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Introduction
The proliferation of services offered via online mediums has been changing the delivery of mental health care, in Australia and globally, heralding new challenges and opportunities1,2. Optimally employed, online services could help overcome geographical disparities in rural healthcare provision and take advantage of technological affordances, such as the potential for anonymity3. For lesbian, gay, bisexual and transgender (LGBT) young people living outside the proximity of specialised services and community support concentrated in metropolitan hubs, these developments may hold particular promise4. Yet, little is known about the landscape of services, how they are accessed and their suitability for meeting the needs of this community. This article presents a qualitative study designed to address this deficit through the investigation of accounts from both young adults and service providers.
Mental health and LGBT youth
‘LGBT’ is used here to refer to community members who do not identify with heteronormative or cisgendered identities and practice, and extends beyond the denoted abbreviations to include an array of identities such as gender queer, gender fluid, non-binary, queer, pansexual and omnisexual5. Given that people who are born with an intersex variation have different needs from mental health service providers than people who are LGBT6 they have been excluded from the scope of this study. While acknowledging the limited inclusivity of this term, it serves as a referent for a community who may have similar experiences of heterosexism and cisgenderism and inequality.
An all-too-common experience shared by young people in the LGBT community is that of poorer wellbeing7,8. This is a chief concern in the Australian context of the study, where LGBT young people aged 16–27 years are five times more likely than heterosexual peers to experience mental ill health9. In LGBT youth (aged 16–24 years) surveyed, 55% of females and 40% of males were identified as extremely vulnerable to mental health risks: over three times the national average for young females (18%) and over five times the average for young males (7%)9. Further, LGBT young adults are approximately twice as likely to report a mental health condition than their heterosexual peers10. This article is especially concerned with the wellbeing of young people who reside in rural areas.
Rurality and LGBT youth
For LGBT communities, experiences of wellbeing and care may be shaped differently by living in rural or urban areas11,12. Rural LGBT residents face barriers in the availability, access and quality of health services13. ‘Rural’ here refers collectively to areas defined as ‘rural’, ‘regional’ and ‘remote’, and that home almost a third of the Australian population14. These areas can vary from very small remote communities, several hundreds of kilometres from services, to towns of thousands that are regional and considered ‘service centres’15.
In addition to service issues in rural areas, the social context is considered a significant mediator of wellbeing. The Minority Stress Model posits that minority group members experience enduring stress, which originates in social contexts, at higher levels than the general community16. Research suggests that LGBT people residing in rural areas experience higher levels of minority stress, associated with internalised homophobia (feelings of self-loathing, fear and shame) and concealment (a fear of being discovered) compared with their metropolitan counterparts17,18. Factors associated with increased minority stress include a strong presence of prevailing heteronormative assumptions and beliefs that ‘homosexuality is immoral’ in rural areas19,20 and the associated victimisation, discrimination and homophobic abuse4. In addition to being a stressor, a secondary impact of concealment is the reduction in opportunities to connect and interact with other supportive members of the community16. This is concerning, as affiliation with LGBT community and supportive networks is thought to mitigate the impact of minority stressors21. Only a modest literature base exists concerning LGBT experiences of rurality and mental health: little is known about how geographical contexts shape healthcare access experiences and LGBT young adult wellbeing.
Internet-based mental health care
The proliferation of online technology potentially bolsters capabilities to deliver specialist ‘LGB’ mental health services to rural areas and could help overcome support-seeking barriers related to concealment and stigma22. The lack of physical presence, often considered a ‘drawback’, may be beneficial in this case as research suggests the perceived anonymity in online interactions to be valuable for rural LGBT young adults23. Specifically, the internet affords an additional level of privacy and confidentiality that may be missing in rural settings with typically smaller populations, tight-knit communities and limited choice in services22. Similarly, this group has grown up in the digital age, so internet communication may feel less shameful and anxiety provoking than face-to-face communication for some young people24.
The potential benefits of this medium are recognised but numerous challenges remain unaddressed25,26. Internet-based mental health care is not easily accessible for all. It is estimated that 19% of households in regional, rural and remote Australia are without internet access27 and quality of connections can vary. The associated costs may also be unaffordable for some. Additionally, in rural areas, community attitudes towards internet-based mental health care and a lack of knowledge of available mental health services may impede service uptake28.
Internet mental health services in Australia have been criticised for a lack of standardisation and integration within the healthcare system, due to the independent development of these services and an absence of policy25,29. A wide and varied range of services are offered by multiple providers, from not-for-profit organisations to government health bodies. Some services focus on producing online programs, some exist to complement another service (including filling gaps in care provision), while others are online adaptations of existing on-premises services26. This variability may result in inconsistencies for those seeking access to services. For example, a rural LGBT young adult who is depressed in relation to sexuality might have two very different experiences depending on whether they engage with online providers whose focus is general mental health or LGBT social support.
A seminal review of mental health services report identified problems with the standardisation and integration of services30. Subsequent recommendations highlighted the need for specialised internet-based mental health support programs for rural populations and minority groups30. Recommended also was that internet-based mental health services should be culturally sensitive and knowledgeable about these communities/groups30. The difficulties faced by LGBT communities as well as the burden of mental illness experienced in rural contexts are recognised issues under the current national mental health plan31. Online technologies are embedded within models of care in public mental health care, and opportunities for their use will be further harnessed as part of the national health strategy29,31. However, the authors concur with Hayes et al, who remain critical of the lack of research into using the internet to provide targeted mental health services to minority groups such as rural LGBT young adults26.
Current research
The present study aimed to promote understanding about the provision of internet-based mental health services for LGBT young adults in rural areas. To this end, perspectives of both LGBT young adults in rural areas as well as individuals who provide internet-based mental health services were examined.
Methodology
Research design
Based on the recognition that the experiences of those who deliver services and those who rely upon them are shaped differently, a constructivist perspective was used to frame this inquiry32. Constructivist-informed research assumes there are multiple realities and each person’s view of reality is authentic and unique32. This provides insight into how people create their own perspectives of the social world that they inhabit and how they derive meaning from these experiences33. Semi-structured interviews with LGBT young adults in rural areas and online mental health service providers were undertaken and thematically analysed to explore perspectives34. A fieldwork diary was kept by the researcher to reflect on their role in the process and gain insight into how the findings were generated35.
Procedure
Recruitment: Young adults (group 1) were recruited from LGBT organisations and networks via social media platforms. The criteria for inclusion was that participants (1) had lived in a rural, regional or remote zone of Australia in the preceding 6 months (consistent with measurements), (2) self-identified as a member of the LGBT community and (3) were aged between 18 and 25 years.
Service providers (group 2) were included in recruitment if they provide an internet-based mental health service that is relevant to LGBT young adults. Invitations to participate were sent to a shortlist of eligible providers. Recruitment incentives were not offered to either participant group.
Participants: Group 1 consisted of nine young adults aged 18–25 years (average of 20 years). Participants identified as male (4), female (2), transgender male (1) or non-binary (2). Participants described themselves as heterosexual (1), gay (1), lesbian (1), bisexual (4), pansexual (1) or questioning (1). Pseudonyms have been assigned to each young adult.
Group 2 consisted of six individuals from four different service providers. This sample represented the rich diversity of the services provided, including providers of general mental health support, youth focused (12–25 years), issue-specific services (eg depression and anxiety) and LGBT-dedicated support services. The providers operated through a range of models including online-only service providers and differing combinations of telephone, in-person and online services. Within their respective organisations participants held the role of director (4), manager (1) and unspecified (1). As organisational representatives, personal demographics data were not collected, and participants are identified in the transcripts as service providers (SP) 1–6.
Sample size was mediated by the significant difficulty of accessing rural LGBT young adults who have might have experienced issues with their mental health. Nine young adults was a satisfactory number based on the specificity of the topic and richness of the data. The number of service providers was deemed satisfactory given the modest number of professionals with sufficient experience and expertise on these issues. In light of this, it was not possible to reach saturation with the data; however, the perspectives of these groups are highly valuable for advancing understanding.
Data collection
Interviews conducted with young adults explored experiences of the internet as a means of delivering mental health, their observations regarding the needs of rural LGBT young adults and future directions for internet-based mental health care. Interviews with service providers explored their experiences provisioning services to rural LGBT young adults, knowledge of how their services are accessed by this community and views on future directions for internet-based mental health care. All interviews were conducted in person, had an average duration of 14 minutes, were audio-recorded and transcribed verbatim.
Data analysis
A data-driven, inductive thematic analysis technique was used to identify themes generated in the data sets for the respective groups34,36. Given the expected variations in the coding, the selection of themes was based on both the theme’s prevalence and the contribution that the theme made to answering the research question34. This approach maximised the opportunity for unique and often divergent constructions of reality to be extracted from the data set37. The analyses from the young adults and the service providers were integrated, with care to promote accounts from the young adults as more important in some themes, while focusing more on the service provider’s accounts where they have overarching knowledge of areas such as service design.
Reflexivity
Reflexivity was an important aspect of the process. The researchers’ own passions and experiences facilitated partial insights and solidarity with the young people involved. They also recognise the comparatively privileged position that adults are afforded, as well as that which may stem from association with an academic institution. These considerations were valuable to engage with when writing about and attempting to capture young people’s experiences.
Ethics approval
Ethics approval was granted by the Charles Sturt University Human Research Ethics Committee (H16081).
Results
Analysis revealed benefits as well as limitations of mental health services for rural LGBT youth, described by both the young adults themselves and the service providers. Service providers described the growth of online technologies, reporting both positives and concerns. A final theme was generated that related to education and support for families and communities.
Benefits of internet mental health services
In general, young people reported benefits to internet-based mental health service access and Bruce noted, it ‘furthered the reach of support’ into rural areas.
Privacy and anonymity: Service providers reported that anonymity and privacy are important benefits and, as suggested by SP1, ‘anonymity is a major driver for bringing people into our [online] space’. Another service provider considered their webchat service to be beneficial because ‘people use us as a way to talk about things they feel like they can’t talk about with other people including their mental health providers’ (SP2). They reported this facilitated opportunities for identity exploration: ‘they had to be a particular identity face-to-face and then [when online] they could play with their identity’ (SP6).
The young people elaborated on these benefits: reasons given for not wanting face-to-face interactions included being ‘too afraid’ (Sophie), or having a ‘social phobia or anxiety’ (Sam). Andrew argued the ‘impersonal’ nature could be a positive, and added that ‘it would be very important for people who, for example … don’t want to go face-to-face’.
Combating isolation: While the above suggestions involve greater anonymity, paradoxically service providers saw capacity for internet-based services to provide connection that might be lacking:
Young people are also using us … to combat that loneliness and isolation that is part of their lives … which is a result of often being an LGBT person in a community in which you are not really connected to other LGBT people and in rural and regional areas that’s highly relevant because what we know is young people struggle to make face-to-face connections with peers … so things like the internet become very important. (SP2)
It was significant that the young adults did not report isolation in quite this way – it may be that the young adults interviewed were not representative of some rural individuals who might find themselves far more isolated, or it may be that the service providers perceive this issue in polarised terms that are not quite the reality of young LGBT lives. Certainly, some isolation may well be likely and creating online communities appeared to be one way that service providers were attempting to alleviate loneliness.
Technologies and growth: Not inherently of benefit, but at times positioned positively, was the perceived growth of online services for mental health. Future growth was reported as being more client led and prevention focused:
Early intervention … is this idea that when you are intercepting someone’s mental health trajectory early on … you are … [mitigating the need for] mental health services that are more burdensome or more expensive. (SP2)
While benefits were reported, there were concerns about the design for future models:
The pathways into care are extremely diverse and we can’t sort of build packages and then ask people just to (laughs) use it that way, it needs to be the other way around … service providers and those building these areas need to have consumers right at the middle of the design process. (SP1)
The service providers raised concerns that the rapid development of internet-based services may result in a drop in total mental health funding: if ‘they [the government] are just pulling money out of … [face-to-face] psychology services and not putting equal investment into other strategies it is going to be a disaster’ (SP2).
It is important to note here, that despite this reporting of services needing to be tailored to clients, none of the service providers interviewed presently provided customised solutions that target young adults who are LGBT from rural areas.
Limitations of internet mental health services
Despite positives, internet-based mental health care was also reported as limited and most participants still felt there was a need for in-person services. Ivan lamented the loss of ‘personal interaction which is something you need [for] mental health [support]’. For Max, this was a belief that internet-based mental health services could not ‘deliver the quality of counselling that a physical service could’. Rather than viewing the internet as a complete service, for Max it was ‘helpful enough to make me realize that I probably did need to go and see someone’.
Stigma, even online: For many young people, LGBT-associated stigma prevented help seeking, even online, despite the privacy and anonymity described earlier. As explained by Max:
I know a lot of people who haven’t felt comfortable reaching out … just because they weren’t comfortable with an internet service or maybe they just weren’t ready yet … it’s all about fear, [that prevents] people … [from] reaching out a lot of the time.
For Sophie there was the view that, from a rural perspective, some things should be kept private and not be discussed with other people: ‘there is a greater stigma here than in more metropolitan areas … its way more secretive and hush hush’. The young adults stressed that online providers should promote their services as safe spaces for LGBT people as Bruce explained: ‘if you don’t feel safe about something then you are not going to go do it’.
A variable and confusing system to navigate: Both young adults and service providers reported the presence of many different and overlapping services as confusing. When first researching online mental health resources, Mathew found it unduly complicated and ‘a lot of me like running round chasing my tail’. Sam suggested that ease of use is important ‘so that someone who is really in distress is not wasting their time … looking around for the right button to press’. Sophie suggested that sites ‘start off with a quiz or something to see how you are feeling and then direct resources based on that’.
The service providers agreed: ‘[it] is hard to navigate’ (SP1). As such, many of them felt the online service environment ‘needs to be integrated a lot more: from a young person’s perspective they’re all quite disparate’ (SP5). Consistency was a concern:
[If a rural LGBT young adult contacted] a more mainstream service … [whilst the service provider] might not be overtly hostile or negative … they might not understand the significance … of the circumstance [that the young person is in]. (SP3)
This importance of providing appropriate help was also identified by a service provider who offered broader mental health services:
We don’t have a lot of information about the use of our services by LGBTI people and I guess we have a sense that perhaps our services are useful and perhaps at other times… are too mainstream, too generalist, to be considered to be safe and helpful. (SP4)
The experiences that rural LGBT young adults have may therefore be highly variable, not always appropriate, and dependent on the nature of the service that they contact. The confusing nature raised by the young adults may lead to some users accessing inappropriate information or to attrition.
Access can be difficult in rural areas: While a lack of access to face-to-face services is an issue in rural areas of Australia, the young adults additionally reported issues accessing online services:
From where I usually live we have very limited access to [the] internet so for people who live in more remote areas with limited internet or no internet at all it would be quite difficult for them to get access to it. (Melody)
That all people have access to the internet has increasingly become assumed and this is highly problematic for groups such as rural people. When access becomes difficult, public devices become necessary and Sam noted that this could be a barrier in relation to privacy: ‘if you don’t have your own personal device … like if you are trying to use public facilities like at the library or something that can feel sort of invasive’.
Knowing about Internet mental health services: Knowledge of different services consistently emerged as a problem, with nearly all of the young adults explaining that they had been or still were unfamiliar with the services that were being offered or where they should go to find them. Ivan believed that ‘some people haven’t heard of [the different service providers]’ and that he did not ‘know enough about them to determine the difference’ between them. Similarly, Melody made the comment that ‘I don’t think a lot of people [would] know about the services without having been told prior to finding them’. Furthermore, Mathew believed that Internet-based service providers should be advertising more in ‘the real world and not just … on the Internet’. The issues were summarised by Blake:
I think especially in rural areas it’s a lot tougher to know these resources are there without being told about them by someone ... [services should] be more vocal and be more out there so youths can really find these places easily.
Educating and supporting families
Some of the specific impacts of discrimination, harassment and rejection on young people in rural communities were critical issues:
Perhaps in rural and remote areas that can be magnified by the proximity of people around so if there is rejection it is quite immediate and noticeable. (SP4)
Despite this, what emerged from the young adults’ accounts was a strong desire to educate families and communities in rural areas. Mathew noted that television and internet exposes young adults to different ways of ‘being’, which they may want to explore with families and community in a supportive and safe environment:
Young people may go through things that, in today’s society [are] seen on TV [or] the internet … they are aware that they can be like that … [that] it’s not a crime to be … gay, lesbian, trans you know the whole alphabet basically so … I think it’s about educating the adults as well.
For rural LGBT young adults this meant being able to ask questions and discuss sexuality with family and community, such as about coming out or introducing family to partners or LGBT friends. In addition to family support, Mathew’s comments regarding the whole alphabet (a play on the LGBTIQA+2 phrase) acknowledged the fluidity and variability that young people may associate with their sexuality and gender.
Consequently, the internet has the means to both support LGBT young adults directly as well as indirectly via their family. Service providers reported being aware of this issue:
More and more we are getting contacted by the parents of people who are under 26 ... if we think there are few services for young people out there, there are even fewer services for families. (SP2)
Some providers responded by developing online services or incorporating ‘content on sex and sexuality’ (SP6) into tools targeted to parents/carers. The audience that service providers should and are targeting thus appears to be expanding to include support networks of family and community.
Discussion
Analysis of the accounts given by rural LGBT young adults and providers of online mental health services elicited insights into the experiences of services, perceived needs of this community and the way they are shaped by residing in rural areas. Findings raise several issues that are important for those involved in developing and offering services via online mediums to consider. Presupposed advantages and disadvantages were complicated through deeper understanding of young adults’ engagement (or lack thereof) with online services, including what facilitated and inhibited. The young adults’ discussions about internet access extended beyond the potentially poorer availability in rural areas27 to meaningfully consider the nature of this access. Optimal access is not assured when, for example, a household may have internet access, but devices may have multiple users. Further, access may need to be weighed against desired privacy. As raised by an interviewee, where there may be limited availability, more public options (such as the library) may be the only possibility, which, in turn, may exacerbate privacy concerns.
Young people reported a lack of knowledge about what online services were available and the most suitable service to seek. Given the aforementioned access issues, efforts to increase awareness of services may benefit from ensuring that services are promoted through offline mediums. Employing client-centred approaches in the design of services may help young adults to better navigate a confusing landscape of online provision. The authors would agree with the point made by a service provider that the input of young adults should be meaningfully engaged within the processes of developing and delivering services. The difficulties experienced by young adults to find the appropriate service are likely reflective of the challenges associated with the integration of online technologies within the service landscape30,38. To this end, the authors welcome the focus upon rural communities and minority groups as part of the current national mental health plan to address these issues31.
Consistent with other accounts, the anonymity facilitated through online services was found to be valuable38. However, this should be carefully balanced with needs surrounding connection with others, and the means available to do so. Where the community context is not one of acceptance and where greater anonymity is less possible, concealment may be more likely18. This may in turn diminish capacity to facilitate the protective factor of connection to a visible LGBT-supportive community in the longer term. Community-building online may facilitate some of these connections while having capacity to simultaneously facilitate anonymity where desired.
Correspondingly, a flexible selection of ways to engage with services (in person, online, via phone) as well as to transition between these modalities of delivery could be useful. Interviewees emphasised the value of having in-person support in addition to online services. In the context of the current shortage of mental health professionals in rural areas31, it is emphasised that online delivery was not able to replace in-person service delivery for these young adults.
Perhaps unsurprisingly, discussions about improving wellbeing for LGBT young adults shifted beyond their service access towards ideas for health enablement and fostering more support in their communities. The compounding effects of stigma on wellbeing experienced by LGBT communities forms a priority of the current national mental health plan31. As previous research suggests that young adults in rural communities may experience more entrenched heteronormativity19, efforts by service providers in relation to awareness-raising and community education could be valuable, and potentially lessen minority stressors. Consistent with the Minority Stress Model, such efforts may be considered part of prevention rather than intervention measures16. In the same vein, the development of tools/resources for parents and families to better support young people emerged as an important need and an area where service providers could have a critical role.
The study presented accounts from a young adult population, who for various reasons may be considered a hard-to-reach population, but provides only partial insight into the issues explored. The average interview length with a young person was quite brief, and perhaps issues could have been explored more deeply in a longer interaction. Interestingly, many of the young adults interviewed were typically part of university or other LGBT/queer social groups located in regional centres, which may have implications for their experiences of social support and service access. Absent were the voices of young adults who may not have this support, who may not publicly identify as ‘LGBT’ or those aged under 18 years, all of whom may have differing and complex needs. Learning about needs of the aforementioned groups poses significant methodological and ethical challenges for researchers and necessitates exploration of innovative strategies for inquiry.
Conclusion
The study found that, when engaging with internet-based mental health care, rural LGBT young adults faced difficulties in finding and accessing the right service. Further research is needed to guide the harnessing of online technologies in order to address the needs of LGBT rural young people, including the abovementioned subgroups, who may have more complex needs. LGBT youth in rural areas are likely to have sensitive, customised needs that are not easily addressed by an en masse approach to internet-based mental health care. Developers and providers of online services should take account of the challenges of negotiating availability, anonymity, privacy and connectedness for young adults. Furthermore, there is a vital role for service providers to promote health enablement with families and communities in rural areas.
The authors recommend that internet-based mental health providers work closely with LGBT and youth communities in rural areas to facilitate the designing and refining of client-centred services best placed to meet the complex needs of this community.
Acknowledgements
We would like to thank the service providers and young adults who participated in this research.