The Promise of Digital Mental Health for LGBTQ+ Youths

Many youths have not disclosed their identities to important people in their lives and find it stressful to navigate decisions about disclosure (1, 2). “Coming out” is often viewed as a universal goal and as a reflection of self-acceptance. However, youths have valid reasons for concealing, such as maintaining relationships and avoiding violence. Coming out can have negative consequences, and it can lead to receiving support and building community.

DMH is well suited to help youths who are contemplating disclosure and may provide a way to practice disclosing prior to actually doing so. In addressing coming out, DMH tools could be developed to help youths weigh the potential risks and benefits of disclosure, to offer tips for assessing whether it is safe to disclose, to encourage youths to develop a safety plan in case of negative reactions, and to guide youths through exercises to identify their values to help inform their decisions.

Chatbots could be programmed to respond to entries about coming out with something like the following: “There are lots of reasons to come out, and it’s important to think about whether it’s safe to do so.” Users could describe pros and cons, and tools could be designed to help users decide what is best for them and to plan accordingly (e.g., “It sounds like coming out to your mom is important to you, and you think she’ll be accepting. Do you want to practice what you’re going to say? What can you do if she doesn’t react the way you think she will?”).

For youths who are exploring their identities, DMH could include educational content that distinguishes sex, gender expression and identity, and sexual orientations. Users could be prompted to imagine how they might like to present themselves and to create avatars to virtually experiment with gender expression, as has been suggested by user feedback (8).

The internalization of invalidating messages about one’s identity (“internalized stigma”) can contribute to self-invalidation, which contributes to psychiatric morbidity among LGBTQ+ people (1, 2). LGBTQ+ users of DMH have reported a desire for content to address this stigma (8). Online interventions that challenge stereotypes, identify sources of negative beliefs, and acknowledge positive aspects of being LGBTQ+ (9) could be leveraged by DMH to combat internalized stigma. To translate this research into practice, developers could consider including modules that present common stereotypes (followed by information busting these myths) and that prompt users to reflect on negative messages they have received and to identify the sources of those messages. Chatbots could respond to comments such as “I wish I wasn’t LGBTQ+” by offering “It can be hard to feel good about yourself when you receive negative messages about your identity. What messages have you received and where have they come from? What evidence do you have that those messages are true?” Relatedly, users have identified a desire for self-compassion skills to combat shame (6).

Rejection sensitivity (i.e., expecting and fearing rejection on the basis of identity) is another risk factor for psychiatric morbidity among LGBTQ+ youths (1, 2). From their rejection experiences, some LGBTQ+ people are understandably rejection sensitive. Coping strategies from affirmative versions of evidence-based therapies (3) could address this need digitally. First, users could be encouraged to check the facts to assess the likelihood of rejection. Chatbots can be designed to respond to worries about rejection with, “Have you observed that person make negative comments about LGBTQ+ people? If you don’t know how they feel, try mentioning an LGBTQ+ celebrity and see how they respond.”

In a case where the mention of an LGBTQ+ topic is met with a negative response, a chatbot could suggest problem-solving strategies, such as identifying alternative support people and avoiding harmful people. If checking the facts does not prompt a negative response, the chatbot could be designed to acknowledge that the fears do not seem to fit, and it may be safe to engage. Regardless, it can be helpful to offer cope-ahead plans, because none of us have crystal balls, and rejection can occur. This concept could be illustrated graphically with a crystal ball and a measuring stick, accompanied with messaging, such as “Someone else’s reaction to you is not a measure of your worth.”

Psychiatric morbidity can also be driven by intraminority stress from within the LGBTQ+ community (10). Those who identify with multiple minority groups are particularly vulnerable. DMH can be helpful here too; artificial intelligence responds to the concerns a user enters. A person who enters text about experiencing racism at a Pride event could be supported with content about coping with racism within the LGBTQ+ community.

Representation is important; when LGBTQ+ youths see role models who share their identities, this conveys that they too can lead fulfilling lives (2). Developers of DMH technologies can collaborate with LGBTQ+ celebrities to provide models of proud LGBTQ+ people. Developers of DMH tools could also create playlists featuring LGBTQ+ artists to foster pride. Chatbots could be designed to prompt users to enter text focused on positive aspects of being LGBTQ+. Apps featuring celebrities could include stories describing how being LGBTQ+ is a strength.

For some people, expressions of pride may include advocating for social justice. To acknowledge how exhausting advocacy work can be and to encourage self-care, chatbots could offer “We think about advocacy as a relay race, not a sprint or a marathon” and “What can you do to take care of yourself so that you don’t burn out?” Finally, affirmative mindfulness practices that explicitly amplify LGBTQ+ resilience can be incorporated into mindfulness-based DMH.

The well-being of LGBTQ+ youths depends on who surrounds them not only physically but also virtually (2). DMH can foster connections among individuals who lack local communities or support. For instance, some apps include a public mode, which allows users to be visible to each other. Given that LGBTQ+ identities are often invisible, DMH can offer ways for users to visibly self-identify to increase opportunities to connect.

Gender-diverse youths who express their authentic gender and those with access to affirming health care show improvements in psychiatric outcomes following access to care (11). By using location-based services, DMH could connect users with local affirming health care providers. When not locally available, connections could be made to providers virtually. Educational content on how to change legal documentation, such as name changes, could also be included in DMH.