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Lesbian, gay, bisexual, and transgender (LGBT) youth and other young people diverse in terms of their sexuality and gender (LGBT+) are at an elevated risk of mental health problems such as depression. Factors such as isolation and stigma mean that accessing mental health services can be particularly challenging for LGBT+ young people, and previous studies have highlighted that many prefer to access psychological support on the Web. Research from New Zealand has demonstrated promising effectiveness and acceptability for an LGBT+ focused, serious game–based, computerized cognitive behavioral therapy program, Rainbow Smart, Positive, Active, Realistic, X-factor thoughts (SPARX). However, there has been limited research conducted in the area of electronic therapy (e-therapy) for LGBT+ people.
This study aimed to explore how and why LGBT+ young people use the internet to support their mental health. This study also sought to explore LGBT+ young people’s and professionals’ views about e-therapies, drawing on the example of Rainbow SPARX.
A total of 3 focus groups and 5 semistructured interviews were conducted with 21 LGBT+ young people (aged 15-22 years) and 6 professionals (4 health and social care practitioners and 2 National Health Service commissioners) in England and Wales. A general inductive approach was used to analyze data.
LGBT+ youth participants considered that the use of the internet was ubiquitous, and it was valuable for support and information. However, they also thought that internet use could be problematic, and they highlighted certain internet safety and personal security considerations. They drew on a range of gaming experiences and expectations to inform their feedback about Rainbow SPARX. Their responses focused on the need for this e-therapy program to be updated and refined. LGBT+ young people experienced challenges related to stigma and mistreatment, and they suggested that strategies addressing their common challenges should be included in e-therapy content. Professional study participants also emphasized the need to update and refine Rainbow SPARX. Moreover, professionals highlighted some of the issues associated with e-therapies needing to demonstrate effectiveness and challenges associated with health service commissioning processes.
LGBT+ young people use the internet to obtain support and access information, including information related to their mental health. They are interested in LGBT-specific e-therapies; however, these must be in a contemporary format, engaging, and adequately acknowledge the experiences of LGBT+ young people.
Lesbian, gay, bisexual, and transgender (LGBT) young people and other young people diverse in terms of their sexuality and gender (LGBT+) are thought to form up to 12% of the adolescent population [
The internet has opened up a range of possibilities for LGBT+ young people, including psychosocial support and self-care for mental health problems. This assistance may be especially pertinent for LGBT+ young people, where parental support, a crucial protective factor in adolescence, may be lacking [
To date, little has been published on how LGBT+ young people use the internet to successfully support their mental health. However, research from Canada and the United States has highlighted that LGBT+ young people are particularly active internet users [
Formal online mental health interventions have become far more accessible in the last decade; in particular, in the form of computerized cognitive behavioral therapy (cCBT), which has become an effective and recommended form of e-therapy for the treatment of depression [
Although LGBT+ young people are an underserved population in terms of their mental health needs, few therapies, online [
It is perhaps surprising that, to date, no e-therapies have been developed or tested for LGBT+ young people in the United Kingdom. This is particularly noteworthy, given that LGBT+ young people have indicated a preference for Web-based help, and there is a strong policy push toward providing more e-therapies in the United Kingdom. For instance, one of the key recommendations when planning services from 2016 to 2021 from the Mental Health Taskforce to the NHS in England was that the NHS “...should expand work on NHS Choices [the main patient-facing website] to raise awareness and direct people to effective digital mental health products...” (p. 42) [
This study sought to explore the acceptability of a non-United Kingdom-developed intervention, Rainbow SPARX (
Building on prior mixed-methods research related to Rainbow SPARX [
The consolidated criteria for reporting qualitative research [
Rainbow SPARX image. SPARX: Smart, Positive, Active, Realistic, X-factor thoughts.
Ethical approval for this study was obtained from The Open University’s Human Research Ethics Committee (reference HREC/2017/2507/Lucassen/1).
For inclusion in this study, participants needed to be living in the United Kingdom and to be:
An LGBT+ young person aged 12 to 22 years,
The parent or guardian of an LGBT+ young person, or
A professional with either expertise in working with LGBT+ young people or in adolescent mental health service provision or commissioning.
Young people who were exclusively heterosexual and cisgender (ie, those who experience congruence between their gender identity and the sex they were assigned at birth) were not eligible to participate.
Recruitment of LGBT+ young people in research projects is often fraught with challenges and ethical issues [
Potential participants who were LGBT+ young people and parents of LGBT+ young people were informed about the study via advertising on social media (eg, on closed Facebook groups for LGBT+ individuals and their allies) and from networks of LGBT+ organizations known to or recommended to the authors. For instance, key LGBT+ youth organizations with a Web presence in major cities in the United Kingdom were contacted in London, Cardiff, Manchester, Edinburgh, and Belfast, and staff in these organizations were informed about this research. Primarily, young people heard about the study from staff supportive of this project at relevant LGBT+ youth groups. Potential participants who were professionals were known to the authors and were approached by either ML or LW.
The interviews and focus groups were led by ML (a gay and queer male-identified academic experienced in youth mental health work) with assistance from fellow academics (ie, RS and LW). Written parental and participant informed consent was obtained from those LGBT+ young people aged between 12 and 15 years. Adult participants and LGBT+ young people aged 16 years or older provided written consent for themselves. Each interview and focus group began with personal introductions (eg, names and correct gender pronouns) and confirmation of the research objectives and processes; ML explained that he led the development of Rainbow SPARX and also highlighted his interest in supporting the mental health of LGBT+ young people. The semistructured interview guide used in the focus groups and interviews was developed by the authors and reviewed by colleagues independent of this study. See
Participants completed a brief demographics questionnaire at the end of the interview or focus group. Specifically, young people were asked questions, which included open-response items asking their age, gender or gender identity, and ethnicity. They were also asked about their sexuality (ie,
In total, 3 focus groups (which were young people and the LGBT+ staff members responsible for these groups only) and 5 interviews (1 LGBT+ young person interview and 4 interviews with professionals) occurred during 2017. They lasted between 51 min and 1 hour and 24 min (mean length 62 min).
We used a general inductive approach for data analysis [
A total of 21 LGBT+ youth participants took part and they were aged between 15 and 22 years (mean age 17.9 years) (see
The domain of
Several LGBT+ young people and professionals highlighted that the internet is ubiquitous and influential:
I think we have grown up and been shaped by the internet, so we know it intrinsically in a way that perhaps older generations don’t...
It’s fast; it’s there; they [LGBT+ young people] have access to [the]internet practically everywhere.
In contrast, the minority of young people who do not have ready access to the internet were viewed by participants as being socially excluded.
It would appear that from an early age, youth participants begin to discern Web-based resources in terms of their acceptability, and this is then used to assess the suitability of Web-based solutions for different aspects of their lives:
...there’s online counselling or online suicide helplines, so if you’re feeling suicidal or depressed or whatever or you’re going to relapse on drugs or self-harm then you can have like this, either you can call a number, you can find that on the internet, or you can do an online chat, which I think is really good, because most people, calling someone makes you feel quite anxious and stuff and I think a lot of people don’t want to call, because it’s a lot of effort.
Web-based environments were viewed as being unhealthy or unhelpful in several ways by a range of participants. For instance, LGBT+ youth participants cited
[it] can maybe make people feel less confident about their bodies, less confident about their sex and their relationships as a result...
Participants’ demographic information (grouped by interviews).
Format (researchers present) [settinga] | Participant number | Participant category | Age (years) | Sexuality | Gender/Gender identity | Ethnicity |
Group interview 1 (ML and LW) [participant’s workplace] | P1 | Professional (commissioner) | —b | — | Male | White British |
Group interview 1 (ML and LW) [participant’s workplace] | P2 | Professional (commissioner) | — | — | Female | White Other |
Individual interview 2 (ML) [participant’s workplace] | P3 | Professional (LGBTc+ stakeholder) | — | — | Male | White British |
Individual interview 3 (ML) [participant’s workplace] | P4 | Professional (mental health) | — | — | Male | White British |
Individual interview 4 (ML) [participant’s workplace] | P5 | Professionald (LGBT+ stakeholder) | — | — | Male | White British |
Individual interview 5 (ML and RS) [city library] | YP12 | Young person | 19 | Gay | Male | White British |
aInterviews and focus groups were conducted in private spaces.
bNot asked.
cLGBT: lesbian, gay, bisexual, and transgender.
dThis professional attended 2 focus groups and participated in an individual interview.
Participants’ demographic information (grouped by focus groups).
Format (researchers present) [settinga] and participant number | Participant category | Age (years) | Sexuality | Gender/Gender identity | Ethnicity | ||
P5 | Professionalc (LGBT+ stakeholder) | —d | — | Male | White British | ||
P6 | Professionale (mental health) | — | — | Female | Black British | ||
YP1 | Young person | 18 | Gay | Male | White British | ||
YP2 | Young person | 19 | Not heterosexual | Male | White British | ||
YP3 | Young person | 19 | Questioning | Male | White British | ||
YP4 | Young person | 21 | Queer | N/Af | White Irish | ||
YP5 | Young person | 18 | Gay | Male | White British | ||
YP6 | Young person | 21 | Queer | Nonbinary | White British | ||
YP7 | Young person | 22 | Pansexual | FTMg | White British | ||
YP8 | Young person | 16 | Gay | Male | Mixed | ||
YP9 | Young person | 18 | Gay | Male | White British | ||
YP10 | Young person | 18 | Bisexual | Female | White British | ||
YP11 | Young person | 19 | Gay | Male | White British | ||
YP13 | Young person | 17 | Bisexual and questioning | Slightly queer | Caucasion (sic) | ||
YP14 | Young person | 20 | Lesbian | Female | White Welsh | ||
YP15 | Young person | 15 | Not heterosexual and asexual | Trans female | Caucasian | ||
YP16 | Young person | 17 | Queer | Queer | White British | ||
YP17 | Young person | 17 | Pansexual | Woman | White Welsh | ||
YP18 | Young person | 16 | Lesbian | Female | White British or Welsh | ||
P5 | Professionald (LGBT+ stakeholder) | — | — | Male | White British | ||
P6 | Professionale (mental health) | — | — | Female | Black British | ||
YP19 | Young person | 15 | Transgender or pansexual | FTM transgender | White British | ||
YP20 | Young person | 15 | Gay, questioning, queer, and not hetero | Male cisgender | White British | ||
YP21 | Young person | 15 | Gay, questioning, queer, and not hetero | Male | Black British |
aInterviews and focus groups were conducted in private spaces.
bLGBT: lesbian, gay, bisexual, and transgender.
cThis professional attended 2 focus groups and participated in an individual interview.
dNot asked.
eThis professional attended 2 focus groups.
fN/A: not available.
gFTM: female-to-male.
Overview of results. the letter "a" indicates subthemes of particular salience to professionals, and "b" indicates subthemes of particular salience to LGBT+ young people. LGBT: lesbian, gay, bisexual, and transgender; SPARX: Smart, Positive, Active, Realistic, X-Factor Thoughts.
For professional and LGBT+ youth participants, internet safety and security issues were important, including the risk of LGBT+ young people being outed on the Web, challenges around how suicidality was safely managed in a Web-based context, and how LGBT+ young people can be specifically targeted for sexual exploitation. For these reasons, digital privacy and confidentiality appeared to be of fundamental importance. As described in focus group 2, with many LGBT+ young people adapting how they used technology for reasons of self-preservation and avoiding harassment:
It’s like you can get stalked on Snapchat now.
Yeah.
That’s the other thing. You can also put the ghost mode on so you can’t be followed.
Yeah, because I’ve only chosen a few people that can see my location and [YP16 is] one of them.
LGBT+ youth participants sought resources and material on the Web for reasons such as job searching, obtaining information, and to acquire health-related information (eg,
...YouTube videos of like, because I have anxiety and my counsellor suggested doing something called, well, they suggested doing something called mindfulness, so like there are just some good videos on the internet of guided meditation and stuff which helps me through my anxiety.
A common challenge mentioned by several professionals and LGBT+ youth participants was finding and accessing
...the issue with the internet is you have to know which of these multitude of sites is the one for you.
Several participants shared examples of how the internet was an empowering tool or force for LGBT+ young people. For instance:
RUComing Out [a LGBT+ website], which shares celebrities but also real people’s experiences of coming out...And through that as a means to actually learn, discover, feel like there’s someone like them out there is really good.
Professionals, in particular, highlighted that the internet was a valuable medium by which access to mental health services could be widened to potentially include
Social media enabled LGBT+ young people to communicate freely with others and to be part of Web-based communities, something that was especially important to several youth participants:
I think with LGBT people it’s different, because I’d say we’re a more, what’s it called, a hated group by some people, and a bullied group so we would need more support.
LGBT+ young people can also usefully connect with others who share their experiences and provide support online in ways that would be difficult for them to do in person:
...[The internet is] a really big support system...because not all, but most of the LGBT community have had hard times and they can all identify and relate with each other, so for the older [members of the]community they help out the younger [LGBT+ people] that are struggling.
The internet was used for entertainment purposes (eg, to watch sports, shop online, and listen to music) as well as for other reasons. For instance, pornography was viewed as being both fun and for
One LGBT+ young person said:
Yeah and I also use the internet, when I’m feeling low and depressed I also use it to distract myself. It’s a good coping mechanism, because it’s better than self-harming or getting too deep into my thoughts and having all these suicidal thoughts in my head, I can watch YouTube videos or I can go on Instagram or Tumblr or whatever...
The domain of
Most of the LGBT+ youth participants reported playing a range of commercial games (eg, Rage, Skyrim, Mortal Kombat, and The Sims). They also outlined a variety of gameplay preferences: the game’s style of graphics; whether the game had a prologue; the amount of dialog that was used; and the degree of violence portrayed.
Some participants could see the therapeutic value of commercial games for mental health, as outlined by an LGBT+ young person:
I play a lot of the Lego games, just because they’re all the same controls and it’s easy and they’re so not stressful...I can just sit there and just zone out and just do anything, because they’re meant for like five-year-olds, so it’s fantastic.
However, despite serious games being seen by some as valuable for those uncomfortable engaging with face-to-face therapy, challenges were identified for developing a serious game that would be acceptable to a range of LGBT+ young people. For instance, participants noted that such games would need to work for those of different abilities, levels of maturity, and stages of acceptance and understanding of their LGBT+ identities.
LGBT+ youth participants, in particular, highlighted that a mental health serious game should be available across a range of Web-based platforms (eg, on mobile phones, computers, and tablets). Moreover, a mobile serious game should not take up too much data storage.
After trialing module 1 of Rainbow SPARX during their interview or focus group, LGBT+ and professional participants recognized the purpose of the program (ie, it was intended to be a mental health tool for LGBT+ young people). However, several youth participants really wanted a more explicit focus on them and their particular needs, and some participants felt that Rainbow SPARX was inadequate as an LGBT+ resource:
...they don’t focus on the LGBT side of it, point blank, it is just mental health and I think if you were to do that it needs to be marketed as such. You can’t just change a few words around and have a slightly different message at the start and say “oh yeah it’s a completely different game for LGBT people.”
Several LGBT+ youth participants also indicated that the language used in Rainbow SPARX was sometimes problematic:
...it mentions guys who like guys, like why don’t they just use the proper term? [ie, gay].
In contrast, professionals appeared less concerned about whether the program had sufficient LGBT+ content and appeared more focused on whether Rainbow SPARX was too niche to be viable for a rollout:
I think there would be, given we’re talking about already a minority group. I think a minority of that minority group would find that platform quite attractive to use perhaps.
Some LGBT+ youth participants also raised concerns about the avatar in Rainbow SPARX, in particular, the forced sex binary inherent in the program (ie, the user can only customize a male or female avatar with
Several LGBT+ youth participants liked the
Do you know, I’d definitely play that...
Furthermore, the affective experience for some youth participants using the program was positive:
I really liked it. I would play it if it was released. I think it’s good, like it’s entertaining just as a game like if you were feeling stressed or bored or sad it would just take your mind off of it because it’s quite fun to do and then also I think it is good just the messages and stuff, I don’t know, it just cheered me up.
By contrast, a few young people reported that Rainbow SPARX was
...I don’t know exactly how it all plays out in the computer game world. But I think it’s pretty cutting edge...and that if you’re competing with that then that’s [Rainbow SPARX] going to look I think quite basic in comparison...
They also highlighted issues in terms of speed:
It needs to be faster, it’s far too slow.
And the controls:
I feel like maybe the actions and the freedom to move and what you could do on the game could be developed, like the movement was quite simple and stuff like just playing it and fighting the bad spirits...
There was also some discussion between LGBT+ youth participants about whether the spoken dialog in Rainbow SPARX was always understandable. There were times when young people seemed to struggle with the Māori (New Zealand indigenous language) phrases used in the program and a character’s accent. For example, the term takatāpui (a traditional Māori term meaning
This domain consisted of 2 themes: recognizing and acknowledging the LGBT+ youth experience and preferences and requirements for therapy and e-therapy.
LGBT+ youth participants described forms of mistreatment and other challenges that their heterosexual peers would not face. In particular, their family not accepting them because they are LGBT+ and the difficulties associated with accepting oneself, in part, because of internalized negativity:
...So when I was sprouting into the blossom that I am now, that part of the conflict came from not knowing what it [my own LGBT-specific identity] was. And the only context I’d ever heard of it being in-between was in like a promiscuous context like “oh that’s what people do if they have loose morals or anything"
Furthermore, being transgender was described as being more stigmatized and resulting in increased mistreatment by a few participants, compared with those who were diverse in terms of their sexuality:
I think trans people are probably more at risk than LGB people, because it’s less normalized...So it’s like really overwhelming and stuff and I feel like, I don’t know, I feel like there’s more people on the internet preying on T people than LGB generally, because it’s easier to spot someone out and there’s more trans people who are like excluded from their families and stuff.
LGBT+ youth participants recognized that dual stigma could be an issue for LGBT+ young people, whereby they could be faced with the stigma associated with having mental health problems as well as the stigma linked to being LGBT+. Being isolated was also reported to be an issue, with this being
Professionals also recognized that stigma creates barriers to LGBT+ young people getting help:
I think almost this group has double stigma because you would have the one around disclosing that you might have some mental health difficulties, and then the additional stigma of being, lesbian, gay, or transsexual on top of that. So there would be quite a lot of barriers for you to come out and start talking about how you feel about things.
Developing and maintaining LGBT+ communities on the Web was especially important for youth participants. This allowed them to date other LGBT+ young people and engage in leisure activities with other LGBT+ youth (eg, an online friendship had the potential to lead to face-to-face activities), and it provided a sense of LGBT+ community and belonging.
Participants reinforced that CD-ROMs and websites were viewed as outdated means by which to offer an intervention. Access issues would also need to be taken into account; for instance, Wi-Fi is not always freely available to young people, so it was recommended that Web-based e-therapies have a downloadable option. Serious games presented their own set of problems in terms of the need to move in line with expectations based on commercial games:
I think what you need to think about as well is the life span of the game. So gaming in general will have updates every single year because there is quite a lot of competition.
Some professional participants were particularly concerned with the effectiveness of an e-therapy. RCTs were cited as a means to provide the evidence required to demonstrate that an e-therapy was effective, and so the focus was on demonstrating effectiveness at a population level although their limitations were recognized:
I suppose it’s a question about a rigorous evaluation, you know, like an RCT, versus something which is, I don’t know, a sort of user-experience evaluation where we’re not going to randomize people because if people want to use it then they should be able to use it, you know, rather than saying well, fine but we’re going to randomize you to a waitlist control now.
In contrast, LGBT+ youth participants seemed to evaluate cCBT interventions (such as Rainbow SPARX), more generally, in terms of their ideas about the perceived usefulness of the CBT content:
...where it [Rainbow SPARX] said things that you can do or ways you can think to change how you feel. Which is a concept that works but sometimes it’s really not helpful to hear. And it’s obviously not that exciting.
Professional participants were especially concerned that any e-therapy has sufficient moderation and guidance to ensure risk is managed effectively. There was a consensus among professionals that an e-therapy should be provided in a blended way so that LGBT+ young people always had the option of face-to-face therapy, if required.
Among LGBT+ youth participants, there was some debate about how explicit therapy should be in a serious game, with some suggesting that this should almost be achieved by stealth:
So do you think there’s a way that you could innovate the game to where it’s not therapy talk...it’s just, it’s a way of not thinking that it’s therapy talk.
Commissioning e-therapies on the NHS requires certain criterion be met, specifically around effectiveness and safety, as explained by a commissioner:
...in our specification we will have a standard sentence around that it has to be evidence-based. And you sort of hang all sorts of things off that really. So in the procurement process we went through they had to show us evidence of how that particular sort of online service was going to work and that it was going to be safe.
However, commissioning was acknowledged by some professionals to involve further challenges; in that, for an e-therapy to be
Of 21 LGBT+ youth participants, 18 (18/21, 86%) indicated that they had felt down or low in the past (based on the single question:
Participants’ written responses.
Would recommend use of Rainbow SPARXa | Comments | |
Yes (n=4) | "I would recommend that they try it, but would follow up to see if they felt their needs were met, or if further assistance was required." [P1, professional, interview 1] "Yes in principle, but would like to see final version [ie, all 7 modules] first before recommending." [P2, professional, interview 1] "As part of or accompanying face-to-face intervention." [P3, professional, interview 2] I think it’s a great, accessible self help tool" and "Lovely game, very useful, accessible." [P5, professional]b |
|
Possibly (n=1) | "Possibly – depends on whether they feel the internet intervention would be helpful. Many prefer face to face interventions." [P4, professional, interview 3] |
|
No (n=1) | "I think they need someone to talk to face to face" and "It will provide extra support." [P6, Professional]b |
|
Yes (n=8)c | "I enjoyed it." [YP12, individual interview 5] "It’s awfully good." [YP17, focus group 2] "For anxiety and when my mood is especially low." [YP 19, focus group 3] "For anxiety." [YP20, focus group 3] "I think it could help up to a poin[t] [sic]." [YP21, focus group 3] |
|
No (n=13)d | "I have nothing to add." [YP2, focus group 1] "Would rather develop skills when better." [YP4, focus group 1] "Bit too basic and CBT for my liking." [YP6, focus group 1] "I’d see my care coirdinator [sic] instead." [YP7, focus group 1] "I don’t require a game to make me feel better I have [P5, Professional – LGBT+ stakeholder] and [P6, Professional – Mental health]." [YP8, focus group 1] "I don’t think it would help me." [YP13, focus group 2] "More of a distraction than how to solve a problem." [YP14, focus group 2] "Outdated system/terms." [YP15, focus group 2] "No thanks." [YP16, focus group 2] "Skims over topic at hand." [YP18, focus group 2] |
aSPARX: Smart, Positive, Active, Realistic, X-factor thoughts.
bThe same participant completed 2 surveys.
cParticipants YP1, YP3, and YP11 did not provide a written comment, for reasons unknown to the authors.
dParticipants YP5, YP9, and YP10 did not provide a written comment, for reasons unknown to the authors.
This study sought to explore 2 main research objectives. First, to explore how and why LGBT+ young people use the internet to support their mental health. This is important to consider to minimize the risks of developing interventions that do not address LGBT+ users’ needs or do not fit-in well with how LGBT+ young people use the internet. Notably, rather than accessing existing e-therapies developed for the general youth population, young people in our study created personal pathways to use the internet for enhancing their mental health (eg, by locating resources on mindfulness via YouTube). Their apparent lack of knowledge about e-therapies, combined with the challenges associated with finding and accessing
The second objective of this study was to elucidate whether LGBT+ young people and professionals consider an e-therapy, such is Rainbow SPARX, as a useful tool to assist in supporting the mental health of LGBT+ young people. Most of the professionals indicated that they would recommend the program to an LGBT+ young person who was
A considerable body of research has been published, which reinforces that LGBT+ young people are an
For e-therapies to be used meaningfully by LGBT+ young people, they will need to include relevant content. Although e-therapies are demonstrably important tools in addressing mental health problems, the vast majority are designed for a general population [
Given the findings from this study, which indicated that a minority of LGBT+ young people who participated in this study would use Rainbow SPARX, but that discussions revealed others might if the content and format were improved, this research suggests that adapting existing resources designed for LGBT+ youth can be a worthwhile endeavor. Nonetheless, whether new LGBT-specific e-therapies are created or whether they are modified from existing interventions, to ensure they are up-to-date, all e-therapies need to be more rapidly tested and implemented [
In this exploratory study, we have highlighted that LGBT+ young people are interested in mental health support via the internet and that e-therapies should be tailored for LGBT+ young people and their cultural context. We have further identified that the needs and preferences of LGBT+ young people are diverse and, in some cases, polarized. For example, the affective experience with Rainbow SPARX included those LGBT+ young people reporting positive emotions associated with the program and others, in contrast, who felt patronized by the language used within the game. It may not be as simple as developing 1 tool or approach that suits all LGBT+ young people. However, there could be future scope to develop multiple
This is a small-scale exploratory study, and as is not uncommon in research conducted in the area of LGBT+ mental health, recruitment had its challenges [
This study’s sample was not representative of all LGBT+ young people in the United Kingdom or the professionals working with them. Furthermore, not all LGBT+ youth organizations in the United Kingdom are likely to have been contacted, especially those organizations that do not have a Web presence outside of London, Cardiff, Manchester, Edinburgh, and Belfast. Some young people from the organizations contacted may not have heard about this study. Regardless of our attempts to recruit them, no parents or guardians of LGBT+ young people took part in this study. Despite this, we had a range of LGBT+ young people and professionals taking part in this study, including young people questioning their sexuality and those who were nongender binary. We had a strong sense that no new concepts or ideas were raised on the conclusion of focus group 3. Transcripts were not returned to LGBT+ youth or professional participants for comment or for participants’ feedback on the findings. No field notes were taken.
When using Rainbow SPARX in focus groups, only 1 young person played the game at a time while others watched and commented. However, Rainbow SPARX was designed for use in a single player format. It is, therefore, possible that using the program in this manner influenced how much participants were able to engage with this e-therapy. Moreover, participants knew that ML led the development of Rainbow SPARX, and as such, young people may have felt reserved in relation to expressing criticisms of the program. To attempt to remedy this, every participant was explicitly asked to comment on what they did not like about Rainbow SPARX. Nonetheless, it is possible that the results are skewed toward a more positive view of the program. In focus groups 1 and 3, the professionals responsible for these youth groups chose to attend these focus groups. The inclusion of these professionals in 2 youth focus groups is a limitation, as their presence may have influenced what young people said. However, professionals’ data from the focus groups were not included in analyses, and our impression is that having these professionals present made young people feel at ease.
LGBT+ young people frequently experience stigma and isolation, and they also have high mental health needs. The internet is an important source of information and support for these young people, and e-therapies appear particularly valuable for this unique population. In this study, the first where Rainbow SPARX was used outside of New Zealand, LGBT+ young people emphasized that e-therapies must be appealing, up-to-date and inclusive of LGBT-specific content. Professional participants reinforced the need for proof of efficacy and that an e-therapy appeals to a sizeable proportion of a population. LGBT-specific e-therapies, such as Rainbow SPARX, show promise, but only those that are tested sufficiently should be made available to support the mental health of LGBT+ young people. To reduce costs and increase access, these tested interventions should be considered for implementation by commissioners across wide geographical areas.
Focus group guide.
computerized cognitive behavioral therapy
electronic therapy
lesbian, gay, bisexual, and transgender
LGBT and other people diverse in terms of their sexuality and gender
National Health Service
randomized controlled trial
Smart, Positive, Active, Realistic, X-factor thoughts
The authors would like to thank the participants who took part in this study. They also thank Professor Sally Merry for her guidance, support, expertise, and leadership in relation to SPARX’s development and research. The authors would also like to acknowledge the funding received from The Open University’s Health & Wellbeing Priority Research Area to conduct this study. Finally we would like to thank Dr Bev George for her feedback on earlier drafts of this paper.
The intellectual property for SPARX is held by UniServices at the University of Auckland. Any proceeds from licensing or selling SPARX outside of New Zealand will be shared in part with UniServices and KS, TF, MS, and ML. LW is a nonexecutive director of the health service where recruitment of commissioners took place for this study.