LGBTQ2S+ (Lesbian, Gay, Bisexual, Trans, Queer, 2-Spirit, and other identities) youth experience mental health disparities and higher rates of substance use when compared to their cisgender and heterosexual peers (Plöderl and Tremblay, 2015; Hatzenbuehler, Keyes, & Hasin, 2009; Liu et al., 2019; Marshal et al., 2008; Day, Fish, Perez-Brumer, Hatzenbuehler, & Russell, 2017). A systematic review by Plöderl and Tremblay (2015) suggests that 97% of reviewed adolescent studies indicate higher rates of depression among LGBTQ2S+ youth , as well as 98% of studies indicate higher rates of adolescent suicidality in this population. In addition, all studies that explored anxiety indicated disproportionate rates of mental health issues for LGBTQ2S+ youth The research also indicates higher rates of post-traumatic stress disorder (Hatzenbuehler, Keyes, & Hasin, 2009) and non-suicidal self injury (Liu et al., 2019) among LGBTQ2S+ 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 findings 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 influence mental health outcomes, where Black and Hispanic sexually diverse youth were significantly more likely to report suicidality compared to their White, heterosexual peers (Mueller, James, Abrutyn, & Levin, 2015).
Several structural mechanisms have been identified 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 identified in a meta-analysis by Dürrbaum and Sattler (2020). Mereish and Miranda (2019) supported this finding 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 identified as protective against depression and suicidality for LGBTQ2S+ youth (Gower et al., 2018). Community supports have also been identified as a protective factor, where the presence of events, community resources, and organizations that offer programming specific 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) identified 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 identified in the literature. A large-scale study of mental health service utilization across three post-secondary institutions in California found that students who identified as LGBTQ2S+ were significantly more likely to report barriers towards accessing on-campus mental health support, and significantly more likely to report multiple barriers (Dunbar et al., 2017). It is also reflective 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 identified 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 identified in a qualitative study of 104 youth, where system level barriers (i.e. lack of competence to provide affirmative 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-confidence) were identified (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 significantly 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 influence experiences within the mental health system, where a qualitative study of Black and Hispanic LGBTQ2S+ young adults identified several additional barriers, including stigma associated with mental health symptoms and sexuality, ambivalence about the efficacy 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. Specifically, the literature has identified 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 significant impact on their mental health, compared to 26% of the national average (Egale, 2020). It has also been identified 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.