong’ with an LGBTQ+ young person, to focus instead on developing skills and trust in communicating about feelings.

Biomedical models of mental health support tend to be individualistic and pathologise human emotion as ‘irrational’ or ‘dysregulated’ when feelings are often reasonable reactions to life (dis)stress. 13,235 The pathologisation of feelings interplays with stereotypes of young people for whom normative discourses related to puberty and hormones also position them as inherently irrational and attention seeking. 107 Add to this the pejorative implications that LGBTQ+ identities are also ‘a phase’ that will be outlived236 and we have a set of norms that serve to diminish the distress of LGBTQ+ young people.

Rather than saying what’s wrong with the rest of the world, individual young people are deemed mad but the world is mad. If we had more capacity to do trans youth work and LGBT youth work, we wouldn’t see as much distress, and as much mental health conditions as we do see amongst our young people.

Harper, staff member

Our analysis identified that an asset-based emotion centred approach, which involves non-pathologising and usualising communication about feelings, is beneficial in validating the experience of LGBTQ+ young people. The feelings of LGBTQ+ young people must be taken seriously and responses or practices that may minimise their feelings need to be actively avoided. Conversely ‘good feelings’ can be boosted without any pressure to ‘be happy’, for example through relaxation, fun and activities that offer a ‘sense of purpose’.

The analysis suggested that explicit and open communication about feelings on young people’s terms using their own language (not necessarily verbal) can be facilitated by staff, for example actively reassuring around experiences that are likely to be difficult such as first meetings, wider world/media events. To be most effective, this can be done while tailoring reassurances to the needs of the person.

When things are happening with me, I don’t enjoy advice. I prefer comfort or a distraction. This is exactly what they would do. They’d take me into the kitchen or outside and just let me ramble, whether it’s about the issues I’m facing or my current hyperfix. They know what each individual needs and adapts to make sure that’s what they get.

Alix, a young person

The de-pathologisation of feelings and emotions, the findings indicate, includes ensuring a diagnosis is not a requirement to access the service and an understanding of the role of mental health diagnosis to young people. Maria (staff member) explains:

We’re conscious that young people often have a lot of diagnosis. For some that will have been a relief to have a diagnosis. And for some, it is not something they feel happy about and it feels that it was imposed on them. So diagnosis is important but more in terms of how that person views their own life choices.

Maria, staff member

Structural

The findings suggest that improvement in accessibility structural factors is important. Services need to proactively demonstrate that they can support people to access them, for example hardship funds and transport costs, all-gender toilets and make this clear on the website or in information about the service. The service must be easy to locate and have an online presence – online material is very important for responding to searches for help and also for managing expectations and an online service can appeal to young people who are distant and cannot commit to regular attendance. Services should offer online as well as face-to-face support.

The analysis suggests the timing of services is crucial. Measures such as providing support after school, with regular drop-in hubs at different locations and times. Service locations and delivery (digital or in-person) are important, but our analysis indicates there is no ‘one size fits all’ and flexible hybrid structures offer the best chance of meeting most people’s needs, some of the time. Art (young person) said, ‘I haven’t actually taken part in the online sessions as I don’t find them very easy to access. I live with my family so don’t necessarily feel comfortable with the possibility of them overhearing me’.

Disciplinary (systems)

The findings suggest that the systems used to access services, for example referral forms, must not be too demanding, burdensome or exclude LGBTQ+ youth. For example, complicated referral forms, absence of LGBTQ+ identities within the service information, or pathologising LGBTQ+ identities in mental health assessment forms. Systems to access the service should also provide brief explanations of confidentiality, privacy and information sharing as part of sign-up forms and ensure that forms reflect the diversity of LGBTQ+ young people’s identities to encourage LGBTQ+ young people that the service is safe.

The fact it was made clear it was specifically for younger people made me feel comfortable about contacting them. [The referral form] was probably the most stressful part as I had no clue what to put for some of the answers since I was doing it for myself. But I e-mailed and they offered to call me and guide me through it which helped a lot.

Jack, a young person

Our analysis illuminated a power imbalance between different organisation types. Statutory services and NHS/clinicians have more authority than LGBTQ+ charity sector services despite the latter providing the majority of LGBTQ+ specific mental health support. This imbalance has implications for the robust, reliable networks of services that our findings demonstrated as necessary to ensure LGBTQ+ youth find suitable support. ‘Successful’ engagements of LGBTQ+ youth were often because wider institutions (e.g. schools) were aware of LGBTQ+ specialist services and were working effectively with them:

A support teacher at my school sat me down and we did the referral process together […] they told me about the support they have for LGBTQ+ teens […] Immediately I felt comfortable because I knew that I wouldn’t be judged.

Tomi, a young person

In 25% of our case study services, there were funded partnerships between statutory services/NHS and LGBTQ+ organisations. These funded partnerships provided appropriate support and resources while legitimating the role of non-statutory (LGBTQ+) service.

Cultural

Typically, we consider structural ‘barriers to access’ as factors such as service location, transport and opening hours. While important, this view of accessibility is limited and undermines the importance of myriad social and cultural factors. Our intersectional analysis found oppressive structures and associated discriminations are key barriers to access. Tackling these barriers from the ‘top down’, that is, having LGBTQ+ senior leadership, or grassroots responses to need, for example by Queer, Trans and Intersex Black people and People of Colour (QTIBPOC) for QTIBPOC, can facilitate access that is inclusive and operates against existing systems that marginalise LGBTQ+ youth.

Because it’s a trans only space, everything else about you is seen first or more importantly. So when you go as a trans person into a generic space or an LGBT space you’re seen as ‘the trans person’, right? But when you come into a trans only […] it’s the given and it’s the norm.

Harper, a young person

To be accessible, services must actively demonstrate an LGBTQ+ inclusive culture and ensure a multiplicity of LGBTQ+ identities is welcome, for example QTIBPOC, LGBTQ+ youth with disabilities. Inclusive resources co-designed with LGBTQ+ youth representing diverse identities can safeguard against exclusion. In addition, recruiting staff with diverse experiences and displaying LGBTQ+ inclusivity clearly in online and print resources can improve accessibility.

Interpersonal

Our model has emotions are the centre and the emotions of LGBTQ+ young people newly accessing services need to be intentionally and considerately managed in order to keep LGBTQ+ youth engaged with a service. The analysis suggests that LGBTQ+ young people need to feel ‘comfortable’ for service access and engagement to improve. Managing fear of the unknown, fear of being outed, fear of not being taken seriously means active efforts by services to ensure young people are reassured. Our analysis indicated measures such as featuring diverse service staff in online content, providing service walk-throughs online showing the service building and layout and offering buddy systems for first-time attendees were all effective ways of building the young person’s trust and confidence in the service.

We would meet them at our office, or at their home, or at school or in a café, wherever they felt most comfortable […] to reassure them or give them information about what to expect, what the groups are like […] to hopefully make them feel safer.

Ema, staff member

Use of care services

Our starting point was a crude analysis of the number of visits to and users of primary care, community health, community mental health services and other mental health as reported by the participants with a recall period of 4 weeks. We performed the same analysis for the services provided at each CSS (Table 13). There was a total of 486 contacts both with the NHS and CSS (280 contacts in CSS against 206 with NHS services) reported by 45 participants in a 4-week period with no missing values. The two least used services provided by the NHS were appointments with nurses at GP surgeries and GP appointments. On the opposite end, the two most used services were the ones provided by other mental health professionals (50 visits) and other services including helplines/online (56 visits). As for the CSS, activity sessions were the most frequent reason to visit (104 sessions) followed by peer support (78 contacts) and 1 : 1 sessions that motivated 76 visits.

We then calculated the mean frequency of use of all services for the same 4-week recall period (Table 15). Looking at the mean number of contacts reported by the patients, we observe that participants in CSS 13 had an average of 20.3 contacts in 4 weeks, followed by participants in CSS 10 reporting 18.7 on average for the same period. Participants in CSS 3, 7 and 9 had the lowest mean number of contacts across all the services available.

Overall use of health services was low, with a very small number of participants reporting high levels of service use. In CSS 6 and 7, participants have not reported any appointments with GP, nurses and psychiatrists. Participants in CSS 4 reported a low use of NHS services; however, the average use of services provided by this CSS was the second highest in our sample.

As the individuals using the NHS services and the CSS were the same, we computed a paired sample t-test to determine whether the difference between the mean use of NHS services (4.6) and the mean use of CSS (6.2) was statistically different from zero (Figure 8). A paired sample t-test is a statistical method used to compare the means of two related groups to determine if there is a significant difference between them in a given variable of interest; in this case, it was the mean use of services.

FIGURE 8.

Paired samples t-test.

The results obtained for the differences between the values for the mean use of services in the NHS and in the CSS do not allow us to say that their average use by participants is not the same, as the confidence interval includes zero and the significance value is 0.187 (> 0.10) for a two-sided distribution, not allowing us to say that the differences observed have statistical significance.

Costs of services used

We applied the unit costs in Table 14 to the service use reported in Table 15 to calculate the cost of care services used presented in Table 16.

Overall costs are £402.00 per participant over 4 weeks. We have observed that the average use of services was higher in the CSS than in the healthcare services; however, costs are identical. The use of services provided by the CSS amounted to £201.20 and the use of services provided by the NHS was £200. The most meaningful costs are the 1 : 1 sessions (£86.13) followed by psychiatrist visits (£68.33) in the NHS. The mean costs of observed cases for nurse visits can be considered negligible (£2.80). The category with the lowest mean costs in the CSS was the one of other sessions (£12.22).

Our sample is too small to allow us to draw representative conclusions either at site level or at national level. Nevertheless, it is important to note the high use reported by the participants for a recall period of 4 weeks. In some CSS, participants had an average of 5 contacts per week. If we extrapolate our average 4 weeks costs to 52 weeks, each participant would have a cost around £5000. Overall use of health services in the NHS was low and skewed, with a small number of participants reporting very high levels of service use. In CSS around half of the participants reported no contacts in each category of services available.

What’s the problem?

• LGBTQ+ young people are more at risk of poor mental health and worse mental health outcomes than heterosexual peers. 5,6,8,59,237,238

• These inequalities start as early as age 10, increasing throughout adolescence and peaking between the ages of 13 and 19. 6

• Common mental health problems occur at higher rates for LGBTQ+ young people who are black or people of colour, trans or gender diverse, intersex or disabled. 37,239

The most prominent model in explaining these inequalities is ‘minority stress’12 whereby experiences of stigma, prejudice and discrimination create hostile environments, leading to mental health problems. Being LGBTQ+ means young people do not conform to expectations or ‘norms’, that is, that you are heterosexual and cisgender (non-transgender). LGBTQ+ young people are marginalised through lack of mainstream visibility, discrimination, (micro)aggression, bullying and victimisation they experience. 13,14 Even within LGBTQ+ communities, young people may also come up against assumptions and pressures about the ‘right’, ‘normal’ or ‘best’ ways to be LGBTQ+, such as stereotypes about ‘good’ or ‘bad’ bisexual people, or what it means to be ‘trans enough’.

Among peers and in places like school or college, stigma can result in social isolation; a quarter of the LGBTQ+ young people surveyed for Stonewall’s 2017 School Report experienced being ignored and isolated as a pattern of bullying. 28 Young people may also experience the erasure of their identities within service settings and in their interactions with adults, that is, where it is not considered that they could be LGBTQ+ and cis-heterosexuality is presumed.

Mental health inequalities faced by LGBTQ+ young people have been exacerbated by COVID-19 and the impact of national and regional lockdowns, with evidence emerging that lockdowns have led to high levels of stress and depressive symptoms reported by LGBTQ+ people, especially young people. 36,37 Among 1140 LGBTQ+ young people surveyed for research commissioned by the charity Just Like Us, 68% reported that their mental health worsened during the pandemic. Fifty-five per cent reported worrying daily about their mental health, rising to 65% for black LGBTQ+ young people, trans and gender diverse young people, and disabled LGBTQ+ young people. 37

What works to reduce poor mental health for LGBTQ+ young people?

Hopelessness and isolation are crucial components of poor mental health among LGBTQ+ young people. In the model of what works to support LGBTQ+ young people’s mental health at an early point the principles of Belonging, Possibility, Body were key. Feeling connected to a wider community enables LGBTQ+ young people to feel less alone and to experience a sense of collective care and respect. To uphold the principle of Belonging our findings suggest services can provide or facilitate access to LGBTQ+ youth groups across different age ranges and identities; connect LGBTQ+ young people with wider communities and community histories; help build bonds with peers, forming friendships.

The principle of Possibility relates to LGBTQ+ young people’s ability to imagine happy and fulfilled futures for themselves on their own terms. This works to counteract the feeling of ‘failing’ to meet expectations around what or who they ‘should’ be (which they may face in other areas of their lives). Our findings suggest services can make sure LGBTQ+ young people can see their own experiences reflected in the adults providing support and enable LGBTQ+ young people to explore their passions and interests. Support related to the Body centres LGBTQ+ young people’s bodily health and well-being, and their ability to express themselves, for example in dress, make-up, hairstyles, body hair and so on. Self-expression can support mental health. Our findings suggest services can facilitate access to LGBTQ+ specific sports or activities such as climbing or swimming (note: it is vitally important that young people are not pressured into these activities – implying that young people will feel better if they ‘go for a walk’ or lose weight can also be harmful) and provide safer spaces where LGBTQ+ young people can explore their self-expression and presentation. This may be facilitated through clothing swaps, and the provision of make-up, clothing or gender-affirming resources for young people to use.

Recommendations to improve LGBTQ+ young people’s mental health

Mental health services and policies need to:

• Acknowledge isolation and hopelessness as major factors impacting LGBTQ+ young people’s mental health.

• Develop support that supports connectedness, self-expression, and hope for the future on young people’s own terms.

• Address isolation, for example:

  • Providing LGBTQ+ groups or signposting to trusted LGBTQ+ youth groups.

  • Connecting LGBTQ+ young people with wider communities in safe ways, such as hosting LGBTQ+ guest speakers or organising group attendance at Pride events.

• Support self-expression, for example:

  • Providing resources for young people to dress and present themselves in ways they want to, and to be called by the names and pronouns that feel best.

  • Facilitating access to inclusive sports and activities and support around sleep, without framing exercise, weight loss or diet changes as ‘cures’ or obligations.

• Address hopelessness, for example:

  • Modelling diverse LGBTQ+ lives and futures, whether directly (through visits or staff’s own lived experience) or indirectly (through partnership working with LGBTQ+ specific services or organisations).

  • Supporting LGBTQ+ young people’s skills and interests and providing or signposting to development opportunities.

What’s the problem?

Evidence shows that LGBTQ+ young people are reluctant to seek support, particularly from mainstream services or authority figures. Findings from a 2015 UK-based study indicated that in a sample of 789 LGBTQ+ young people, just over a fifth of the sample had not sought help at all when they were self-harming or feeling suicidal. 41 When they do seek support, LGBTQ+ young people tend to seek mental health help online and from peers40,41 and prefer accessing LGBTQ+ organisations for mental health support. 42,46 Experiences with ‘mainstream’ healthcare and mental health services are variable; helpfulness ratings for GPs and mental health services are low in comparison to friends, the Internet and LGBTQ+ youth groups. 42

Studies have found that LGBTQ+ young people are reluctant to access mental health support services because of:40,42–44,51

1. Actual or anticipated experiences of homophobia, biphobia and transphobia

2. Cisgender and heterosexual norms, including a fear that their sexual orientation and/or gender identity would be scrutinised or blamed for their mental health problems

3. Difficulties disclosing their sexual orientation and/or gender identity due to fear or lack of options for LGBTQ+ identities on forms

4. Fear of being misunderstood or judged by adults due to being young

5. Stigma related to having mental health problems

What works to increase LGBTQ+ young people’s use of mental health services?

A crucial starting point in establishing early intervention support pathways is ensuring LGBTQ+ young people do not need a mental health diagnosis before they can receive support for their mental health. Subjective assessment of mental health needs by an LGBTQ+ young person themselves should be sufficient to access support. Given the reluctance of LGBTQ+ young people to seek support from mainstream services or figures such as teachers, parents or school/college counsellors, access to care should not rely exclusively on referral pathways facilitated by adults. Referral can also be supported through the development of ‘one-stop-shop’ services based in the community, as advocated for by Future in Mind guidance. 240 Referral to services with waiting lists can be supported by complementary offers of group spaces and informal one-to-one support ‘while you wait’.

To increase access to, navigation of, and engagement with mental health services the model of what works to support LGBTQ+ young people’s mental health at an early point indicates the principles of Safety, Time, Recognition were key. To uphold the principle of Safety, our findings suggest services can implement clear and robust policies around discrimination and bullying; ensure that LGBTQ+ young people are able to see clearly that a service is safe for them to access and feel confident they will not face prejudice, discrimination, or stigma within it; ensure that it is clear in online information about a service that LGBTQ+ identities and experiences are affirmed and welcomed.

The way that Time is organised and structured within service delivery should centre LGBTQ+ young people’s lives and needs. It is crucial that young people not be left ignored and unheard while in distress. Our findings suggest services can ensure that there is always support and a response of some kind accessible. This could be supported online or via telephone, or through the provision of groups and non-clinical one-to-one support. In addition, services should ask for LGBTQ+ young people’s input on the frequency, pace, timing and duration of support. Recognition is concerned with the fundamental sense of being valued, respected and affirmed within a service. Our findings demonstrate that services should make it clear across in-service and promotional materials that diverse LGBTQ+ identities are respected, affirmed, and valued; work collaboratively with LGBTQ+ young people to ensure that the service is inclusive and safe for them; invest in staff knowledge and development to support LGBTQ+ young people.

Recommendations for increasing LGBTQ+ young people’s use of mental health services

Mental health services and policies need to:

• Acknowledge that LGBTQ+ young people are more likely to access mental health support when they can see clearly that the service is safe, knowledgeable and affirming, and when the support offered fits into their lives.

• Provide a safer service for example:

  • Transparent policy around confidentiality and safeguarding, communicated in young person-friendly ways, for example providing reassurance that no young person will be ‘outed’ without their consent.

  • Seek regular feedback from LGBTQ+ young people on the service’s safety.

• Ensure that young people feel recognised, respected and affirmed, for example:

  • Service providers should have a demonstrable track record of working with and understanding LGBTQ+ young people’s identities and experiences.

  • Ensure facilities are accessible and inclusive, for example providing gender-neutral toilets.

• Ensure that the service fits within LGBTQ+ young people’s lives, for example:

  • Provide rapid response to initial contact from LGBTQ+ young people, as well as ‘while you wait’ support.

  • Seek feedback from LGBTQ+ young people on the frequency, pace, timing and duration of support.

  • Provide drop-in as well as sign-up support sessions.

What’s the problem?

For those LGBTQ+ young people who do access support services, research suggests an overall poor experience due to limited staff understanding of LGBTQ+ issues and minority stressors among service staff; fear of being ‘outed’ to parents/carers, other service providers, or other young people; and being excluded from decisions about their care. 38,40,241

A 2020 EU study found that barriers to health care for LGBTQ+ people are exacerbated by two related assumptions held by healthcare professionals. First, the assumption that patients are heterosexual and cisgender and, second, the assumption that LGBTQ+ people do not experience significant problems related to their LGBTQ+ identity, meaning that LGBTQ+ identity is viewed as incidental or irrelevant to the delivery of appropriate health care. 19

While it is unhelpful (and can be harmful) for the importance of the LGBTQ+ experience to be dismissed, it is also damaging for support practitioners to overemphasise LGBTQ+ identities in excessive or pathologising ways. When staff have limited understanding and awareness about LGBTQ+ identities this can manifest as the attribution of mental distress and poor mental health exclusively to a young person’s being LGBTQ+, particularly when the young person is trans or gender diverse. 13,49

What works to improve LGBTQ+ young people’s experiences of mental health services?

To improve LGBTQ+ young people’s experiences of mental health services, the model of what works to support LGBTQ+ young people’s mental health at an early point indicates the principles of Space, People, Agency and Emotion were key. LGBTQ+ young people usually navigate Space that is defined by adults and in which being cisgender or heterosexual is assumed. Having access to affirming spaces that centre LGBTQ+ young people is invaluable in supporting mental health and building LGBTQ+ young people’s confidence to explore the world around them beyond the service. Our findings suggest services should create LGBTQ+ only spaces that centre the experiences and needs of LGBTQ+ young people and seek LGBTQ+ young people’s input on the design, decoration, and layout of support spaces.

Trusting relationships with service staff, peers and other important People are crucial in supporting LGBTQ+ young people. Our findings demonstrate that services should pay attention to LGBTQ+ young people’s ability to form trusting connections both with other young people and with the adults providing them with support; recruit staff whose experiences LGBTQ+ young people can relate to (e.g. LGBTQ+ staff); facilitate LGBTQ+ groups to support friendship and peer connection.

The principle of Agency can be upheld when LGBTQ+ young people are actively involved in decisions about their own support. The idea that ‘adults know best’ means LGBTQ+ young people’s distress and experience may be minimised. To best support LGBTQ+ young people, our findings suggest services can facilitate and encourage independent decision-making; position young people as experts of their own experience; provide respectful options-based approaches to support LGBTQ+ young people where there may be gaps in their experience due to age. In addition, we found that mental health support approaches that centre Emotion and move away from the usual position of deficit in which something is ‘wrong’ with an LGBTQ+ young person, to focus instead on developing skills and trust in communicating about feelings. Our findings indicate that services should validate LGBTQ+ young people’s distress as a logical response to marginalisation and stigma and support the development of emotional resilience.

Youth work is unique in centring engagement with young people’s cultures and communities, and using asset-based philosophies to develop young people’s strengths and well-being. 242 Youth work frameworks are more likely to have anti-oppressive practice, non-pathologising and rights-oriented principles as foundations. These fundamental principles can counteract the kinds of exclusion and discrimination that may accompany experiences of mental distress,242 alongside the marginalisation that LGBTQ+ young people often face in relation to their sexuality and/or gender identity.

Recommendations for improving LGBTQ+ young people’s experiences of mental health services

Mental health services and policies need to:

• Acknowledge that LGBTQ+ young people have better experiences of mental health services when they feel ownership of the support space and can build trust with the people providing support.

• Ensure mental health provision supports LGBTQ+ young people’s informed independent decision-making.

• Create spaces that centre LGBTQ+ young people, for example:

  • Services should have a demonstrable track record in offering LGBTQ+ focused spaces, or should be able to demonstrate robust signposting or referral pathways to LGBTQ+ specific spaces.

  • Detailed space planning and costs should demonstrate clear LGBTQ+ inclusion, for example through the provision of all-gender toilets.

• Foster trusting relationships for example:

  • Advocacy support can help LGBTQ+ young people to navigate important relationships in their lives, for example at school or work, with family or caregivers, or with peers.

  • Ensure diverse LGBTQ+ identities and experiences among mental health service staff.

• Develop agency and informed independent decision-making, for example:

  • Options-based support that upholds young people’s rights to be heard and to autonomy

  • Policy and service specification that prioritises LGBTQ+ young people and ensure that they will be included in decisions about their care.

• Centre asset-based emotional support, for example:

  • Ensure that services have demonstrable expertise and understanding of LGBTQ+ young people’s emotions when seeking support, such as fears around being ‘outed’ to parents, carers, peers, or other services without their consent.

  • Include emotions and feelings words in service materials for example sadness, panic, fear, anger, hopelessness.

• Incorporate youth work expertise and approaches in the development of mental health support services for LGBTQ+ young people, for example:

  • Include youth provision in mainstream NHS approaches to the commissioning of early intervention mental health services for this population.

• Demonstrate long-term planning and development around how to ensure service/policy is reflective of diverse LGBTQ+ young people’s needs.

Centring human rights

The UN and the WHO identify the fundamental relationship between human rights and mental health. UNICEF (UK) argues that ‘it is key that local government, services and professionals frame good mental health as a basic human right, one all children and young people are entitled to’. 2 The UNCRC outlines the rights of children and young people to good mental health and mental health services (Article 24), alongside rights to non-discrimination (Article 2), and identity (Article 8). While the integration of youth rights into law, policy and practice worldwide has been slow and inconsistent,243 international human rights commitments for children and young people are emphasised in public facing and online presence of the children and young people’s commissioners for Scotland, Wales, and NI.

At the time of this report being written, LGBTQ+ young people are facing active legislative and policy attacks on their human rights; the UK was identified alongside Hungary and Poland in a 2021 Council of Europe report condemning attacks on LGBTQ+ human rights, particularly for trans people. 244 Legislative attacks have placed young people’s access to gender-affirming health care at risk,245,246 and trans and gender-diverse young people have been excluded from the development of legislation banning conversion practices. In addition to ongoing attacks on LGBTQ+ young people’s rights, the long-term legislative and policy implications of major political developments, such as Brexit on LGBTQ+ rights, remain uncertain. Within this uncertain landscape, it is more important than ever to centre and uphold children and young people’s human rights in service commissioning and delivery.

Under Section 149 of the Equality Act 2010, public sector services have duties to eliminate discrimination and advance equality of opportunity between groups who share a protected characteristic (including gender reassignment and sexual orientation) and those who do not share this characteristic. The Health and Care Act 2022 further emphasises Integrated Care Board responsibilities to address health inequalities across access to and outcomes from health services. 26

Between nations

While legislation such as the Equality Act 2020 applies to all four UK nations, there are also significant legislative and policy differences across NI, Scotland, Wales and England. The Scottish government is, at the time of writing, publicly affirming and taking steps towards a self-declaration legal model of gender recognition. Scotland has become the first country in the world to commit to embedding LGBTQ+ inclusive education across all schools. Access to gender-affirming health care is particularly difficult in NI, where young people must be referred to CAMHS before further referral can be made to the Knowing Our Identity service. Service backlogs and waiting lists are a major issue for young people trying to access gender-affirming health care across the UK, but due to this referral process, these difficulties are particularly acute in NI.

NHS England GIDS interim service specifications

Rapid and substantive changes to the landscape of care and rights for trans and gender-diverse young people in the UK make the creation of mental health services and policies challenging. At the time of writing, public consultation is ongoing regarding interim service specifications for two new GIDS regional centres. These specifications undermine the findings from this study with regard to LGBTQ+ young people’s mental health, particularly in the areas of framing transness and gender variance as a ‘phase’; discouraging social transition and implying that it is harmful to affirm young people as they develop understanding of their own gender; and implementing pre-referral gatekeeping processes that exclude young people from decisions about their care. It is likely that these specifications will make delivery of effective mental health support for trans and gender-diverse young people more difficult and underpins the urgent need for policy-makers, commissioners, and services to centre and uphold the human rights of trans and gender-diverse young people.

Stage 1: limitations

The strength of the review was that it utilised a theory-led MNR methodology to detail the underlying theory of effective mental health care. This was the first, to our knowledge, theoretical framework to be produced for supporting LGBTQ+ youth mental health and was a significant advancement in developing effective services and interventions because eventually, after testing empirically, it was being used to provide the principles for appropriate LGBTQ+ youth mental health support. However, the review is of course limited by language and there may be important evidence written in countries that we were unable to include. In addition, we realise that the adaptation of the PICOS formula for selecting studies for MNR methodology is unwise. This is because the PICOS framework, although widely used within SR methodology, cannot be easily applied in interpretive and iterative approaches.

Stage 2: limitations

During the mapping exercise, there were instances where charity-provided services had to dramatically reduce their service provision or even close all together due to loss of funding especially during the COVID-19 pandemic. This meant we were not able to fully recruit sites across the four nations. We were unable to recruit any CSS in Wales and one site in Scotland was unable to participate in the study because they were over-burdened with providing support and services to LGBTQ+ young people. We did however have input in terms of Scotland through another CSS and through the Project Advisory Group.

Stage 3: limitations and the COVID-19 pandemic

Conducting a research study during the COVID-19 pandemic has been extremely demanding particularly given the focus was LGBTQ+ young people’s mental health. We had to revise the methodology which meant reconfiguring data collection tools and data security and consulting LGBTQ+ young people. We adjusted the research ethics protocol and experienced time delays while amendments had to be approved. These adjustments were instituted from 16 March 2020 and all data were collected exclusively online. This was only a partial deviation from the study protocol because online data collection was an integral component of the original stage 3 case study design. The Sponsor approved all three non-substantial changes to the ethics protocol. A summary of the revisions to the original protocol is given below:

• Microsoft Teams/Zoom online interviews with staff only

• WhatsApp text online interviews with LGBTQ+ young people only

• Microsoft Teams/Zoom online carers and parent interviews only

• The Research Team, Project Advisory Group and LGBTQ+ Youth Advisory group worked remotely and effectively.

Data collection during the pandemic and periods of lockdown and restrictions all impacted on fieldwork. This included:

• Losing key CSS in Wales and Scotland and recruiting two new sites (in England).

• Long delays with CSS due to service staffing problems, transferring services online, illness, etc.

• Online communication fatigue from participants (staff and young people) and research staff slowed the recruitment process.

• Data collection took much longer than usual.

• We were unable to conduct the planned focus groups due to participant burden.

• In order to ensure the adapted online methodology was ethically robust, we had to limit data collected to answer research question 4.

• All the research staff have been affected by COVID-19, for example having COVID-19, child-care responsibilities, family caring commitments, death of close family/friends, accommodation difficulties, mental health problems, all of which have caused delays.

To compensate for some of these methodological issues, we conducted a number of verification activities. The aim of these activities was to substantiate the final data analysis in order to answer all the research questions and fulfil the remit of study in terms of Scotland and Wales. These activities focused on additional consultation with LGBTQ+ young people and interviews with key informants in Wales and Scotland.

WhatsApp was selected to use for interviews with LGBTQ+ young people based on feedback from LGBTQ+ young people and service staff. We acknowledge that digital technologies and the requirement to use a digital device to participate (e.g. smartphones or laptops) is exclusionary for some young people, for example due to digital poverty. To assist in this way, we offered vouchers to cover costs for data albeit this offer was not taken up by any LGBTQ+ young person. For some, we were aware that disabilities or living circumstances, for example being in care home settings, would limit participation remotely but in the context of COVID-19 national lockdowns we were unable to offer a face-to-face alternative. Overwhelmingly those who took part communicated directly that they appreciated the format as it offered them a chance to think about their responses and retain their privacy. We know that many LGBTQ+ young people prefer engaging online, so this method was facilitative to those who prefer this compared to face-to-face engagement.

Because we were unable to meet in person during the fieldwork, we were also unable to deliver our intended focus group activities with LGBTQ+ young people that were structured around a board game co-designed by LGBTQ+ young people.

The service cost analysis has some weaknesses. As is common practice, we relied on self-reported data on health service use. 247,248 This may have been subject to recall bias. In addition, the small sample size meant we were unable to draw any generalised conclusions from the study. The purpose of the service cost data was to inform the NHS commissioning guidance that was produced at the end of the study by key stakeholders in the NHS, local authorities NHS England etc. The guidance was cognisant of ‘best practice approaches’ to designing NHS commissioning guidance and the requirements of mental health services across a range of locations. It was decided that the service use costs did not fit into the priorities of the guidance which needs to be extremely succinct and practice orientated. Funding and costs are included within the guidance but as possible ways of funding a service. Please see: https://queerfutures2.co.uk/wp-content/uploads/2022/12/Queer-Futures-2-What-Works-NHS-Commissioning-Guidance.pdf.

Participant representation

The diversity of the participants recruited from the CSS was monitored to ensure the sample was diverse in terms of sexual orientation, gender identity, disability, ethnicity and socioeconomic status. To boost representation within the sample, we specifically targeted recruitment in terms of both ethnicity and gender. The ethnicity of the sample was increased through working with key CSS that either employed staff of colour or had a specific services provision for LGBTQ+ young people of colour. This strategy was successful in ensuring a third of the sample where from a range of ethnic backgrounds in comparison to two thirds who were White English/Irish/Scottish/British.

All the recruitment materials and outputs reflected the diversity of the LGBTQ+ young people. See for example the model of What works? housed on an interactive website https://queerfutures2.co.uk/what-works/.

The study findings indicated that there is a gap in mental health provision for LGBTQ+ young people of colour. Few of the CSS had incorporated working practices that provided for this group of young people. Further research is required on why LGBTQ+ young people of colour have elevated rates of poor mental health, and how best to improve mental health in this population group.

Reflections on research team and wider involvement

The research team included those from the LGBTQ+ population. To ensure diversity a researcher who was a LGBTQ+ person of colour and a researcher who was trans were recruited to the study. This ensured an inclusive approach to the research design.

The public were involved throughout the study but at key moments, we sought extra input from those working in the field especially LGBTQ+ staff of colour and gender diverse staff.