Experiences and Needs of Sexual and Gender Minority Young Adults with a History of Suicidal Ideation Regarding Formal and Informal Mental Healthcare

Disparities in mental health between SGM and heterosexual, cisgender individuals are to a large extent explained by the experience of gender and sexual minority stress, as outlined in the minority stress framework (Meyer, 2003) and extensions (Hatzenbuehler, 2009; Testa et al., 2015). Notions from the minority stress framework are supported by research showing associations between minority stressors and suicidality (Burton et al., 2013; Hatchel et al., 2019b; Mustanski & Liu, 2013; Perez-Brumer et al., 2017). For example, Burton et al. (2013) showed that LGB youth reported higher levels of suicidal ideation than heterosexual youth, and this was partly explained by LGB-related victimization, and in a study among transgender adolescents, level of suicidal ideation was partly explained by in-school victimization (Perez-Brumer et al., 2017). A study conducted in the Netherlands also demonstrated an association between LGB-related victimization and suicidal ideation among LGB adolescents (Van Bergen et al., 2013). In addition, negative responses by family or parents to youth’s sexual orientation or gender identity such as rejection, non-affirmation, and verbal or physical abuse are important risk factors for developing suicidal ideation (Grossman & D’Augelli, 2007; Ryan et al., 2009).

The minority stress framework and its extensions emphasize the importance of protective factors, such as social support from family, friends, and community (Hatzenbuehler, 2009; Meyer, 2003; Testa et al., 2015). Previous studies have shown that family, friends, and peers are important sources of social support for SGM youth (McConnell et al., 2016; Parra et al., 2018; Poštuvan et al., 2019; Shilo & Savaya, 2011; Watson et al., 2019). Support from parents, caregivers, and family can protect SGM youth from developing mental health problems, for example, by affirming and accepting youth’s sexual and gender identities (Espelage et al., 2008; Ryan et al., 2010; Simons et al., 2013). In addition, parental connectedness can protect against suicidal ideation (Taliaferro & Muehlenkamp, 2017).

However, little research has been conducted on parents’ needs in supporting their SGM child. In a qualitative study among transgender youth and their caregivers, caregivers expressed their need for support during their child’s transitioning process (Schimmel-Bristow et al., 2018). And, to our knowledge, there are no studies that specifically examined parents’ needs in supporting an SGM child who is struggling with suicidal ideation.

There is little research on SGM youth’s usage of and experiences with mental healthcare, particularly for SGM youth with suicidal ideation. Studies among SGM youth showed that SGM youth found it difficult to ask for help when experiencing mental health problems (McDermott et al., 2018) and SGM youth did not seek help at all or went to friends for help and less often went to a healthcare professional for help (Lytle et al., 2018). Moreover, a study on lesbian, gay, bisexual, transgender, and questioning (LGBTQ) adolescents’ help-seeking beliefs found that LGBTQ adolescents who reported a higher level of help-seeking beliefs reported less suicidal behavior (Hatchel et al., 2019a). This underlines the importance of SGM youth’s beliefs about the helpfulness of professional healthcare in reducing mental health problems. However, research on healthcare experiences indicates that mental and physical healthcare do not always fulfill SGM youth’s needs and that healthcare is not always perceived as helpful (Fuzzell et al., 2016; Gridley et al., 2016; Meckler et al., 2006). For example, some LGB youth did not disclose their sexual orientation to their physician for confidentiality concerns (Meckler et al., 2006) or because a healthcare provider did not ask about it (Meckler et al., 2006; Rossman et al., 2017). Similar to these findings, a systematic review on disclosure of sexual orientation in healthcare demonstrated that barriers for disclosure were, for example, use of non-inclusive language by a healthcare provider and fear of discrimination, adverse reactions, or a breach of confidentiality by a healthcare provider after disclosure (Brooks et al., 2018).

In addition, some LGBTQ youth had distressing and negative experiences with healthcare providers (Goldberg et al., 2019; Gridley et al., 2016; Snyder et al., 2017). They experienced, for example, poor communication and disrespectful behavior by their physician regarding their LGBTQ identities (Snyder et al., 2017). In addition, transgender youth experienced the use of offensive language and non-affirmation of their gender identity by pediatric and other healthcare providers (Goldberg et al., 2019; Gridley et al., 2016), and transgender youth perceived a lack of knowledge and competence in transgender issues by mental health professionals (Goldberg et al., 2019; Schimmel-Bristow et al., 2018). Moreover, findings from a qualitative study revealed that LGBTQ young people expressed a need for training practitioners in SGM issues (Sherriff et al., 2011).

Furthermore, transgender youth might seek both mental healthcare and gender-affirming care (e.g., hormonal or surgical treatment) and as a result have unique needs and experiences with both types of care. Some healthcare systems require transgender youth to access mental healthcare before they can start gender-affirming care. In the Netherlands, where the current study was conducted, transgender youth need a referral from their general practitioner for an intake at a gender clinic (VUmc, n.d.). Waiting lists for each step of the treatment are long—the waiting time for an intake appointment at a gender clinic can go up to almost 2 years (Radboudumc, n.d.; VUmc, n.d.). This means that while transgender youth are on a waiting list, they might seek and require mental healthcare elsewhere. This further underlines the need for affirming mental healthcare for transgender youth.

In sum, mental healthcare does not yet seem to fulfill SGM youth’s needs. To improve mental health services for SGM youth with suicidal ideation, it is important to gain a deeper understanding of experiences and needs regarding mental healthcare, particularly among those who struggle with suicidal ideation.

Insights into experiences of mental health professionals and volunteers of LGBTQ organizations in supporting SGM youth with suicidal ideation are essential for optimizing suicide prevention efforts in care and community settings. Insights in experiences and needs may inform mental healthcare services and LGBTQ organizations about what is needed to facilitate mental healthcare professionals and volunteers in adequately supporting SGM youth with suicidal ideation. Few studies focused on mental healthcare professionals’ needs regarding working with SGM youth. One study examined mental healthcare professionals’ perceptions regarding suicidality in LGBT youth (Hughes et al., 2018). It was found that more than half of the professionals felt that they were competent in working with LGBT youth with emotional distress. However, some professionals indicated that they lacked confidence in talking about LGBT issues, and half of the professionals indicated that they did not have access to skills training regarding LGBT youth with suicidal thoughts (Hughes et al., 2018). Another study demonstrated that master’s and doctoral-level counseling students felt competent in their awareness of and knowledge about LGB individuals. However, counseling students felt less competent about their counseling skills, especially when they had never seen an LGB client (Graham et al., 2012). Similar findings were demonstrated in a study among pediatric residents. Almost half of the pediatric residents felt they lacked knowledge of SGM youth’s needs to discuss these issues with youth (Zelin et al., 2019).

Moreover, a study conducted in the Netherlands reported that when youth care professionals did not discuss youth’s sexual orientation or gender identity, this was because they believed it was “irrelevant for their treatment”; others reported not discussing it because they did not want to make someone feel “uncomfortable” or they did not want to “make being LGBT an issue.” Nevertheless, the majority of youth care professionals in this study indicated that they wanted to learn more about sexual and gender diversity (Emmen et al., 2015). In addition, in a qualitative study among practitioners in mental health, education, housing, police, social, and youth services, practitioners expressed a need for training to gain confidence in talking about SGM issues, for example, by using real-life examples (Sherriff et al., 2011).

In sum, professionals lack confidence in talking about SGM issues and wish to improve their skills and knowledge. However, not much is known about the needs of volunteers in supporting SGM youth with suicidal ideation.

Three groups of participants were interviewed. The first group consisted of 23 Dutch SGM young adults with a history of suicidal ideation, aged between 18 and 31 years old, except for one 35-year-old participant (M = 24.7, SD = 4.2). We conducted a pilot interview with a 35-year-old participant, and as we wanted to utilize all the information, we included the 35-year-old participant in our sample.

As for gender identity, eight participants self-identified as transgender men, two as transgender women, four as non-binary, five as cisgender women, three as cisgender men, and one participant was unsure about one’s gender identity. Regarding sexual orientation, four participants identified as lesbian, one as bisexual, one as bi/lesbian, three as pansexual, five as gay/homosexual, one as gay/a little bisexual, and two as queer. One participant did not want to label his sexual orientation. Finally, four participants described their sexual orientation as attracted to women, and one participant described it as attracted to men. The sample consisted of 20 White participants and three multi-ethnic participants.

The second group consisted of 16 Dutch parents of SGM youth with a history of suicidal ideation. These parents were not the parents of the interviewed young adults. Eleven parents were women and five were men. At the time of the interview, their children were aged between 11 and 22 years old. Five of them described their child’s gender identity as transgender women, seven as transgender men, two as cisgender women, and two as cisgender men. Parents described their cisgender child’s sexual orientation as lesbian, bisexual, and gay. Transgender children’s sexual orientation was not systematically asked for in the interviews.

The third group of participants consisted of professionals and volunteers (n = 14) who worked with or were in contact with SGM youth with suicidal ideation. We included a diverse group of professionals and volunteers because we found it essential to learn about perspectives on suicidal ideation of SGM youth from a broad range of care and youth workers. Every professional within social services or mental healthcare could encounter SGM youth, and it is therefore important that they can adequately support SGM youth with suicidal ideation. Moreover, volunteers of LGBT organizations may encounter young people who suffer from suicidal ideation. Participants worked as youth care workers (n = 4), social workers (n = 4), and public health workers (suicide prevention care, n = 2, and sexual health nurse, n = 1), and three participants worked as a volunteer in an LGBT community-based organization. Not all professionals were trained to address suicidal ideation.

This study was reviewed and approved by the ethics committee of the Department of Pedagogical and Educational Sciences of the University of Groningen on March 7, 2018. Participants for all three groups were recruited through online advertisements on websites and social media of LGBT organizations and were subsequently directed to a website specifically designed for this research project. All interviews were conducted between June 2018 and July 2019, audio-recorded, and transcribed verbatim. All participants gave informed consent before they participated in the interview.

Semi-structured interviews with SGM young adults were conducted face-to-face by the first author, at a location preferred by the participant. Interviews lasted 51 min on average. SGM young adults received a 10-euro voucher for participation. After enrollment, but before making an appointment for an interview, potential SGM participants were asked to complete the Suicidal Ideation Attributes Scale (SIDAS) (Van Spijker et al., 2014). The SIDAS measures current severity of suicidal ideation. A score higher than 20 indicates a high risk of suicidal behavior (Van Spijker et al., 2014). If a potential participant scored above a cut-off score of 20, they could not participate in the study and were encouraged to seek help from a list of resources.

Semi-structured interviews with parents were conducted by an external researcher. These interviews were conducted by telephone and lasted 56 min on average. Parents received a 10-euro voucher for participation.

Interviews with professionals and volunteers were conducted by two external researchers. Data was collected via two focus groups, each comprised of six participants, and due to scheduling issues, two additional interviews were conducted one-on-one. The focus group interviews lasted 110 min on average, and the two one-on-one interviews lasted 48 min on average. Professionals and volunteers received a 20-euro voucher for participation.

Topic lists were developed by the research team, based on existing literature on suicidal ideation and SGM youth. Two pilot interviews with SGM young adults and two pilot interviews with parents were conducted, upon which a few changes in the topic lists were made. SGM young adults’ interviews included questions about gender identity and sexual orientation, development of suicidal ideation, social support, mental healthcare experiences, and mental healthcare needs. Parents’ interviews included questions about the development of the child’s suicidal ideation, recognizing suicidal ideation, behavior towards the child’s suicidal ideation, mental healthcare experiences, and parents’ needs. Professional and volunteers’ interviews included questions about recognizing suicidal ideation, helpful and unhelpful approaches and experiences, and needs regarding working with SGM youth with suicidal ideation. The topic list for the focus group interviews and the individual interviews was similar.

Thematic analysis was used to analyze the interviews (Braun et al., 2019). Thematic analysis is a method for analyzing and identifying patterns in qualitative data (Braun et al., 2019). Using reflexive thematic analysis, we aimed to interpret, understand, and describe participants’ experiences and needs. The first author coded all three participant groups’ transcripts separately using Atlas.ti 8.4. Transcripts were coded with an inductive as well as a deductive approach. Codes were not pre-determined but were derived from the data, the research questions, and the interview topics. The first three coded transcripts from the SGM young adult sample and the first three coded transcripts from the parent sample were discussed with the second coder (second author) before coding all the transcripts; codes were adjusted, deleted, or added. After coding all the interviews, the second coder read and looked at all coded transcripts precisely and gave suggestions for changes and new codes. Again, codes were discussed, changed, deleted, or added.

Themes were derived from patterns throughout interviews, the research questions, and the interview topics. Themes were developed for each participant group separately. First, data were added together on a semantic level, for example, statements about helpful and unhelpful experiences with formal healthcare were added together. Next, within and across these broad categories, themes were developed based on shared experiences from participants. For example, one theme that emerged from data of young adult participants was “professionals’ unfamiliarity with the impact of growing up as an SGM individual.” Our coding frame distinguished between SGM-related and not specifically SGM-related healthcare experiences and needs. Not specifically SGM-related healthcare experiences included, for example, no “click” with a therapist or the perception that their therapists only focused on a psychiatric diagnosis. As a result of our focus in this paper, mainly SGM-related and suicidality-related experiences and needs are discussed.

Results of the 23 SGM young adults’ interviews are presented in two sections: formal mental healthcare and informal mental healthcare. Four themes regarding formal mental healthcare were identified: (1) addressing suicidal ideation, (2) professionals’ unfamiliarity with the impact of growing up as an SGM individual, (3) knowledge about transgender identities, and (4) general counseling skills. Two themes were identified regarding informal mental healthcare: (1) sharing suicidal thoughts and (2) perceived support. See Table 1 for a summary of SGM young adults’ results.

Most young adults received mental healthcare from more than one professional (e.g., psychologists, psychiatrists, coaches, and social workers). Not all healthcare was focused on young adults’ suicidal ideation but was also aimed at coping with depression, AD(H)D, or bipolar disorder. Almost all transgender young adults received transgender-specific healthcare (e.g., in a hospital gender clinic).

Results from the sixteen parent interviews are described in two sections: mental healthcare experiences and parents’ own experiences and needs. Three themes regarding mental healthcare experiences were identified: (1) addressing suicidal ideation by mental health professionals, (2) unfamiliarity with and lack of knowledge of SGM individuals, and (3) support from LGBT organizations and SGM peers. Two themes regarding parents’ own experiences and needs were identified: (1) recognizing suicidal ideation and (2) talking about suicidal ideation and mental health. See Table 1 for a summary of parents’ results.

Overall, parents indicated multiple factors that played a role in their child’s suicidal ideation. They mentioned factors related to gender identity and sexual orientation, for example, feeling different, loneliness, worrying about the future, and bullying. Factors unrelated to gender identity or sexual orientation were also indicated, for example, divorced parents.

All parents’ children had received some sort of mental healthcare, ranging from psychologists, psychiatrists, social workers, coaches, and youth care workers. Eleven children accessed a combination thereof. Mental healthcare was not always focused on suicidal ideation, but also on self-esteem, social anxiety, and depression. Furthermore, all transgender children of parents in the current study received healthcare from a gender clinic. Six parents mentioned waiting lists for gender-affirming care as a problem, varying between 4 and 18 months. Some parents changed to a different gender clinic where they hoped to receive care sooner.

Results of two focus group discussions and two individual interviews with professionals and volunteers are described in three themes: (1) recognizing and addressing suicidal ideation, (2) training in sexual and gender diversity, and (3) addressing sexual orientation or gender identity. See Table 1 for a summary of professionals’ and volunteers’ results. Most participants worked in youth care or social work (n = 8), one of them worked specifically with SGM youth, and two of them had expertise in sexuality topics. Three participants worked as volunteers in LGBT-specific organizations, two participants worked in care regarding suicide prevention or aftercare, and one participant worked as a sexual health nurse. Participants had a wide range of experiences in working with SGM youth.

They mentioned various factors as important for the development of suicidal thoughts among SGM youth. For example, they mentioned that most youth experienced a combination of SGM-related issues, such as loneliness, internalized transphobia or homophobia, fear of rejection and actual rejection by family, and other issues such as difficulties in their home environment.

The findings of this study give several suggestions for social policy and practice regarding formal and informal healthcare for SGM youth with suicidal ideation in the Netherlands. First, professionals and professionals in training, such as social workers, counselors, and psychologists, should have the possibility to learn within their organization or attend training about sexual and gender diversity, including minority stress, sexual orientation and gender microaggressions, and the use of inclusive language. For example, social studies and institutes that train future mental healthcare professionals need to include sexual and gender diversity as a part of their curricula. In addition, within youth care and mental healthcare organizations, sexual and gender diversity should be included in training programs. For example, organizations that provide mental healthcare for individuals with suicidal thoughts should provide training on inclusive language. Furthermore, the use of inclusive language should be included in organizations’ policies. Second, the early identification of (the development of) suicidal ideation is crucial. Therefore, it is important to educate parents, mental healthcare professionals, and volunteers of LGBT organizations into recognizing and addressing suicidal ideation. Within professional healthcare, training on suicidal ideation should be offered in the regular curriculum. In addition, resources and tools on how to support an SGM child with suicidal ideation should be made available for parents and volunteers of LGBT organizations as they can serve as gatekeepers for suicide prevention (Holmes et al., 2021; Torok et al., 2019).

The current study had several important limitations. First, there was an underrepresentation of participants of color within all participant groups. Second, the parent sample consisted mainly of parents of transgender children. Specific needs of parents of sexual minority children are somewhat understudied in this article. Third, almost all parents were supportive of the SGM identity of their child. Because of this, parents’ findings are not generalizable to all parents. Fourth, even though the group of professionals was diverse in occupations, psychologists or psychiatrists were not included. Regardless of these limitations, since suicide prevention is by definition multifaceted in nature, it is valuable that our study brought together perspectives from three sources, which can be used to improve formal and informal mental healthcare for SGM youth with suicidal ideation.

For future research, it is crucial to better understand the specific needs and experiences of SGM youth of color with suicidal ideation and their parents, as well as the experiences and needs of SGM youth from different ethnic backgrounds and religions. In addition, it is important to gain more insight into the specific needs of psychologists, psychotherapists, and psychiatrists regarding addressing sexual and gender diversity. Finally, it would be valuable to investigate how inclusive and SGM affirmative practice could be implemented and whether this improves mental healthcare for SGM youth.