An Environmental Scan of Ontario’s Mental Health and Addiction Services Exclusive to LGBTQ2S+ Youth During COVID-19

Background: LGBTQ2S youth experience mental health disparities and higher rates of substance use when compared to their cisgender and heterosexual peers yet also experience more barriers to access to services. The purpose of this environmental scan is to determine the types of mental health and substance use programs and services exclusive to LGBTQ2S youth in Ontario and how these services have changed during the pandemic. Methods: This environmental scan was conducted to identify existing programs and services in Ontario that offered exclusive mental health and addiction services to LGBTQ2S+ individuals aged 16-29, either by offering services to all or subgroups within the population. Results: In total, 113 organizations and 240 programs and services were identied as providing mental health and substance use services exclusively to LGBTQ2S+ youth. Four main themes were identied from the scan, including the distribution of services, types of services, methods of service delivery and program criteria. Adaptations for the COVID pandemic included cancelling in-person services, increasing online and telephone services, and expansion to province-wide from local availability. Conclusions: The ndings from this scan highlight the importance of offering services that provide culturally inclusive care for LGBTQ2S+ youth, and these results can also be used by policy makers to inform policies. In particular, there was a lack of culturally-relevant clinical services for youth requiring greater intensity of treatment.

youth . A meta-analysis by Marshal et al. (2008) illustrates that youth sexual orientation was associated with higher rates of life-time alcohol, cannabis, and tobacco use, as well as life-time illicit and injection drug use. Similar ndings emerged through a cross-sectional study exploring transgender youth substance use, where transgender youth had higher rates of substance use, past 30-day use, and earlier age of onset for cannabis use compared to their cisgender peers (Day, Fish, Perez-Brumer, Hatzenbuehler, & Russell, 2017). Research has also shown that ethnicity and race in uence mental health outcomes, where Black and Hispanic sexually diverse youth were signi cantly more likely to report suicidality compared to their White, heterosexual peers (Mueller, James, Abrutyn, & Levin, 2015).
Several structural mechanisms have been identi ed as risk and protective factors LGBTQ2S+ youth.
Minority stressors, such as harassment, discrimination, violence, and internalized stigma, were found to be positively associated with negative mental health outcomes for lesbian, gay male and bisexual youth as identi ed in a meta-analysis by Dürrbaum and Sattler (2020). Mereish and Miranda (2019) supported this nding by demonstrating a causal relationship between cravings for alcohol and sexual stigma cue exposure through an experimental design with LGBTQ2S+ youth. Lack of family support is also associated with higher emotional distress for LGBTQ2S+ youth, even when controlling for victimization and overall social support (McConnell, Birkett, & Mustanski, 2016). Several factors such as feeling connected to parents and other adults in one's community as well as feeling safe at school have been identi ed as protective against depression and suicidality for LGBTQ2S+ youth (Gower et al., 2018).
Community supports have also been identi ed as a protective factor, where the presence of events, community resources, and organizations that offer programming speci c for LGBTQ2S+ community members are associated with lower rates of substance use, suicide attempts, and self-harm behaviours among LGBTQ2S+ youth (Saewyc et al., 2020; Watson et al., 2020; Eisenberg et al., 2020).
Despite experiencing higher rates of mental health and substance use, LGBTQ2S+ youth also report a greater likelihood of not having their needs met through treatment. In a study of addiction treatment outcomes and experiences using a convenience sample of 81 men from the LGBTQ2S+ community, compared with 55 heterosexual men, showed that men from the LGBTQ2S+ community were less likely to report abstinence following treatment, reported lower levels of connection during treatment, and were more likely to identify "needs not met" as the main reason for ending treatment early (Senreich, 2010). Burgess et al. (2007) identi ed that people in their LGBTQ2S+ sample were more likely to report having unmet mental health needs compared to the heterosexual comparison group within the past year. This is consistent among transgender individuals, where an Ontario-based cross-sectional study by Steele et al.
(2017) found that transgender women were 2.4 times more likely to report having unmet mental health needs compared to cisgender women.
In addition to having unmet needs, there are several barriers to care that have been identi ed in the literature. A large-scale study of mental health service utilization across three post-secondary institutions in California found that students who identi ed as LGBTQ2S+ were signi cantly more likely to report barriers towards accessing on-campus mental health support, and signi cantly more likely to report multiple barriers (Dunbar et al., 2017). It is also re ective of an analysis conducted by Lyons et al. (2016) of the results for three open prospective cohort studies of individuals who used illicit drugs in Vancouver. This analysis identi ed that a higher percentage of LGBTQ2S+ women reported barriers accessing treatment (12.7%) compared to the heterosexual sample (7.7%). Several barriers to mental health care were identi ed in a qualitative study of 104 youth, where system level barriers (i.e. lack of competence to provide a rmative care, dominance of medication, service availability and accessibility, and previous experiences), sociocultural barriers (i.e. stigma, not wanting parents to know, and lack of family support), and individual barriers (i.e. beliefs about the severity of need, beliefs about ability to cope, and lacking self-con dence) were identi ed (Higgins et al., 2020).
For some members of the LGBTQ2S+ community, these barriers appear to be exacerbated by the conditions of COVID-19 where individuals were signi cantly less likely to access telehealth for mental health support during the pandemic, while being more likely to be connected to a mental health professional (Ruprecht et al., 2021). This research indicates that there is greater need for mental health services targeted to LGBTQ2S+ youth, however the research also shows that there are also greater barriers to accessing care. Different social locations intersecting with gender diversity and sexuality also in uence experiences within the mental health system, where a qualitative study of Black and Hispanic LGBTQ2S+ young adults identi ed several additional barriers, including stigma associated with mental health symptoms and sexuality, ambivalence about the e cacy of treatment, and lack of family support due to family's previous negative experiences with mental health interventions (Moore, Lopez, Camacho, & Munson, 2020).
The literature has acknowledged the mental health disparities, unmet mental health needs, unique barriers to care and added potential vulnerabilities for LGBTQ2S+ youth in the context of the COVID-19 pandemic. Speci cally, the literature has identi ed that existing structural disadvantages and vulnerabilities have been exacerbated in the context of COVID-19, where 47% of LGBTQ2S+ individuals indicated that COVID-19 has had a signi cant impact on their mental health, compared to 26% of the national average (Egale, 2020). It has also been identi ed that mental health and substance use services exclusive to LGBTQ2S+ youth are well positioned to address these disparities in a culturally informed and safe way. However, little is known about the current state of these programs and services within Ontario's mental health and addiction system, nor what adaptations have been made during the pandemic in response to public health regulations and recommendations. Therefore, the purpose of this environmental scan is to determine the types of mental health and substance use programs and services exclusive to LGBTQ2S youth in Ontario in the context of the COVID-19 pandemic.

Environmental Scan
The purpose of pursuing an environmental scan was to determine which services currently exist speci cally for LGBTQ2S+ youth in Ontario, as well as to understand how these services may have been adapted within the context of the COVID-19 pandemic. For the purposes of this paper, the term LGBTQ2S+ youth refer to individuals between the ages of 16-29 years of age who identify as members of the LGBTQ2S+ community. It was necessary to rst determine the current state of services for LGBTQ2S+ youth in Ontario, in order to move forward with trying to understand how to decrease barriers and increase access to mental health and substance use services for LGBTQ2S+ youth.

Search Process
This environmental scan intended to identify existing programs and services in Ontario that offered exclusive mental health and addiction services to LGBTQ2S+ individuals, either by offering services to all or subgroups within the population. A set of inclusion criteria were established to determine eligibility of the programs and services to be included in the scan. The programs and services were required to serve youth (ages 16 to 29), either speci cally or as part of the broader adult population. In addition, the services were required to offer support or interventions for mental health or substance use, either as an entry point or exposure to the mental health and substance use treatment system or by directly offering treatment. Private mental health practitioners and psychotherapists were excluded from this scan, however organizations and networks of several private mental health practitioners and psychotherapists that offered services speci cally for LGBTQ2S+ clients were included. For additional details of the inclusion criteria, please see Figure 1 (Appendix A).
The list of programs and services were compiled through an Internet search leading to several Ontariobased service databases (n=5), resource guides (n=4), and a Facebook group (n=1). Initially, each resource was scanned for mental health and substance use programs and services exclusive to LGBTQ2S+ individuals. This information was captured in an Excel spreadsheet. Each program and service's website and/or social media pages (Facebook, Twitter, or Instagram) were manually reviewed for inclusion criteria. All resources were identi ed for inclusion between November 2020 to February 2021.

Analysis
Once programs were identi ed as meeting the inclusion criteria, the environmental scan extracted the following information from the identi ed programs and services: Organization that offers the program/service; Name of program; Location; Setting where services are offered (e.g. community, hospital, residential treatment); Whether the organization and/or program offered exclusive services to LGBTQ2S+ populations; Target population for the program/service (e.g. post-secondary students, Indigenous Peoples etc.); Target age range for the program/service; Program topic focus (e.g. mental health or addiction/substance use); Relationship to mental health/addiction system (e.g. entry point into the system, therapeutic intervention); Type of program (e.g. peer support group, counselling, etc); Cost; Method of program delivery during the COVID-19 pandemic and Website.

Results
In total, 113 organizations and 240 programs and services were identi ed as providing mental health and substance use services exclusively to LGBTQ2S+ youth. Four main themes were identi ed from the scan, including the distribution of services, types of services, methods of service delivery and program criteria. In addition, there were various adaptations identi ed in light of the COVID-19 pandemic, which are described below as they relate to each of the four themes.

Distribution of Services
One goal of this environmental scan was to identify the distribution of services across Ontario as a means of exploring accessibility. The scan identi ed that most services were offered in a community setting. Only one full mental health program was offered through a hospital or residential treatment setting, where others that took place in these settings offered a particular group or service within a broader program. Distribution of programs and services per location were also identi ed. As identi ed in Table 1, regions of Local Health Integration Networks (LHIN) were used to categorize locations. LHIN regions were selected due to their role in the distribution of healthcare spending and provisions across the province, their ability to capture distinct population centres, and the availability of region-speci c Canadian census information for further analysis. When looking at the distribution of services relative to population density, the North West LHIN region was identi ed as having the most services per 100,000 people at a rate of 5.26 followed by Toronto Central at 3.57, with Central having the least service per population at 0.94. When looking at the distribution of services relative to geographic layout, the Toronto Central LHIN region had the most services per 100 square kilometers at a rate of 22.90, over 13 times the next highest number of services with Mississauga Halton at 1.71, and much higher than the lowest rate per LHIN with North East at a rate of 0.0028.

Types of Services
Most population-based mental health and substance use services geared towards LGBTQ2S+ youth in Ontario were either free or included some free aspects (Figure 1). This is to be expected as individual private mental health practitioners were excluded from the environmental scan. Peer support groups were the most frequently available form of support at 91of all speci c services. Peer support groups along with several other modalities of services operate as entry points into the mental health system, consisting of 78.33% of services across the province. These are valuable services where individuals can be introduced to many topics around mental health and receive education around treatment options and referrals. They are also important sources of support for the social and cultural domains of mental health through sharing of common experiences and the recognition of social and political determinants of health, which can lead to the alleviation of shame and improve self-acceptance. For those that experience added layers of disenfranchisement, they can also be a valuable source of meeting basic needs such as food for those with limited nancial resources, or information sharing around navigating the health care or immigration systems for those that are newcomers to Canada (Logie et al., 2016).
For those that are seeking mental health or substance use treatment options that are speci c for LGBTQ2S+ individuals, options are few and they decrease in frequency the further distance they are from the Greater Toronto Area. Removing Toronto-based services from the tabulations resulted in almost a 3% decrease in mental health and substance use interventions for this population. There is also a dearth of addictions-speci c programming across the province, as only 1 was identi ed. Most services that did offer substance use support did so in conjunction with mental health interventions, which may pose as a barrier to care for those without concurrent mental health concerns or who are experiencing stigmarelated perceptions of mental health.

Methods of Service Delivery
Most services have moved online with a variety of different formats. This means that out of the 113 services many of them were categorized into multiple adaptation categories, as shown in gure 2. Virtual Counselling, such as through Zoom, was the most common platform used. However, others such as Discord, Skype, Cisco Webex, Olark, tawk, and Google Meet were also identi ed. Social media sites such as Facebook and Instagram were identi ed as ways of maintaining engagement through sharing resources, interactive activities, hosting live events, or used to chat with community members seeking support. Several organizations implemented a "check-in" program, where a staff would reach out once a week via email, text, or social media to remain in contact with those facing increased isolation during this time. Other creative ways that organizations attempted to meet community needs during the pandemic include offering socially distanced walks, offering monthly kits for online group participation, and offering new online support or treatment groups in response to the needs of the community during COVID-19. Several programs increased their service areas due to their shift to online formats and no longer requiring travel to a centralized area to receive services. Some programs expanded to province or nation-wide, and others were better able to serve those living on the peripherals of their service area.
The pandemic has also created many limitations to the mental health and substance use system. Seventeen percent of organizations reported cancelling all or parts of their services that were not adapted for online formats. Walk-in, drop-in, and in-person programs adapted by moving to either online only formats, appointments only, reducing number of people allowed in a space, requiring masks for in-person services, limiting the amount of people accessing in-person services to those urgently in need, and/or providing time limits for in-person services. Some counselling programs stopped accepting new participants related to increased need of current clientele and resource constraints. It is also important to note that current service delivery methods were not able to be identi ed on websites or social media for 17 services. Not updating websites with service disruptions may operate as a barrier to care related to accessibility needs as described in the Accessibility for Ontarians with Disabilities Act (Meilleur & Ontario, 2006).

Program Criteria
There is much diversity among LGBTQ2S+ youth, where the intersection of identities and social locations in uences experiences in unique and important ways. All programs included in this environmental scan offered exclusive programming to LGBTQ2S+ individuals, however many programs also considered additional social locations within LGBTQ2S+ experiences, offering programming to meet identi ed needs within the community (Figure 3). It is important to note within programming for transgender and gender diverse individuals, there was a notable inconsistency with language used to describe the target population of programs, where some programs made no mention of non-binary and gender diverse identities, or those who were questioning their identities. As it is beyond the scope of this environmental scan to reach out to the programs individually to con rm whether this was an oversight or intentional speci c programming, programs were categorized based on the information listed on their websites or social media. Other speci c social locations considered within programming included cultural, religious, or ethnicity related criteria (44 services); post-secondary enrollment (29 services); sexuality related criteria (22 services); physical, cognitive, developmental, and mental health related abilities (7 services); and criminal justice involvement (2 service). Many programs also identi ed age criteria for participants. One note is that although only 1 service was identi ed for young adult speci c programming, 29 services were identi ed speci cally for post-secondary students. Although no age criteria was listed for post-secondary students, many are young adults and therefore these spaces may offer programming targeted to this demographic. A nal note regarding target populations of services is that several offered support to multiple, intersecting social locations, further recognizing the diversity of experiences.

Limitations
There are several limitations in this study, including that the information extracted from websites and social media was not con rmed with the organization offering the service, and therefore it was assumed that the available information was accurate and up to date. Certain programs also had inclusion criteria that was ambiguous and may have bene tted from further clari cation regarding the target population for their service. In addition, private mental health services and services that offered welcoming or a rming programming without exclusively serving LGBTQ2S+ youth were excluded from the scan, meaning that the results of this scan may not include the entirety of mental health and substance use services available to LGBTQ2S+ youth in Ontario.

Discussion
This scan was able to discern the mental health and substance use services available for LGBTQ2S+ youth in Ontario, as well as certain adaptations that were put in place due to the COVID-19 pandemic.
Although there are currently some speci c services available for LGBTQ2S+ youth, more work needs to be done to ensure accessibility to these services in Ontario. For example, this scan identi ed that many of the available services were in the Toronto Central Region, as well as most services were being offered within community settings. Therefore, it will be important for future research to consider how to improve access to mental health and substance use services for LGBTQ2S+ youth in the entirety of Ontario, and to determine in which settings these services are most accessible.
This scan also distinguished the difference in access for individuals based on program criteria. The results of the scan showed that although certain services were geared towards LGBTQ2S+ youth, they had additional inclusion criteria that may be limiting for individuals. In other words, the services identi ed in the scan are not accessible by all LGBTQ2S+ youth due to additional criteria re ective of intersecting identities. Although this allows for the recognition of intersecting social locations within the community, it also speaks to a dearth of exclusive services as the number of services is smaller than it initially appears. When considering the methods of service delivery, it was discovered that certain programs are now able to offer services province wide due to the increase in remote services being offered during the pandemic. Prior to the pandemic there were limited services offering programs to particular ethno-racial groups across the entirety of Ontario. Therefore, funding to support the expansion of these programs to virtual services might offer an opportunity to connect individuals with similar social locations outside of a centralized area for their mental health and substance use care. Ultimately, this may provide opportunity to increase access to culturally sensitive services for LGBTQ2S+ youth who would not otherwise have access to these services within their geographic region.
However, as identi ed in the research, there are also many barriers that have arisen during the pandemic making mental health and substance use services less accessible for LGBTQ2S+ youth. For example, the results from the 2SLGBTQ+ Commercial Tobacco Project Screening Questionnaire, a survey administered to youth in Ontario and Quebec who identify as gender or sexually diverse, showed that 75% of respondents sought help for their mental health and faced barriers to accessing services (Chaiton et al., 2021). It will be important for future policies and practices to address these barriers, to subsequently increase access to a rming care in this population. Finally, most of the available services were offered through peer support, which is an important consideration regarding the hiring practices of mental health and substance use organizations. It will also be important for organizations to consider the additional need for clinical counsellors to support individuals from this community, as the scan highlighted a lack of necessary counselling support to meet the needs of LGBTQ2S+ youth. The themes identi ed from the scan should be used to inform future policy and practices in terms of providing culturally appropriate care to LGBTQ2S+ youth.
These results are also consistent with the literature on this topic, which suggest that certain individuals may be differentially affected by the psychological impacts of the COVID-19 pandemic (Ruprecht et al., 2021). Individuals who faced barriers such as discrimination or decreased social support before the pandemic, including LGBTQ2S+ youth, may experience exacerbated psychological effects as a result of the COVID-19 pandemic (Ruprecht et Al., 2021). Further, this scan ampli es a body of evidence that indicates the importance of increasing the availability of mental health and substance use services for LGBTQ2S+ youth and decreasing barriers that exist for this population to access services.
The literature offers several strategies that the mental health system can implement to address the identi ed disparities and offer culturally informed care. One way to do this is by offering a rming care. This involves clinician inquiry around gender and sexuality and addressing the mechanisms in which mental health disparities are fostered, such as by normalizing the impacts of minority stress and restructuring related cognitions (Barbara, Chaim, & Doctor, 2007; Coyne, Poquiz, Janssen, & Chen, 2020).
There are limitations to this approach, however. Individual clinician competency can vary, and as youth may engage with multiple service providers within a given organization, there is risk or perception of risk of having their identity stigmatized by providers, which may result in a youth not disclosing their identity or acting as a barrier to seeking out support (Moore et al., 2020). There can also be risk or anticipation of risk of experiencing discrimination and harassment from other participants such as in the waiting room or in group settings which may act as a barrier to care (Cochran, Peavy, & Cauce, 2007).
For those who are unable to meet their needs through general mental health practitioners offering a rming care, the literature has identi ed mental health and substance use services exclusive to LGBTQ2S+ youth as a means to better address disparities. A pilot study conducted by Craig and Austin (2016) looked at the impact of LGBTQ2S+ youth speci c group cognitive behavioural therapy (Project AFFIRM) on experiences of depression, noting a signi cant decrease in depression at post-test sustained at 3-month follow up. A randomized control trial of group cognitive behavioural therapy for sexually diverse young adult men found similar results, where compared to waitlist control, participants reported a signi cant decrease in depressive and anxiety symptoms as well as alcohol use problems and past 90day heavy drinking (Pachankis, 2015). Encouraging results of targeted care were also described by Senreich (2010), where when sexually diverse men received substance use treatment exclusive to LGBTQ2S+ participants, a signi cant increase in program completion, abstinence following treatment, and interpersonal connection was noted to the point where all signi cant outcome differences between sexually diverse men and heterosexual men disappeared. Interventions exclusive to LGBTQ2S+ youth hold an important place in the mental health and substance use system to respond to speci c needs of this group.

Conclusion
This environmental scan sought to identify the landscape of mental health and substance use programs and services exclusive for LGBTQ2S+ youth in Ontario during the COVID-19 pandemic. Several themes were identi ed, including distribution of services, types of services, methods of service delivery, and target populations served. These results have important implications for mental health and substance use policy and practice considerations. The ndings from this scan highlight the importance of offering services that provide culturally inclusive care for LGBTQ2S+ youth, and these results can also be used by policy makers to inform policies and procedures in various health care settings including hospitals, community health settings and residential settings. Although the information gathered is looking speci cally at services for LGBTQ2S+ youth, the need for culturally sensitive services must consider the intersecting identities of individuals to truly understand barriers to accessing care. The elicitation of this information will be helpful for informing future research, policies and practice around mental health and substance use care.

Abbreviations
LGBTQ2S+   Service delivery adaptations among organization (n=113) Figure 3 Number of services per service type, service focus, and target population (n=240) [1] Category includes social and support groups; support groups; peer wellness groups; drop-in support groups; peer support and social groups; social support groups; peer support groups; social groups; social and peer supports; social support groups with referrals and strategies; social support drop-ins; social groups with health and wellbeing promotion; social support groups with topics of mental health