LGBTQ+ Community Center Providers' Perceptions: Tensions and Solutions for Serving LGBTQ+ Youth With Suicidal Thoughts and Behaviors and Their Families

Abstract

Minimal research focuses on the perspectives of providers in LGBTQ+ centers who support youth with suicidal thoughts and behaviors (STB) and their families. Youth suicide is a public health concern and SGM youth are at a higher risk than their peers. The increased risk of STB in this population is partially due to experiences of minority stress. SGM youth often report concerns related to engaging with healthcare organizations who may disaffirm their identities. Instead, they often turn towards specialized community centers where they are affirmed. The present study focuses on exploring the perspectives of providers within LGBTQ+ centers (N = 18) regarding treatment of youth with STB and their families. Three themes and six subthemes illustrated how providers noticed, reacted to, and addressed social distal stressors experienced by the youth in their care. Recommendations for affirmative treatment are discussed in relation to the challenges and techniques offered by the participating providers.

1. Introduction

Little is known about LGBTQ+ (lesbian, gay, bisexual, trans‐identified, queer, and other related minority identities) community center providers' experiences of caring for sexual and gender minoritized youth (SGM) ¹ who experience suicidal thoughts and behaviors (STB). In particular, the unique perspectives of these providers may illuminate the needs and experiences that community center providers have when sharing social locations with their clients and navigating the healthcare system, while facing their own identity‐based stressors (Eliason et al. 2017; Meyer 2003; Streed et al. 2024). Though there is a dearth of research available regarding provider experiences, there is strong evidence supporting the multitude of issues the youth they serve face.

1.1. SGM Youth Mental and Relational Health Concerns

Suicide is consistently reported as a leading cause of death amongst youth populations and SGM youth are at increased risk (CDC 2023). Consistent with previous findings (Johns et al. 2019; Kann et al. 2018; Miranda‐Mendizábal et al. 2017), a recent study found that youth who identify as lesbian, gay, or bisexual are about five times as likely to attempt suicide than their heterosexual peers (Jones et al. 2022). STB and other mental health concerns are also higher for trans‐identified youth when compared with cisgender peers (Lefevor et al. 2019).

The mental health of SGM youth is impacted by environmental stressors such as stigma, discrimination, and rejection, known as minority stress (Meyer 2003). Indeed, SGM youth experience high rates of minority stress: stress that is experienced above and beyond what is expected in typical day‐to‐day stress, and is based on an individual's minoritized identity/ies (e.g., sexual and gender minority identities; Meyer 2003; Monick et al. 2023; Lefevor et al. 2019). Social distal stressors, a type of minority stress, are any identity‐based stressors occurring outside of the individual (e.g., bullying; Frost and Meyer 2023; Meyer 2003). Social distal stressors, such as identity‐based discrimination and low social support, contribute uniquely to increased likelihood of suicidal ideation in SGM youth (Liu and Mustanski 2012).

The disparity in mental health concerns for SGM youth is likely due to experiencing greater amounts of social distal stressors (Lefevor et al. 2019). Experiencing these environmental stressors can result in increased STB and other mental health challenges due to chronic exposure to minority stressors (e.g., gender dysphoria, internalized stigma, expectations of rejection, etc.; Clark et al. 2024; Frost and Meyer 2023; Hidalgo et al. 2019; Lawlace et al. 2022; Lefevor et al. 2019; Meyer 2015; Mustanski and Liu 2013; Toomey 2021). Distal stressors that contribute to youth mental health concerns may include parental rejection, identity‐based violence, anti‐LGBTQ+ discrimination, and others (Asakura 2016; Fish et al. 2019; Olson et al. 2016; Phillip et al. 2022; Russell et al. 2011; Testa et al. 2017). Taken together, SGM youth may face multiple challenges in their social systems that impact suicidality, mental health, and wellbeing.

Family relationships are a potent factor impacting SGM youth mental health and, in turn, are associated with STB. Availability of family support and closeness buffers against suicide for all youth, while isolation and disconnection from caregivers ² is predictive of increased STB (Weissinger et al. 2023). SGM youth face unique relational challenges. For example, familial responses to identity disclosures of SGM youth have a significant impact on youth mental health and caregiver reactions to learning about their child's transgender identity may range from acceptance to ambivalence and rejection (Beeler and DiProva 1999; Conley 2011; Klein et al. 2023; Toomey 2021).

Conversely, receiving acceptance and support of family has been associated with decreased mental health symptom burden among SGM youth (Klein et al. 2023; Liu et al. 2023; Olson et al. 2016). Notably, SGM youth who report receiving support from family members have lower odds of both attempting and seriously considering suicide (Lytle et al. 2018; Rivas‐Koehl et al. 2022). In fact, caregivers who do not engage in affirmative services with their SGM youth often lack exposure to transformative education that is beneficial to the caregiver‐child relationship (Olson et al. 2016). In sum, the availability of support from caregivers in particular has lasting implications for this population. Furthermore, in light of the importance of family relationships, family therapy is a promising avenue for cultivating greater family acceptance and corresponding positive relational benefits (Abreu et al. 2019; Frey et al. 2022; Heiden‐Rootes et al. 2025).

1.2. Providers Serving SGM Youth and Their Families

Mental health providers face challenges when supporting youth experiencing STB and their caregivers. Despite receiving referrals, many caregivers do not follow up on recommended treatment, leaving providers struggling to engage families who may feel ambivalent or overwhelmed (Radez et al. 2021). Providers also face barriers rooted in stigma and denial from both youth and caregivers, as well as logistical obstacles (e.g., transportation options and scheduling difficulties that interfere with care) (Pailler et al. 2009). Providers must also navigate families' skepticism regarding the effectiveness of mental health services and concerns about how youth will be perceived for seeking help (Meredith et al. 2009). These challenges become even more complex when working with SGM youth, whose access to affirming care remains inconsistent. Research from The Trevor Project (2020) shows that nearly half (46%) of help‐seeking SGM youth are unable to access treatment within a given year, underscoring the systemic gap that providers must address while providing care for this population. In addition, extended wait times, medical mistrust, and historic anti‐LGBTQ+ practices in the mental health profession have been consistent barriers for SGM clients seeking mental health services (Pachankis et al. 2021; Gillani et al. 2024).

Zullo et al. (2021) found that SGM youth specifically seek providers who are LGBTQ+ affirming when locating a healthcare provider, and that accessing affirmative care is protective against SGM youth suicide. Interestingly, Meyer et al. (2015) found no evidence that, in general, seeking mental healthcare for STB was protective against SGM youth suicide attempts. This disparity may be resultant of inadequacies in training and could demonstrate a lack of cultural competence amongst providers working with SGM populations in conventional healthcare settings (Fish et al. 2023; Rhodes et al. 2023; Schmitz et al. 2012; Taliaferro et al. 2021; Yu et al. 2023). In fact, studies acknowledge that mainstream healthcare systems are often not equipped to meet the needs of LGBTQ+ individuals (Knight et al. 2016; Zullo et al. 2021). Lack of access to affirmative providers for SGM youth without accepting families can increase the risk of STB for this population (Willging et al. 2021). As such, there is a critical need to examine where healthcare systems can improve their treatment of this vulnerable population (Cummings et al. 2023).

To access affirmative care, many SGM youth tend to seek support within LGBTQ+ centers and community organizations (Chen et al. 2021; De la Croix and D'Emilio 2012). It is typical that healthcare providers within LGBTQ+ community centers have lived experiences that mirror those of their clients, enhancing trustworthiness to SGM youth and their families (Barnett et al. 2023). Unsurprisingly, availability of LGBTQ+ community‐wide supports is associated with a lowered risk of suicide attempts amongst SGM subgroups (Saewyc et al. 2020). This association is sustained even when controlling for the presence of multiple mainstream community and school resources (Eisenberg et al. 2021). The presence of SGM adults is another protective factor against youth suicide in this population (Goodenow et al. 2006; Johns et al. 2019). LGBTQ+ centers across the United States serve over 2 million people each year, with about half of such agencies providing mental healthcare support (CentreLink 2022). These resource hubs have served as central positions in LGBTQ+ communities and SGM youth are often connected with such affirming providers through word of mouth (Williams at el. 2024). When considering all options for behavioral healthcare, LGBTQ+ community centers are well‐positioned to address STB and engage families in treatment as a supportive resource (Lytle et al. 2018; Rivas‐Koehl et al. 2022).

1.3. Unique Challenges for Providers in Affirmative Care Settings

While LGBTQ+ community centers increase access to affirmative care, they may not be uniformly prepared to address STB and engage family members and caregivers in these efforts. Indeed, of the LGBTQ+ centers that do provide mental healthcare services, only 25% offer crisis response and 46% family counseling (CentreLink 2022). Implementation science frameworks (Wang et al. 2023) offer a lens to situate the challenges that centers might experience if they were to integrate new practices aimed to target STB and engage families. For example, the Consolidated Framework for Implementation Research (CFIR; Damschroeder et al. 2022) encourages the consideration of the individual, procedural, organizational, and contextual factors that shape the uptake and delivery of interventions. This approach specifically recommends understanding the roles and characteristics of both intervention recipients and deliverers. As such, when considering the fit of new practices in unique settings, it is essential to consider the viewpoints of those who would be delivering such an intervention. There is some evidence to suggest that providers (i.e., deliverers) in LGBTQ+ centers have difficulties in offering care to their constituents. They may experience challenging barriers, such as lack of funding, policy and law‐related service restrictions, and anti‐LGBTQ+ threats that target their staff members (e.g., online threats of harassment or violence; CentreLink 2022). It is reasonable to consider that these barriers could influence providers' perspectives on employing practices intended to address suicide and engage families in the process.

To date, little research has explored potential barriers that could affect affirmative providers' practice with SGM youth and their families, though these services are needed and being provided. Recently, however, Morrow and McGuire (2024) discussed some barriers to implementing family interventions in LGBTQ+ community centers from the perspective of youth served within these centers. Namely, family reintegration interventions (where youth and young adults are being united with their parents or caregivers in family therapy) may not be safe for youth who are unhoused or unstably housed because of family rejection and other intersecting problems. Additionally, parents who affirm their child's identity face issues relating to custody which is a barrier for accessing affirmative treatments (Kuvalanka et al. 2019). Though participants within this study (Morrow and McGuire 2024) discussed being rejected by or disowned by the members of their family of origins, the findings show that they still wanted to or had maintained some relationship with rejecting​ family members, consistent with previous literature (Grant et al. 2011). These findings (Morrow and McGuire 2024) demonstrate that young adults who faced family rejection as adolescents are still engaging in relationships with those family members. As such, youth might benefit from safe and appropriate family intervention to improve family relationships (Grant et al. 2011). However, there are challenges in providing appropriate and accessible family intervention for SGM youth with STB experiencing minority stress and family rejection that complicate suicide prevention efforts. Given the dearth of research on affirmative providers within these unique care settings, the next logical step is to explore affirmative providers' perceptions of their experiences working with SGM youth with STB and their families in LGBTQ+ community centers. Doing so sets the stage for family therapists, who are embedded in or partnered with these centers, to help determine how suicide prevention and family‐based practices can aid affirmative providers in their efforts to attend to the needs of this population.

1.4. Present Study

Given the promise of LGBTQ+ community centers for addressing youth suicide and facilitating family support, it behooves the clinical community to better understand the challenges providers in these centers encounter. While prior literature suggests that SGM youth are receiving care from these LGBTQ+ centers over other services, it remains unclear how providers understand and respond to the needs of SGM youth with STB they serve. The purpose of the present study was to explore affirmative providers' perceptions of their clinical work with SGM youth with STB and their families in the context of their LGBTQ+ organizations. As such, our primary research question was as follows, “What are the experiences of LGBTQ+ center providers as they are engaging clients and families within these affirmative care organizations?” Several specific objectives supported the primary research question. Through the pragmatic paradigm and a qualitative approach, we aimed to describe the following: (1) how clients' social distal stressors were perceived and addressed by providers in LGBTQ+ community centers, and (2) what barriers exist when engaging SGM youth with STB and their families in care.

2. Method

The pragmatic paradigm informed and permeated each step of this work including the formation of the research question, the selection of research design and methods, and the analysis and discussion of results. This paradigm draws on the work of Dewey (1919, 1988) which aims to learn about the recursive relationship of the sources of core beliefs and meanings of actions (Morgan 2014). Morgan (2014) describes this paradigm as “doing what works” while also considering how the aim of the pragmatist philosophy informs each step of the research process.

2.1. Participants

The current study served as a part of the initial phase of an implementation project focused on testing a family‐based suicide treatment delivered in LGBTQ+ organizations (Russon et al. 2022). This study was conducted in collaboration with two LGBTQ+ centers in a large, mid‐Atlantic city. These organizations consisted of an LGBTQ+ integrative care clinic and a community center serving SGM youth. Participating centers provide a broad array of services for youth, including gender‐affirming services, psychotherapy, mentoring, social support, and medical care. Providers were eligible to participate if they were offering mental health care to SGM adolescents or young adults at their site. The term “providers” refers to the range of clinicians and other mental health professionals who worked within the two partnering LGBTQ+ centers.

Providers (N = 22) participated in focus group interviews for this study and were interviewed in their work setting. The majority were social workers or had a social work background (63.6%), followed by counselors (22.7%), those trained in psychology or humanities (13.7%). More than half of the sample (68%) had a clinical license. Most providers were cisgender (77%), two identified as transgender, and three as non‐binary or gender nonconforming. Providers reported diverse sexual orientations as follows: queer (22.7%), heterosexual (22.7%), lesbian (18.1%), gay (18.1%), bisexual (9%), and pansexual (9%). Providers predominantly identified as White (72.7%) and African American (13.6%). We recruited seven providers from the youth community center site and 15 from the integrative health center site; however, only 11 out of 15 providers at the latter verbally participated in the focus group interview. Therefore, we reported results from only 18 participants in the present study.

2.2. Data Collection Procedures

The present study received IRB approval from the senior author's institutional affiliations. Data collection was conducted by the senior author in collaboration with leadership from each partnering site. The semi‐structured focus group interview guide was developed to understand providers' needs, barriers, and facilitators associated with supporting SGM youth with STB, their families, and collaborating agencies. The duration of each focus group interview conducted was between 60 and 90 min.

The interview guide was developed using four categories of inquiry: (a) perceptions of the support providers received for themselves and the youth they served, (b) processes of collaborating with wider systems (e.g., schools, psychiatry), (c) usage of suicide treatment models and standardized tools, and (d) experiences engaging families (including families of choice) in clinical services. Questions were asked based on the interview guide categories (e.g., “What are the biggest challenges you face when working with suicidal SGM youth?”; “If you had a full caseload of suicidal LGBTQ patients, what kind of support would you need?”; “How do you feel about engaging families in the treatment program here? What are the challenges and benefits?”).

2.3. Data Analysis Plan

The authors employed Braun and Clarke's (2006, 2019, 2023) six‐step coding framework; an inductive, semantic approach to coding. This approach moves beyond superficial content to make greater connections across data (Braun and Clarke 2006). First, group interviews were audio recorded and transcribed. De‐identification of transcripts was completed by assigning each provider a personal identification number and a site number. For example, Provider 1 from Site 2 would read [1S2]. Initial transcript review and familiarization was conducted by the senior author and a small team of students. The group read the transcripts several times and took notes on initial reflections. These reflections were shared in group discussions until all readers agreed on broad, descriptive categories across the data. Second, the senior author engaged two doctoral students and one undergraduate to review notes from the familiarization process and generate preliminary codes. Using a qualitative analytic software, MAXQDA 2018 (VERBI Software 2018), the team took a semantic approach to transcript coding. This form of analysis explores and identifies themes by examining explicit meanings within the data. Analysis was guided by the objectives of the research. During code generation, the second and third authors first developed a hierarchical codebook based on interview questions. To promote trustworthiness, these two coders independently coded all data. Then, each code in the initial codebook was reviewed in consensus meetings and discussed with the senior author. The generation of codes concluded when consensus was established for the initial codebook. Third, the coding team began searching for themes in the data, guided by the initial codebook. While tracking thoughts and reflections through memoing, coders independently re‐reviewed transcripts, further defined codes, and created preliminary themes. These themes were discussed and refined in collaboration with the first and senior authors. Fourth, the process of reviewing and crystalizing themes was led by the first author who, with the second author, conducted in‐depth reviews of the prior codes in relation to the entire dataset. Fifth, the first author engaged in the process of further defining and naming themes. Namely, using example transcript segments identified in earlier phases, this author storied the linkages between themes in conjunct with the objectives of the study and described their significance. For the sixth and final stage, the first author discussed the significance of themes with the senior author until consensus was reached and hence generated a report of findings according to themes identified.

2.3.1. Reflexivity in Thematic Analysis

The tradition of reflexive thematic analysis (Braun and Clarke 2006) emphasizes the role of the researcher's own positionality through the practice of reflexivity. That is, researchers are called to engage in practicing awareness of how their social location influences and enhances each phase of analysis through creating memos and notes about how their experiences are informing the process of research (Braun and Clarke 2021). The members of this authorship team hold diverse social positions, life experiences, viewpoints, and perspectives.

The fourth author is the principal investigator who conducted the interviews and engaged in initial review of the data as part of a larger study. She identifies as a White, bisexual, cisgender woman and a family therapy researcher focused on adaptation, dissemination, and implementation science. During the data collection process, the fourth author created notes about her reactions and about her own points of privilege and subjugation after each group interview. The other members of the authorship team represent a diverse range of social locations. Identities of team members include bisexual, pansexual, agender, cisgender, Eurpean American/White, Asian, and a variety of economic backgrounds. All members of the authorship team are family therapists with various levels of training and experience who recognize the value of engaging families into the treatment context as a core theoretical stance of providing systemic therapy. As such, each member of the team was encouraged to be open to the theoretical diversity of the providers participating in this study and employ curiosity about their rationale when deciding whether to integrate family or discuss family concerns in care. Consolidated information about the fourth author's reflexive notes was shared with the authorship team of this study during analysis and drafting of the manuscript, and all authors were encouraged to explore the role that their positionalities had in their interpretation of the data. Each member of the authorship team engaged in reflexivity practices (e.g., writing reflexive memos) to consider their influences on each phase of analysis. Additionally, the team met and considered positionality and reactions to the data throughout the analytic process.

3. RESULTS

Three themes and six subthemes were identified in the analysis of data related to providers' perceptions of treating SGM youth with STB and their families. First, participants described noticing social distal stressors experienced by their clients. Second, providers discussed how they were reacting to social distal stressors. Finally, methods for addressing social distal stressors in the context of their organizations were described. These themes and their corresponding subthemes are described below with illustrative examples from transcripts.

3.1. Noticing Social Distal Stressors

In the present study, 88% (n = 16) of providers within our sample discussed noticing the social distal stressors that are experienced by SGM youth in their centers. Providers articulated examples of harmful, anti‐LGBTQ+ events and how these events impacted both their clients and their own work as providers. Due to the nature of services provided at each specific site, providers at Site 2 focused mainly on healthcare disparity (e.g., issues of access) whilst providers at Site 1 focused on discriminatory events their clients shared with them (e.g., identity‐based bullying).

3.1.1. Acknowledging Discriminatory Events

Providers cited multiple examples of learning about discriminatory events experienced by their clients, including identity‐based police aggression, family rejection, ostracization, ridicule, misgendering, and microaggressions amongst others. In addition, they reported how their clients experienced discrimination within the medical treatment systems intending to treat their STB. Providers described how these experiences, particularly those in intensive treatment settings, exacerbated suicidal ideation. The following segment highlights this process:

I'm thinking also about a case that even the way they (the clients) were separated in the [psychiatric] ³ hospital; they were forced to be with boys or girls and only that separation [was allowed]. And the limitation… they were policing gender expressions, so the kids were getting, it seems that… the symptoms [of suicidal ideation] were getting stronger because they [shared with the provider that they] wanted to leave the space and find an opportunity to self‐harm.

[5S1]

Similarly, another provider cited more examples from their experiences of outside medical institutions supporting LGBTQ+ mental health. Participant 6S1 discusses concerns about the harassment a client faced while staying at an inpatient facility to treat STB. The next excerpt demonstrates this concern:

A client was recently voluntarily committed, came back from a weekend inpatient stint having faced a lot of anti‐gay harassment in inpatient and that's the reason that [they] identified as feeling suicidal and so [they] were trying to deal with that and came back primarily talking about being bullied in inpatient for being gay. And also, about trans clients using medical institutions… those are harmful experiences in and of themselves and they also create an atmosphere in which trans people are reluctant to seek institutional support… they (their transgender clients) know that needing to use those institutions is almost certainly traumatic.

[6S1]

The same provider also had concerns about other social systems interfacing with the youth they served. They acknowledged that working with vulnerable families can result in necessary referrals to child protective systems. The following quote describes necessary referrals as having to engage with violent systems:

I think that… [child protective service system] is a violent system, not just for queer people but for black folks especially as well. But like coming in with a baseline understanding that those are violent systems that we might use but they are necessarily violent (as providers are mandated reporters)… for me to trust another practitioner to be working with a family would involve a baseline understanding, that that (reporting vulnerable queer and black families to CPS) is violence.

[6S1]

At Site 2, providers discussed their focus on healthcare disparity that minority individuals may face. They discusse access to resources to support their needs like availability to drive long distances to their site to receive affirmative healthcare. One provider discusses their concern about access to affirmative care and the priority of Site 2's values and ability to do outreach to all that may need their services. The following quote captures this concern:

I see our resources at [Site 2] as being overwhelmed with individuals who make contact in order to get their individual needs met. And that there is a waitlist, 3 months getting into individual therapy, I think it's a question of resources on some level, and also, goals, values and how we do outreach.

[14S2]

Other providers at Site 2 shared concerns about accessing healthcare and expand on the risks associated with losing access or not having access at all. The providers describe the risk of facing homelessness and having other core needs neglected. In the excerpt below, provider 9S2 discusses the effects of discriminatory practices in healthcare systems:

… [adolescents were] feeling like they weren't at a point where challenging those relationships [with rejecting caregivers] were safe in terms of personal bodily harm; in terms of homelessness, and other vulnerability factors; in terms of meeting those core needs, foundational needs.

[9S2]

3.1.2. Family Rejection

As 9S2 notes, providers see systemic discrimination as being linked to family rejection. In addition to facing stressors in medical and social systems, many providers shared that their clients with STB were among those who were the most disconnected from their parents and caregivers. They cited family rejection as being a primary reason for this disconnection. Specifically, provider 9S2 saw the lack of safety in their clients' homes as being associated with the level of family rejection experienced by the youth. The following excerpt is an expansion from participant 9S2 that demonstrates participant 9S2's resultant hesitancy to involve family in therapy sessions:

It would be hard to do family work with most of my clients. It has not been safe to bring in certain family members, especially with rejection and other microaggressions at home.

[9S2]

Another provider discussed their clients' tendency to isolate after experiencing family rejection and discussed being concerned that working with the family would cause problems. This quote demonstrates the provider's concern about involving family who may confirm their rejection of their SGM child during treatment:

…sometimes it could make things worse if they're [the family is] pretty, you know, gung‐ho about [how] this [identifying as LGBTQ+] is not how you're supposed to be…in terms of isolation and feeling like they don't belong. It [not belonging] could just be reconfirmed in that sense.

[4S1]

While another provider shared the sentiment that engaging families who are rejecting is destructive, they also saw an opportunity for change. They described how varied stances amongst caregivers on their child's minoritized identity are detrimental to the wellbeing of the youth they serve. The following selection highlights this participant's thoughts about the nuance of involving mixed‐stance caregivers in treatment:

I think about families that are highly conflicted where there are two parents who don't see eye to eye specifically around the kids gender identity development, and that being incredibly harmful to the young person [as they receive confusing messages about the acceptability of their identity].

[7S2]

3.2. Reacting to Social Distal Stressors

Providers not only acknowledged the complexities of social distal stressors in the lives of their clients; all participants (100%; n = 18) also described their own internal responses to these events. While they expressed their justification for wanting to intervene at the level of social distal stressors to enhance the lives of their clients, they also discussed their tension in figuring out how to do so without exacerbating stress. Providers aimed to intervene at this level without causing new or further harm to their clients.

3.2.1. Justification

Providers described the importance of engaging with the wider systems in which their clients experienced social distal stressors. In doing so, they discussed their rationale for creating change in families and other social systems. Providers' specific justification focused on two areas: creating supportive relationships and promoting change in the family. The following segment illustrates one provider's stance on why working with caregivers is important in the treatment context to promote change in the family:

I think it [family therapy] could be useful for… middle school age to early 19‐year‐olds. Just because the parent or caregiver is always there…I do really like the collateral work with the caregiver, kind of putting the power in their hands to promote some change in the home…

[3S2]

Another described how lacking a sense of belonging contributed uniquely to identity‐specific distress and is, therefore, worthy of consideration in treatment. Specifically, this provider discussed the importance of family attachment in creating supportive relationships through an increased sense of belongingness. The excerpt below describes this sentiment:

When I think about the isolation and the sense of belonging, I think about attachment. One of the key issues around trauma and attachment is the lack of a sense of belonging, the lack of feeling part of something. So, if our heterosexual youth are feeling that and then our LGBT youth are feeling that in a more profound way, that magnifies that isolation and then triggers their trauma, cause they're all intimately connected.

[3S1]

Providers discussed their work with families for the purposes of building connection between family members and creating change at home. Provider 4S1 describes their experience of working with a trans‐identified youth and their foster parent to treat disconnection in the following quote:

I did have one trans youth where I worked with [their] foster parent and I feel like a lot of what we ended up doing was, because there was just so much… disconnection within the house… we all kind of came to an agreement of them spending time together. I think it worked to a certain degree.

[4S1]

Providers also mentioned that the way they are most able to carry forward their intention to create change in social systems was through providing psychoeducation to parents or caregivers in treatment. For this purpose, providing psychoeducation is discussed as a method of empowering the client and their parents to create change and increase support. In the following quote, a provider explained their justification for using this strategy:

I'm working with a family now that has a trans‐identified youth, and [they] were the identified client. I let [them] pick the structure of how [they] wanted to engage, and sort of break up the time between individual sessions, family sessions, and parent sessions. But parent sessions were more focused on psychoeducation around hormone therapies, and things they just weren't sure about. But I gave [them] all the power to choose how to engage in the time [jointly with their parents]. It was about empowering [them] to embrace this identity as a part of [their] family.

[1S2]

3.2.2. Tension

Despite having justifications for addressing social distal stressors directly, most providers described struggling to enact them. These struggles related to their level of trust in wider social systems to react affirmatively to SGM youth. Providers expressed their tension as skepticism towards other systems of care (e.g., inpatient hospitals) and family members (parents and caregivers) who had a history of rejecting SGM youth. Understandably, they were concerned about breaking trust with their clients if they were to engage rejecting family in therapy, and the process went poorly or treatment gains were not lasting. In the segment below, one provider articulates this concern:

I'm not really familiar with [brief family therapy] interventions… would [that] be enough to address suicidality? What happens if there's an increase but once they leave the intervention is that ‐ with support ‐ how can we guarantee that the support [from family] is going to be in place and that [the client] is not going to go back and [they're] going to regret [involving family]?

[5S1]

Another provider wrestled with the merits of incorporating rejecting parents or caregivers into therapy. Provider 10S2 spoke about their experience involving rejecting family members in sessions and tension about continuing this work as it posed a safety concern for their client. A major concern discussed in the following quote is related to working with minors who have limited autonomy:

Parents have medical, physical and financial power of attorney, and they are not accepting at all… they're calling my client by [their] first name now, [and] not pronouns… But it's a touchy situation, because of this piece. So we are continuing to work… and I'm almost hesitant though to have them [caregivers] back in.

[10S2]

Finally, providers also discussed the tension between wanting to build support around the youth, while also navigating identity‐specific concerns. As noted in the following segment, provider 9S2 articulates the unique barrier of a caregivers' readiness to engage in identity work with their child:

In terms [of] whether they're even ready to come out to this caregiver. And kind of recognizing, me personally as a clinician, that would be extremely hard, even impossible at this particular place [LGBTQ+ center]. So, kind of recognizing just that as a big barrier in working with this population in terms of holding that secret, in terms of building this relationship, and whether that relationship you're building is really healthy if you're not kind of bringing in this identity work that they're going through with parents and stuff like that.

[9S2]

3.3. Addressing Social Distal Stressors

Most providers (78%, n = 14) reacted to their own tensions by thinking through pragmatic solutions for mitigating the impact of social distal stressors in support of their clients. In doing so, they considered the role of support in their clients' lives and where this support should come from. The next selection describes an example of how differences in approach are a challenge in identifying who a true supporter is:

…but when you have the gay mom and dad here and we all come here for different things… that's a challenge with identifying family. What is a true support?

[7S1]

This example demonstrates the providers' concern through asking what true support even looks like. When having caregiver involvement, there is a range of who may attend a session with an SGM youth, and part of addressing social distal stressors is identifying family support.

3.3.1. Solutions

Providers considered solutions that would enable them to intervene at the level of social distal stressors. Some of these solutions were related to articulating what they, themselves, needed to support their clients, while others centered on building support. One provider discussed what it would mean to have more affirmative resources to address the lack of acceptance from families. The following quote described this particular need for resources:

Those were definitely some of the things that I was thinking most of, like, I think just a good referral list of places that we could actually trust sending people to… if we actually had a place that we could feel okay sending people to for additional supports, that would be such a relief…some parents don't even know that their kids are coming here or that they are LGBTQ, and if that's included in part of their suicidality, particularly if the parents or caregivers, aren't necessarily accepting of that (identity) and that might be part of why they're feeling suicidal… that could be an excellent time to get a parent on board and supporting.

[4S1]

Family acceptance was discussed as a central part of the decision of involving family members in treatment at all. Some providers shared that involving family members was important to them within the context of their role at LGBTQ+ organizations, so they continually assessed the ongoing level of support. This assessment of opportunities for family connection is described in the following excerpt:

I'm always trying to assess opportunities to [increase family] connection…I have parents who do not accept or affirm gender identity or sexual orientation and then they try to avoid that conversation and they just want to pay attention to the suicidal part and they will engage in treatment only based on that… even if they [parents of their clients] do not accept their [child's] identity they still engage with them and [I'm continually] seeing in which capacity then can be consistent in treatment.

[5S1]

3.3.2. Dismantling Normativity

Efforts to dismantle normativity were described in relation to intervening at the level of social distal stressors. Providers illustrated their methods of helping themselves and their clients think more expansively about options for gaining support and promoting self‐acceptance in relation to their social systems. Specifically, providers dismantled normative definitions of family and use of language in mainstream treatment of SGM clients. Considering involving their client's family of choice was a prominent goal of providers. In particular, they described their openness to involving non‐biological or non‐legal family members in treatment as is illustrated in the following segment:

… it is really about that sort of family of choice for many people. It's about finding the people who serve a similar function to family, like what [function] we think family should serve, but are actually accepting of them for who they are and are consistent sources of support.

[2S1]

Other providers echo the utility of focusing on the function family serves in supporting one another instead of normative definitions of family. The following provider shares their experience identifying family members that can create stability in their client's lives:

… [Youth who are displaced from family] try to create stability in that sense [seeking support from anyone who is consistently accepting] and so when identifying their family, it's not the biological family. And then they [the clients] want to introduce people into their treatment [who] sometimes may need treatment themselves, or are actually youth here, or [are] a part of the community here.

[7S1]

In addition to dismantling normative assumptions about family constitution, the social construction of gender was discussed amongst providers as being counterproductive to their clients' progress in treating STB. These providers spoke about how broader society often tries to fit gender into boxes or categories, constricting gender identification. When youth are not able to trust the conventional healthcare systems, they are unwilling to be treated in intensive settings for their STB. One provider challenged using a categorical approach of understanding gender to housing youth in inpatient facilities:

Gender non‐conforming or trans identified youth cannot trust the people who are providing services to address suicidality. They don't use the pronouns that the youth are using, its counterproductive and youth get triggered, they resist to trust, they resist to be in hospitals and crisis centers, and the parents also get affected by that… They (youth) were separated in the hospital and were forced to be with boys or girls. They were policing gender expressions which were limiting to youth. Their symptoms were getting stronger because they wanted to leave the space, and this felt [like] an opportunity for them to self‐harm or do something else (harmful to themselves).

[5S1]

Many providers described similar experiences and discussed nuance in language and the ways it signals safety or threat to them. In their efforts to dismantle normativity, providers pointed out the discrepancies between signaling affirmative knowledge through language and employing affirmative techniques through practice. One provider discusses that, though use of affirmative language is an important screener for discerning safety, it is a surface‐level measurement for observed changes in larger social systems:

I'm always thinking about whether I'm safe in any given thing on the axis of gender…language is often a necessary screening tool that queer and trans people are using to know whether or not we are safe in a place and so when places try to only change their language (laughter) the language isn't the point. It's that like queer youth and queer others are trying to figure out when we are safe… language is a surface thing.

[6S1]

4. Discussion

Frost and Meyer (2023) describe minority stressors as identity‐specific stress that SGM individuals face above and beyond what is typically expected in day‐to‐day life for the general population. Social distal stressors such as parental rejection, identity‐based violence, anti‐LGBTQ+ discrimination, bullying, stigma, harassment, and social ostracism (Asakura 2016; Fish et al. 2019; Olson et al. 2016; Phillip et al. 2022; Russell et al. 2011; Testa et al. 2017), impact SGM youth. This study examined providers' perceptions of working clinically with SGM youth with STB and their families and providers' experiences navigating social distal stressors experienced by their clients. Little research to date has focused on the role of LGTBQ+ community centers in addressing youth suicide. This study represents one of the first efforts to understand how providers in these settings respond to the challenges of working with this population. Participating providers not only described the impact of social distal stressors on their clients and their perceptions of existing needs, barriers, and facilitators, but they also shared their personal tensions and solutions associated with intervening in the systems surrounding SGM youth.

4.1. Minority Stressors for Providers

Regarding social distal stressors, providers shared their methods for deconstructing what broader systems normalized in the care of SGM youth. The themes identified in this study demonstrated the ways in which providers noticed, reacted to, and addressed social distal stressors in their work with SGM youth and their families. Results described the providers' responses when hearing from their clients about experiences of social distal stressors, feeling professional and personal tension, and being unsure about how to directly address these concerns.

Experiencing tension was the most robust themes in our results, making up 34.6% of all coded segments. For providers, tension illustrated personal limitations in supporting SGM youth and families. For this group of highly committed providers, and particularly for those who also held SGM identities, it may be that these experiences of tension, in and of themselves, represent minority stressors. Just as youth's experiences of social distal stressors, are associated with proximal stressors, like gender dysphoria, internalized stigma, pressure to conceal an LGBTQ+ identity or history of gender transition, and expectations of rejection (Frost and Meyer 2023; Hidalgo et al. 2019; Meyer 2015; Toomey 2021), it may be that providers are simultaneously experiencing their own stressors as a result of helping youth navigate these challenges.

To date, no study has generated illustrative descriptions of the stress providers in LGBTQ+ centers are experiencing. Because all providers hold an SGM identity in our sample, it is possible that they experience a greater sense of distress based on their own lived experiences of social distal stressors while simultaneously acknowledging the weight of their responsibility as providers. We propose the unique term of medial stressors, as the word ‘medial' positions the experience of LGBTQ+ providers—who may simultaneously experience proximal stressors while confronting distal stressors within the greater healthcare and family systems – well in between these previously researched levels of stressors. It was clear from this study's data that these stressors directly impacted the providers' professional and personal lives. These medial stressors may be unique to this group of providers and capture how they experience the tensions involved with serving SGM youth facing social distal stressors. In the paragraphs below, we further summarize our findings to illustrate how secondhand proximal stressors also impacted the providers in our sample. Here, we define secondhand proximal stressors as stressors that involve SGM providers' stress from their concern about an SGM client's identity‐based struggles, as the providers deeply understand the consequences of such stress for SGM youth.

Many providers describe the initial process of noticing social distal stressors that their clients experience. Specifically, most providers shared that they “heard” [3S1] clients discuss bullying, violence, and discrimination that their clients had to “get away from” [2S1] to access affirmative services. Some of these same providers were “concerned” [15S2] that referring their clients to treatment systems in support of their mental health needs meant that they would “risk their clients' safety” [3S2] and that they “did not trust” [6S1] mainstream systems of care. Providers also confirmed that lack of affirmative practice is related to a dearth in training (Fish et al. 2023; Rhodes et al. 2023; Taliaferro et al. 2021; Yu et al. 2023). In fact, many providers mentioned that they would like to vet mainstream systems of care before referring clients to them for services or have access to a pre‐vetted list of providers to ensure that these systems of care were equipped to manage the common social distal stressors clients face. These providers mentioned feeling “overwhelmed” [14S2] by the volume of clients on their waiting lists, which mirrored findings from large‐scale survey data (Trevor Project's results 2020). Providers also felt “burnt out” [7S1] by the persistent lack of training or awareness of affirmative practices available generally for SGM individuals. In these ways, the challenges faced by SGM youth clients have immediate relevance for the providers serving them.

Working with family was another area in which medial stressors emerged for providers. When discussing family rejection, in particular, providers confirmed that being “disconnected” [2S1] and “isolated” [4S1] from family was linked to increased risk of suicidal ideation for their clients, consistent with previous literature (Blosnich et al. 2020; Glassgold and Ryan 2022). At the same time, some providers stated that working with family was an area where training is needed and questioned the safety of involving them in therapy at all. Again, this brought up tensions and discussions about “trusting” families and other systems to fully support youth [5S1]. On one hand, providers sought to intervene in these systems, but, on the other, saw these efforts as a “hard choice.” [9S2] Some providers discussed spending extra time “assessing the level of family acceptance” [2S1] and considering the “safety to include family members” [6S1] while caring for SGM youths. As such, these providers' stressors mirrored those of their clients in that they, themselves, were impacted by navigating the same social distal stressors as their clients, creating secondhand proximal stressors unique to their position.

4.1.1. The Role of Family Therapy

Marriage and Family Therapists (MFTs) are trained to work with families from a systemic perspective. This means during the most stressful times of life, MFTs expect to provide multi‐directed support, holding space for multiple perspectives in the therapy room. Several approaches for working with SGM youth in the context of family therapy discuss the importance of strengthening the family relationship. For example, Diamond and Boruchovitz‐Zamir (2023) discuss the first task of Attachment‐Based Family Therapy for LGBQ+ youth and their families as defining relationship‐building as the goal of the therapy because rejecting a youth's identity creates a rift in the family dynamic which contributes to the youth's mental health concerns. The Family Acceptance Project (founded by Caitlin Ryan and Rafael Dìaz in 2002) is an example of an effort to engage families of SGM youth in learning about the importance of family acceptance.

While not every SGM youth attends therapy because of ruptures in their family relationships, it is known that this is a prevalent presenting issue and that family relationships hold the potential to further harm or help the youth in coping with minority stress (Beeler and DiProva 1999; Conley 2011; Klein et al. 2023, and Toomey 2021). A disciplinary distinction exists in that many providers who have limited training in systemic therapy might (justifiably) worry about their ability to prevent harm that could be caused by involving parents in therapy. As such, increased training in techniques involving families in therapy is a core part of providing affirmative practices in that some of the biggest stressors SGM youth face is family rejection (Meyer 2003). Without addressing family‐level issues, many providers are only equipping youth to be able to individually cope with an emotionally painful home existence, and miss out on treating the cause of the youth's emotional pain. MFTs are especially trained to assess and recognize concerns of safety in family relationships (American Association for Marriage and Family Therapy 2004). As such, they can provide supplemental methods (beyond psychoeducation) for other mental health professionals to navigate family engagement in these settings.

4.1.2. Moving Toward Solutions

A major finding from the present study was how providers used their experience of tension to consider how to intervene in social distal stressors. In the group interview setting, providers worked through the tension by consulting with one another about how they might help connect the youth to systems that are supportive. They also discussed how to help the systems, themselves, become more supportive. By strategizing how to approach family or the process of referring clients to other systems of care, they demonstrated a desire to address social distal stressors for their clients as well as to mitigate their own secondhand proximal stressors. While providers did not know how they might address all the stressors they observed in broader social systems, they discussed involving family of choice (see Weeks et al. 2001 for further explanation of this concept) in the care of these youth, rejecting normative assumptions about family. Normative assumptions of what constitutes family includes essentialist narratives regarding biological or adoptive ties between parents and their children.

While providers in our study were constantly witnessing and learning about social distal stressors experienced by their clients, they were simultaneously considering how their values (e.g., deconstructing language about identity) and practices (e.g., involving families of choice) could support their clients in navigating broader relationships and social systems. In other words, while matters such as family rejection, institutional oppression, and normativity were acknowledged when asked to share what barriers the providers experienced in working with this population, they did not discuss these at great length. Instead, they shifted to describing these barriers as challenges that needed to be resolved.

In sum, these results support the important role that LGBTQ+ community centers, as well as the providers practicing in these centers, serve in supporting SGM youth with STB. As with the providers in the present study, those working in these settings often share identities with their clients, and, therefore, may be positioned as trustworthy resources (Barnett et al. 2023). The presence of SGM providers give clients knowledgeable and empathic supports that are essential to suicide prevention. The current literature states that the presence of such adults is protective against STB for SGM youth (Goodenow et al. 2006; Johns et al. 2019).

4.2. Implications for Practice

While this study offers family therapists some insight into the challenges and importance of working with SGM youth with STB and their families, the implications of this study for the field of family therapy go beyond the therapy room. Broadly, this study illuminated some of the major barriers and strategies for conducting family work in the context of LGBTQ+ centers, a setting that has not traditionally offered these services. The findings provide some information that family therapy educators and researchers, who are embedded or partnered with these centers, might consider to support the uptake of family services and suicide prevention programming.

When considering the CFIR (Damschroder et al. 2022), the themes articulated here describe key roles and characteristics that should be attended to if family‐based strategies for suicide are presented to LGBTQ+ community centers as part of an implementation strategy. For example, for family interventions to be viewed as a resource to affirmative providers in these settings, it could be effective to present them as an opportunity to more directly target social distal stressors. Our findings revealed that these providers are highly attuned to the impact of social distal stressors on the SGM youth they serve and experience personal and professional difficulties when they face barriers to creating meaningful, second and third order change. In this way, family work could fit within the value framework that affirmative providers draw from when working with this population. This study represents one small, but important step toward the future development of implementation strategies aimed to assist LGBTQ+ community centers in the uptake of family interventions for the purposes of SGM youth suicide prevention. This line of work is also consistent with the call to the field of MFT to employ systemic training for the advancement of implementation scholarship (Withers et al. 2016).

4.3. Limitations

This study is not without limitations. Some of the providers at our second site (n = 4) participated nonverbally in the group interview and were, therefore, not included in the analysis. While these participants seemed actively engaged and responsive, they did not contribute content to the present project. In addition, the size of our group interview meetings posed another limitation, particularly for site 2 (LGBTQ+ integrative health center). For Site 2, we encountered time restrictions and may not have dedicated enough time for all providers in attendance to participate fully. Though we would have liked to interview smaller groups of providers, it is an ongoing challenge for clinicians in these settings to devote staffing time to participatimg in research activities.

We also wondered if the constitution of the group posed challenges for participation. Not all participants had a clinical license, creating a group of providers with mixed professional backgrounds and roles. Because providers had different roles from one another, there was some discrepancy in points of view amongst participants based on their differing experiences. Smaller group interviews of providers with similar roles might have provided a platform for greater participation and richer discussion. Lastly, data collection occurred before the COVID‐19 pandemic as well as subsequent political shifts that impacted access to funding. As such, the study does not capture some of the new challenges providers are experiencing in terms of workload, accessibility, and telehealth utilization.

4.4. Future Directions

Future directions include further examination of providers' approaches to overcome tensions in addressing social distal stressors. While this study revealed providers' commitment to dismantling normativity through expanding definitions of family, deconstructing gender, and increasing awareness of affirmative practices, better understanding their strategies of doing so in the contexts of psychotherapy and other clinical services is an avenue worth further attention.

Creating a conceptual model with regard to the direction and relationship of distal, medial, and proximal stressors could benefit providers in LGBTQ+ community centers. Explaining the direction and nature of the relationships of these variables can create clinical implications and further understanding of the needs of SGM providers. Literature to date discusses how burnout is a prominent problem that these providers face (Hill et al. 2020) and examining their unique stressors is a step towards decreasing burnout and job dissatisfaction. Historically, the primary solutions for preventing provider burnout has been framed as the responsibility of the provider alone (Samuels et al. 2021). Samuels et al. (2021) critique this approach and express how the only effective way to address burnout is by going to the source (e.g., minority stress). Understanding the experiences and needs of SGM providers working in LGBTQ+ centers moves us towards resolving these problems and increasing the quality of care for the youth and families they serve.

5. Conclusion

The present study illustrates providers' approaches when working with SGM youth with STB in the context of LGBTQ+ community centers. Results suggest that these providers are both attuned to and influenced by the social distal stressors impacting this population and actively consider ways to intervene in the systems that surround their clients. Their approaches are emblematic of the way they push themselves, families, and healthcare systems to challenge what is considered normative. Providers offer their strategies for and struggles with practicing affirmatively with SGM youth and have contributed valuable insights for working through tensions that arise when intervening in clients' social systems.

Ethics Statement

The present study received IRB approval from the senior author's institutional affiliations, formerly Drexel University of Philadelphia, PA and currently Virginia Tech of Blacksburg, VA.