"Safe Space Stickers Are Not Enough": Ambiguous and Performative LGBTQ+ Affirmation in Organizations Providing Mental Healthcare to Youth

Background/Purpose: Sexually and gender minoritized (SGM) adolescents and young adults experience systemic inequities in access to appropriate mental health services. LGBTQ+affirming services for youth are hard to find, and only about 44% of SGM youth in the U.S. engage with services when they need them, partly due to perceptions or experiences of providers having limited LGBTQ+ competency. Research consistently demonstrates a connection between therapist competence and client engagement, but there are few studies of how organizational-level processes can facilitate or undermine engaging SGM youth in mental health services. To better understand multi-level factors that contribute to mental healthcare inequities for SGM youth, this study examined the experiences of mental health clinicians working with young people in a range of settings across the U.S. In-depth interviews elicited their perspectives on how practice settings and organizational climates affect their capacity to engage young, SGM clients, and contribute to an inclusive service environment.

Methods: Semi-structured interviews were conducted with 35 clinicians who were currently providing mental health services to youth (ages 12-25). Participants were primarily cisgender women (74%), non-Latiné White (69%), and LGBQ (57%). Five were transgender or gender non-binary. Most were licensed social workers (68%), practicing in community mental health (48%), educational (29%), and other healthcare settings (23%). Participants were recruited through emails and posts to therapist directories and networking listservs. Interviews inquired about participants’ experiences of engaging and maintaining young SGM clients in services and the influence that their workplace, colleagues, or organizational policies had on their practice. Data were coded by three analysts using Dedoose software. Analyses were guided by the procedures for thematic analysis, first using inductive, and then shifting to a deductive approach to focus on organizational-level processes.

Findings: Three main thematic categories were observed in the data. Organizations may employ: 1) “silencing” and avoid acknowledging LGBTQ+ identities as significant; 2) symbolic (“safe space stickers,” rainbows, preferred pronouns) with tangible LGBTQ+ affirming cultures for clients and staff, or 3) symbolic affirmation, while offering few affirmative services or staff trainings (“performative”). Participants expressed concerns that silencing and performative gestures negatively affected SGM youth and led to disengagement. Many participants thought policies aimed at supporting SGM youth were ambiguous, and some noted that fear of community backlash deterred organizations from being proactive about providing affirming services or more explicit about supporting LGBTQ+ individuals.

Implications: These findings reflect the importance of organizational factors in mental healthcare inequities for SGM youth. Ambiguous or perfunctory policies can inadvertently undermine individual clinicians with LGBTQ+ competency, or be misleading and complicate finding authentically affirming care for youth. Research aimed at increasing the availability of LGBTQ+ affirming care for youth should include collaboration with organizational administrators and staff, and must target multiple constituents to address limitations at clinician, organizational, and community levels.