Suicide is a leading cause of death in youth and young adults aged 10 to 24 years in the United States [1]. Between 2007 and 2020, the suicide rate steadily increased in the United States for this age group [2]. Within this age group, the risk for suicide is especially pronounced within certain minoritized communities: compared with heterosexual and cisgender youth, youth who identify as lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other minoritized gender and sexual identities (LGBTQIA+) report higher levels of suicidal ideation and attempts; report higher rates of suicide risk factors, such as depression, substance use, and self-harm; and are more likely to disclose a past history of abuse, victimization, bullying, or trauma [3-6]. Despite disproportionately high levels of depression, self-harm, and suicidal thoughts and behaviors in LGBTQIA+ youth relative to the general youth population, there remains a lack of suicide-specific mental health treatment and research addressing this disparity [7]. Preliminary research indicates that LGBTQIA+ youth who participate in adapted treatments demonstrate considerable clinical improvement after treatment [8] and that LGBTQIA+ youth describe the treatment as helpful in addressing their life stresses [9]. Given the disparities and the importance of intervening in serious mental health issues in adolescence and young adulthood, there is a critical need for more research on the efficacy of general and population-specific programming for LGBTQIA+ youth [10].

Studies including LGBTQIA+ youth have consistently highlighted the heightened risk of suicide among this population relative to cisgender and heterosexual youth [11,12]. Given the diversity of gender and sexual identities within the LGBTQIA+ community, subpopulation differences within this group have been explored and yielded findings that substantiate the heterogeneity of risk within this community [13,14]. For example, Jadva et al [13] compared transgender and nontransgender youth within the LGBTQIA+ community and found that transgender youth were 4 times as likely to report self-harm, 3 times more likely to report suicidal ideation, and 2 and a half times as likely to report having attempted suicide. In 1 study of gender minority youth, sex assigned at birth was linked to a higher risk of mental health, self-harm, and sexual assault, and nonbinary youth had higher life satisfaction [14]. Thus, when designing mental health programming and evaluating mental health treatment for LGBTQIA+ youth, it is important to use an evaluative approach that allows the exploration of subgroup differences. However, individual organizations and practices may be limited in how nuanced an analysis they are able to perform, given that small subsample sizes often do not lend themselves to sufficiently powered analyses.

Despite the elevated risk, mental health treatment for LGBTQIA youth can lead to notable symptom improvement and increased well-being. Both treatments adapted for sexual and gender minority clients and treatments with no modifications have reported significant improvements in clinical outcomes [15]. Adapted treatments can address stigma-related stressors and processes that impact both health and health care experiences, such as anxious expectations of rejection or concealed sexual orientation [16]. LGBTQIA+ individuals often report lower satisfaction with their health care experiences and barriers that prevent the initiation and continuation of care [17-19]. Barriers may include a lack of LGBTQIA+-specific clinical competencies, discrimination, the fear of disclosing one’s gender identity or sexual orientation, financial burden, and a practitioner’s perceived or actual lack of willingness to discuss sexuality or gender identity [19-23]. These barriers may lead to decreased willingness to seek treatment and hinder the development of a therapeutic relationship, potentially reducing the effectiveness of treatment [19]. Adapted interventions may help address these processes and barriers, leading to stronger outcomes. To our knowledge, only 1 study has directly compared sexuality-tailored and gender minority–tailored interventions to an intervention without adaptations. This substance use intervention found that the tailored intervention led to greater reductions in substance use [24]. In 2 studies that adapted programming for LGBTQIA+ youth, youth had significantly reduced posttraumatic stress disorder symptoms [25], depression, and borderline symptoms after treatment [8]. Research on adults has similarly documented clinical improvement following adapted interventions [26,27].

Youth broadly face difficulty in finding a therapist, with shortages in mental health professionals prevalent globally [28,29]. This shortage is amplified for LGBTQIA+ youth, as there are even fewer mental health practitioners with expertise and training to specifically address the challenges unique to the LGBTQIA+ community [30]. For instance, among transgender individuals, having a transgender-inclusive provider was associated with decreased rates of depression and suicidality, indicating that one key aspect of effective mental health programming for this population may be improving the LGBTQIA+ competency of mental health providers [31]. Finally, the increased difficulty in accessing quality care is particularly salient for youth living in rural settings [32,33]. This may be exacerbated for LGBTQIA+ youth, as they may not feel safe discussing their gender identity or sexuality with their parents or they may fear that mental health professionals could out them, try to cure their gender identity or sexuality, or turn them away for being LGBTQIA+ [30].

Given the disproportionately high rates of depression, self-harm, and suicidality experienced by LGBTQIA+ youth, there is a growing need for high-quality and accessible mental health services tailored specifically to this population [9]. Even before the COVID-19 pandemic, telehealth was assessed as a way to ameliorate the local shortages of mental health professionals for both youth and adults and as a way to increase access in more rural areas [34-37]. Patients can access telehealth services by phone or computer from anywhere on the internet, removing barriers, such as not having transportation or the time spent commuting, and broadening the scope and availability of services [36,38]. Telehealth treatment may be uniquely beneficial to LGBTQIA+ youth, as this population already has a high use of technology to connect with web-based communities, build support and resilience, and seek resources and information [39,40]. LGBTQIA+ youth also report feeling safer in web-based communities than in offline forums [41,42]. A review of early research on telepsychiatry and LGBT treatment gaps suggests that telepsychiatry can bypass some of the stigma related to seeking treatment and that it allows clients more opportunities to seek a culturally competent therapist without being restricted by geographic proximity [43]. Digital health interventions have high acceptability and low attrition rates among LGBTQIA+ young people [44].

The primary objective of this program evaluation was to explore the effectiveness of a curriculum tailored specifically to LGBTQIA+ youth in a remote intensive outpatient program (IOP). This evaluation is part of an ongoing routine outcome monitoring system, primarily aimed at identifying opportunities for quality improvement in care. Given the lack of research on LGBTQIA+ youth seeking mental health services, this study sought to answer the following questions:

Charlie Health is a remote mental and behavioral health IOP provider serving adolescents and young adults (aged 11-28 years). Charlie Health regularly collects and analyzes patient-reported outcomes data using validated measures to ensure the quality of care and to meet the requirements of stakeholders and accrediting bodies. To increase treatment responsiveness, Charlie Health engages in ongoing program evaluations to identify opportunities for quality improvements. This program evaluation is part of a larger effort to assess what works for youth with mental health needs that necessitate IOP.

This program evaluation research was reviewed by the Florida State University Institutional Review Board, which deemed this investigation “nonhuman subjects research,” given its primary purpose of program evaluation and quality improvement (STUDY00003364).

Data were collected during the patients’ first (intake) and last (discharge) IOP sessions. When patients entered the web-based group room, they were sent to a survey room, where a staff member provided them with a Qualtrics (Qualtrics) [57] link to complete either the intake or discharge survey. Patients who missed their last IOP session were emailed the discharge survey with a small incentive for completion. All patient data were downloaded and deidentified for program evaluation.

Patient demographic data were collected at intake (age) and discharge (sexual orientation and gender identity). Patients were asked to select the sexual orientation that they most identified with from response options that included asexual or graysexuality, bisexual, pansexual, gay, heterosexual or straight, lesbian, queer, and questioning. Similarly, patients were asked to select the gender identity that they most identified with from the following options: gender fluid, gender neutral, man, woman, gender questioning, genderqueer or nonconforming, nonbinary, and “other.” Finally, the patients were asked if they identified as transgender (yes or no). The intake and discharge surveys also included a battery of clinical assessments to assess pre- and posttherapeutic changes, including measures of depression, anxiety, suicidal ideation, and self-harm.

Given the nature of these secondary data analyses as part of an ongoing quality improvement and assurance initiative, missing data affected 2 aspects of the evaluation. First, because gender and sexual orientation were collected as part of the discharge survey, we were unable to compare the demographic characteristics of patients who left treatment before the engagement threshold or who did not complete the discharge survey with those who were ultimately included in the current analysis. Second, there were missing data on some demographic and clinical variables, resulting in variable subsample sizes across the tests. This is a consequence of not “forcing” survey responses, wherein patients are encouraged to complete the surveys fully but have the option to skip over questions they do not wish to answer.

During the study period, 1766 individuals were discharged from programming, of which 1275 (72.22%) met the engagement criteria of attending at least 6 IOP sessions. Among clients who did not meet the inclusion criteria based on the number of sessions attended, 73.7% (362/491) were discharged within the first week of treatment and had attended ≤3 IOP sessions. Of the 1275 clients who met the engagement threshold, 397 (31.14%) did not complete the discharge survey, resulting in 878 (68.86%) clients included in the final sample.

The demographics of LGBTQIA+ and non-LGBTQIA+ samples are presented in Table 1. Compared with non-LGBTQIA+ patients, LGBTQIA+ patients were significantly younger (mean 16.44, SD 3.80 vs mean 17.01, SD 4.03 years; t₈₇₁=2.11; P=.04; Cohen d=0.14).

This evaluation included a large sample of youth who self-identified as part of the LGBTQIA+ community to assess clinical acuity, treatment outcomes, and differences by subgroups. Similar to population research on the disproportionate rates of clinical presentation and severity among LGBTQIA+ youth relative to non-LGBTQIA youth, this study found statistically significant differences in clinical intake scores, indicating heightened clinical acuity within the LGBTQIA+ community. At treatment entry, LGBTQIA+ patients were significantly more likely to report active suicidal ideation, passive suicidal ideation, history of suicide attempts, clinical NSSI, and significantly worse depression. Even within the LGBTQIA+ patient sample, transgender youth and youth who identified as pansexual were more likely to endorse NSSI than nontransgender and nonpansexual youth, respectively, indicating that some minority statuses within the LGBTQIA+ community place youth at even higher risk. This latter finding reflects population statistics on the increased risk of self-harm among transgender patients [63]. These elevated risks fit within minority stress theories, as increased prejudice and stigma lead to additional mental strain for transgender and nonbinary youth, with transgender youth currently facing great societal strains [64].

Although more severe at baseline, LGBTQIA+ patients demonstrated considerable clinical improvement in all outcomes from intake to discharge. Among LGBTQIA+ youth who met the criteria for depression at treatment entry, PHQ-A scores improved significantly from an average pretreatment score in the moderately severe range to an average posttreatment score in the moderate range. Similar improvements were observed across suicide risk and NSSI, with 72.1% (160/222) of LGBTQIA+ youth who endorsed active suicidal ideation at intake no longer reporting it at discharge and 55.1% (109/198) of patients who met the criteria for clinical NSSI no longer meeting the criteria at discharge. This study adds to the preliminary research documenting positive mental health outcomes following LGBTQIA+ programming and represents the first study, to our knowledge, to investigate the outcomes of a web-based IOP with LGBTQIA+ youth.

More than half (557/878, 63.4%) of the clients in this sample reported at least one LGBTQIA+ identity, which is a high proportion relative to the national population and to other IOPs. This may be because of services being provided on the web, as digital tools have high acceptability and retention among LGBTQIA+ clients or to publicizing LGBTQIA+ clinicians and adapted curricula, which are not widely available. Furthermore, there might be a snowball effect. Early research on digital interventions for sexual and gender minority youth suggests that these youth will be more engaged in treatment when they connect with other youth with similar characteristics [65]. It may be that LGBTQIA+ youth interact with other youth with similar characteristics during treatment and have a positive experience, leading them to recommend Charlie Health to other LGBTQIA+ youth.

Although LGBTQIA+ clients demonstrated equitable change across most outcomes, transgender clients were 2 times more likely to report clinical NSSI at discharge. This implies that even within an intentionally designed IOP curriculum, additional barriers to clinical improvement remain for transgender patients to achieve equitable outcomes. This disparity at discharge may be because of the ongoing stigma and strain faced by gender-diverse youth [64]. In a recent qualitative study, Tilley et al [9] conducted focus groups and interviews with 21 “transgender and gender-diverse” young adults (aged 18-25 years) and 10 mental health clinicians to better understand how to adapt DBT to this population of youth. The authors tentatively concluded that the DBT curriculum could be adapted to focus more on skills related to self-care and awareness (vs interpersonal effectiveness), recognizing that this population has a higher exposure to psychologically distressing victimization because of their gender identity. Such nuanced, patient-centered analyses are fundamental to the design and evaluation of population-specific programming.

A considerable strength of the current evaluation is access to a large, high-acuity sample of youth and young adults who identify as LGBTQIA+ as well as data that allowed for nuanced responses within these categories, where youth could select as many categories of identification as they felt resonated with them. However, because this was a clinical sample of LGBTQIA+ youth and young adults in a specialized program, these findings may not generalize to LGBTQIA+ youth in more general, nonspecialized programs. For instance, this analysis only included patients who attended 6 or more intensive outpatient sessions, which introduces an unknown number of biases that make the results not generalizable to the entire population of patients in care at Charlie Health. Demographic information beyond age, gender, and sexual identity was not collected at pretest and thus was not available for this study. The discharge survey was initially determined to be the best time point to ascertain honest responses from youth and young adults on sensitive demographic questions without undue influence from the presence of parents or guardians as the questions were asked, but the unintended consequence was not obtaining these data at the population level. Demographic factors, such as race, ethnicity, region, socioeconomic status, and living situation, have implications for mental health and treatment and should be considered in future research.

This is a program evaluation study, and it was therefore not possible to compare clients to a control group or to a group participating in a curriculum without adaptations. The study lacks a methodology to conclusively determine whether youth improve because of the adapted program or whether time or a more general program could have led to the same outcomes. The outcome data collected are general and cannot measure LGBTQIA-specific outcomes that could identify the mechanisms of treatment effectiveness. Furthermore, this study relied on self-reported outcomes, and the analysis was restricted to binary outcomes in some clinical areas. Demographic information (ie, sexual orientation and gender) was obtained using single-response, multiple-choice options—limiting patients’ ability to select all options that may apply in terms of describing their gender identity. Finally, although this investigation focused on quantitative differences in clinical symptoms following treatment, future evaluations would benefit from the inclusion of qualitative feedback from LGBTQIA+ youth in care to better understand subgroup needs, including why youth who identify as transgender evince smaller improvements in all symptom categories.

This program evaluation is the first to evaluate LGBTQIA+-specific programming for youth in remote IOP, finding that youth had significant reductions in depression, suicidality, and NSSI symptoms. General population research reflects what was discovered in this analysis: LGBTQIA+ youth enter treatment at a heightened risk for suicidality, depression, and self-harm. Charlie Health addresses this need by adapting its general curriculum to intentionally address issues salient to the LGBTQIA+ community. After participating in the program, most clients reported significant improvements in depression and substantial reductions in suicidal ideation and NSSI. Further research on identity-affirming and culturally competent care is necessary to ensure equitable outcomes for the most vulnerable youth.