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Young people (aged 12-25 years) with diverse sexuality, gender, or bodily characteristics, such as those who identify as lesbian, gay, bisexual, transgender, intersex, or queer (LGBTIQ+), are at substantially greater risk of a range of mental, physical, and sexual health difficulties compared with their peers. Digital health interventions have been identified as a potential way to reduce these health disparities.
This review aims to summarize the characteristics of existing evidence-based digital health interventions for LGBTIQ+ young people and to describe the evidence for their effectiveness, acceptability, and feasibility.
A systematic literature search was conducted using internet databases and gray literature sources, and the results were screened for inclusion. The included studies were synthesized qualitatively.
The search identified 38 studies of 24 unique interventions seeking to address mental, physical, or sexual health–related concerns in LGBTIQ+ young people. Substantially more evidence-based interventions existed for gay and bisexual men than for any other population group, and there were more interventions related to risk reduction of sexually transmitted infections than to any other health concern. There was some evidence for the effectiveness, feasibility, and acceptability of these interventions overall; however, the quality of evidence is often lacking.
There is sufficient evidence to suggest that targeted digital health interventions are an important focus for future research aimed at addressing health difficulties in LGBTIQ+ young people. Additional digital health interventions are needed for a wider range of health difficulties, particularly in terms of mental and physical health concerns, as well as more targeted interventions for same gender–attracted women, trans and gender-diverse people, and people with intersex variations.
PROSPERO International Prospective Register of Systematic Reviews CRD42020128164; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=128164
Young people who are lesbian, gay, bisexual, transgender, intersex, queer and other people of diverse sexuality, gender, or bodily characteristics (LGBTIQ+) are known to experience a range of disparities in health outcomes compared with their peers [
These health disparities are compounded by barriers that negatively impact the ability of LGBTIQ+ young people to access health services that are safe and adequately meet their needs. Young people in the general population face many barriers to help seeking, including inadequate resources and lack of accessibility, desire for self-reliance, and anticipated stigma for reporting certain health difficulties such as mental illnesses or HIV [
Digital health interventions, such as those delivered via computers, websites, smartphones, or tablets, have been identified as an important potential avenue to improve health care access and use among young people in this group [
LGBTIQ+ young people are adept and frequent users of digital technologies [
In response, there has been a rapid increase in the number of such interventions over the past decade. To date, however, there has not been a comprehensive review summarizing the scope and use of digital health interventions that currently exist for this population. Knight et al [
A more extensive summary of this rapidly growing field of research will assist in identifying gaps in the development of interventions and determining the overall evidence for their use across the full diversity of the young LGBTIQ+ community. Therefore, this review aims to answer the following questions: (1) What are the characteristics of evidence-based digital health interventions for improving mental, physical, and sexual health outcomes in LGBTIQ+ young people? (2) Are targeted digital health interventions effective at improving health outcomes in LGBTIQ+ young people? (3) Are targeted digital health interventions acceptable and feasible for LGBTIQ+ young people?
The protocol for this review was registered using PROSPERO (Prospective Register of Systematic Reviews; ID CRD42020128164) in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations [
The population of interest was LGBTIQ+ young people. The LGBTIQ+ term was used in its broadest sense to capture young people of diverse sexuality (including but not limited to those that identify as gay, lesbian, bisexual, or pansexual), diverse gender (including but not limited to those who identify as trans or nonbinary), with diverse sex characteristics (including but not limited to people with intersex variations), or people falling across any combination of these categories. The search strategy (below) was designed to be as inclusive as possible of the wide variety of identities that LGBTIQ+ people may hold including, for example, people who fall within these aspects of diversity without explicitly identifying as such (eg, MSM).
The review focused on interventions designed to effect change through predominantly digital means (eg, using a computer, website, tablet, or smartphone). To be included, interventions were required to be targeted or intended to specifically effect change in health outcomes in LGBTIQ+ people. Interventions delivered via telephone with no technological function or an implantable device that is remotely monitored were excluded. Interventions were also required to have minimal human guidance in the intervention itself if present at all. Specifically, the action, process of intervening, or behavior change techniques must have been delivered by the digital technology itself not a health professional working over a digital medium. This criterion was implemented because, in interventions that blend digital and human support, the impact of the intervention cannot be meaningfully attributed to the digital component alone [
The judgment of the level of human guidance was made by considering the ratio of clinicians or staff to users, and the centrality of the human guidance to effecting change in the health outcome, which itself relied on factors such as the ratio of guided versus unguided time during the intervention. No hard limits on these factors were set prior to conducting the review, as making this judgment required the full context of the intervention to be considered holistically. A judgment about the duration of the human guidance, for example, could not meaningfully be made without consideration of the purpose of that period of guidance and how it fits into the goals and process of the intervention as a whole. What was counted as
To be included, studies should have conducted an evaluation of a specific intervention as described above. Evaluation in some form was required in keeping with standards of evidence-based practice. The term
No specification was made for the location of the study; however, studies were required to be published in the English language. With the aim of reducing the risk of publication bias [
The review was designed to capture interventions seeking to improve health outcomes or to prevent negative health outcomes. This was inclusive of mental health outcomes (eg, symptoms or diagnoses of mental disorders, well-being, distress), physical health outcomes (eg, smoking, weight loss), or sexual health outcomes (eg, pre-exposure prophylaxis [PrEP] adherence, condom use). Any outcome reasonably perceived to represent some aspect of health and well-being was considered relevant to the review. For studies evaluating efficacy, changes must have been reported in measures of at least one of these outcomes. For studies evaluating acceptability or feasibility, at least one index of these factors (eg, surveys of participant experiences, adherence, or attrition rates) must have been reported.
Internet databases such as PsycINFO (Ovid) and MEDLINE (Ovid) were systematically searched on August 13, 2019, and potentially relevant peer-reviewed publications were extracted. These searches were conducted using a combination of subject headings and keywords corresponding to the following themes: LGBTIQ+, Youth/Young People (aged 12-25 years), Mental Health, Physical Health, Sexual Health, Digital and Intervention. The search terms for LGBTIQ+, Youth/Young People, and Mental Health themes were adapted from those previously reported by Gilbey et al [
Additional searches were made using Scopus, ProQuest Dissertations, Google, Google Scholar, OpenGrey, WorldCat, ClinicalTrials.gov, and JMIR Publications, during July and August 2019. Each of these searches were conducted with several simple keyword searches (eg,
The titles and abstracts of the articles identified by the search were screened for relevance by the lead author (DG), removing articles with no clear relevance to the topic of the review. Two authors (DG and HM) then screened the full-text of the remaining articles independently, with differences in opinion resolved in discussion with a third author (YP) in which full agreement was sought.
The following data items were extracted from eligible studies: author(s), year, participant age (mean and range), description of sample (eg, LGBTIQ+ status), sample size, study design, study setting, intervention type, content and delivery, digital platform, control group type (if relevant), degree of human guidance in the intervention, health outcome(s), acceptability outcome(s), and feasibility outcome(s). A second reviewer (HM) cross-checked these data.
Following data extraction, studies were evaluated using the Mixed Methods Appraisal Tool (MMAT) [
Owing to the wide array of interventions, targets of intervention, intervention modality, and health outcomes measured, it was anticipated that a quantitative synthesis (of those studies reporting quantitative data) would be neither feasible nor informative. Therefore, the results of the studies were synthesized qualitatively.
The search and screening process is displayed in a PRISMA flow chart in
Study flowchart. LGBTIQ+: lesbian, gay, bisexual, transgender, intersex, queer.
The 38 studies captured the results of studies examining 24 unique interventions conducted across 3 countries (the United States, the United Kingdom, and New Zealand). Of these, 5 targeted primarily mental health–related issues, one targeted primarily physical health–related concerns, one targeted primarily sexual health and well-being, and 17 targeted risk reduction or management of STIs. A total of 22 interventions focused specifically on young people who are attracted to the same gender (referred to with a variety of terms, eg, sexual minority, lesbian/gay/bisexual/queer people, MSM), of which 19 interventions were described as being focused on young men (eg, gay/bisexual men, MSM). Several studies that described their target audience as MSM also included trans women under this descriptor. One study targeted people who identify as lesbian, gay, bisexual, transgender and queer (LGBTQ) generally [
Summary of digital mental, physical and sexual health interventions for lesbian, gay, bisexual, transgender, intersex or queer young people.
Intervention category and name | Primary health outcome | Study | Participant mean age (range; intervention condition) | Description of sample (eg, LGBTIQa status/identification) | Sample size | Study design | Study setting | Intervention type | Digital platform | Primary measured constructs and effects | |||||||||||
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Unnamed intervention | Drug abuse | Schwinn et al [ |
16.1 (15-16) | Sexual minority youth. Same-sex attracted=90, both-sex attracted=116, opposite-sex attracted=14, not sure= 13 | 236 | Quantitative, RCTb and follow-up, efficacy | United States | Interactive skill-building sessions | Computer via web |
Alcohol use –c Marijuana use – Cigarette use – Peer drug use ↓d Other drug use ↓ |
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Put It Out Project | Smoking cessation | Vogel et al [ |
19.7 (18-25) | Sexual and gender minority young adults. Gay/lesbian=6, Bisexual=15, Queer=2, Pansexual=8, nonbinary=10, Trans=2 | 27 | Mixed methods, acceptability and feasibility | United States | Social media (Facebook) | Web | N/Ae | ||||||||||
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Smoking cessation | Vogel et al [ |
21.4 (18-25) | Sexual and gender minority young adults. Gay=29, lesbian=30, bisexual/pansexual=93, other=13 | 165 | Quantitative, RCT and follow-up, efficacy, and acceptability | N/A | Social media (Facebook) | Web |
Number of cigarettes smoked weekly ↓ Self-reported smoking abstinence ↑f Biochemically verified smoking abstinence ↑ |
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Rainbow SPARX | Internalizing symptoms (depression and anxiety) | Lucassen [ |
N/Ae | N/A | N/A | N/A | N/A | N/A | N/A | N/A | ||||||||||
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Internalizing symptoms (depression and anxiety) | Lucassen et al [ |
16.5 (13-19) | Sexual minority youth | 21 | Quantitative, uncontrolled pilot, acceptability and feasibility testing | New Zealand | Serious game | Computer via CD |
Depressive symptoms ↓ Anxiety symptoms ↓ |
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Internalizing symptoms (depression and anxiety) | Lucassen et al [ |
16.4 (13-19) | Sexual minority youth | 25 | Qualitative, acceptability testing | New Zealand | Serious game | Computer via CD | N/A | ||||||||||
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Internalizing symptoms (depression and anxiety) | Lucassen et al [ |
17.9 (15-22) | LGBT+ youth and health professionals | 21 youth and 6 professionals | Qualitative, acceptability testing | United Kingdom | Serious game | Computer via CD | N/A | ||||||||||
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TODAY! | Internalizing symptoms (depression and anxiety) | Fleming et al [ |
19.0 (18-20) | Young sexual minority men. Gay=9 | 9 | Qualitative, usability testing | United States | Mobile app | Mobile phone | N/A | ||||||||||
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Unnamed intervention | Psychological distress | Pachankis and Goldfried [ |
20.2 (Range not provided) | Gay male college students | 77 | Quantitative, RCT and follow-up, efficacy | United States | Expressive writing | PC |
Depressive symptoms – Psychological well-being – |
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QueerViBE | Psychological well-being | Martin [ |
18.0 (15-21) | Young trans men and nonbinary people. Trans male=89, nonbinary=50, questioning=5, other=12 | 156 | Mixed methods, RCT, interviews, acceptability and efficacy | United Kingdom | YouTube videos | Web |
Psychological distress ↓ |
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Queer Sex Ed | Sexual health | Mustanski et al [ |
17.9 (16-20) | LGBT young people. Gay/lesbian=142, bisexual=31, queer=27, unsure/questioning=2, transgender=14 | 202 | Mixed methods, one-arm pilot, acceptability, feasibility and efficacy | United States | Web-based curriculum | Computer via web |
Sexual functioning ↑ HIV knowledge ↑ STD knowledgeg ↑ Contraceptive methods knowledge ↑ HIV testing location awareness ↑ |
aLGBTIQ: lesbian, gay, bisexual, transgender, intersex, or queer.
bRCT: randomized controlled trial.
c–: No change.
d↓: Significant decrease.
eN/A: not applicable.
f↑: Significant increase.
gSTD: sexually transmitted disease.
Mixed methods designs were used well among the included studies overall, with most meeting all of the criteria in the MMAT for such designs. This is not to say that these studies did not have methodological flaws, as the MMAT mixed methods subsection does not generally consider the quality of the individual qualitative and quantitative components but rather their intersection and integration. These components of the studies were also, therefore, considered individually and are included among those described below.
The majority of included quantitative trial studies were described as pilot or feasibility studies (17 out of 27), and their methodological quality was lacking in many cases. In total, 15 of the 27 trials were randomized trials, of which 4 did not report appropriate randomization procedures, 12 did not report blinding procedures, and participant adherence to the intervention was only reported in 2 studies. Of the 12 nonrandomized trials, 10 did not report accounting for confounding variables in their design and analysis; however, representativeness in the study samples was generally adequate. The majority of the 12 quantitative descriptive studies’ methodologies were vulnerable to nonresponse bias.
Studies’ methodologies were generally sufficient to meet the MMAT criteria for qualitative studies. It is worth noting, however, that most of the studies did not specifically outline the methodological framework underpinning the study, and it is unclear whether this was due to inadequate reporting or the absence of such structures entirely. Some studies did not appear to adequately substantiate their conclusions with the data, but again it was difficult to interpret whether this was due to flaws in methodology or omission of reporting.
Of the 5 interventions targeting mental health difficulties, 2 focused on internalizing symptom reduction [
There were few interventions targeting physical health problems or sexual health and well-being in LGBTIQ+ young people. Only one digital intervention focused on smoking cessation and targeted physical health in LGBTIQ+ young people [
The majority of the interventions identified in this review were targeted toward risk reduction or the management of STIs. Of the 17 interventions identified as having focused on risk reduction and management of STIs, 1 focused on pre-exposure prophylaxis adherence [
The most common platforms for digital health interventions were websites and mobile apps that, combined, represented over half of the interventions identified. A smaller number of interventions were delivered via computer software. Many interventions used gamification, or elements of game playing such as point scoring, in their delivery; however, only 2 interventions were fully gamified in nature [
The vast majority of interventions delivered information to effect change either in terms of building awareness about the health issue in question or teaching skills to enable behavior change. This information is typically delivered via text or videos. For some interventions, this was the entirety of their scope; however, others included quizzes, games, or practice scenarios to consolidate the knowledge being presented. Interventions varied significantly in the extent of their personalization; some interventions delivered the same content to all participants, while others provided opportunities for personalized input and then delivered information specific to the individual’s situation or needs at the time.
Interventions varied in the duration and intensity of their delivery. In total, 16 of the 24 interventions appeared to be intended to be a perpetually available resource that could be accessed at any time and largely completed in a single instance if desired. Intervention duration ranged from very brief completion times, as low as 10 min [
With regard to the effectiveness of these interventions, there was consistent evidence from a number of interventions that digital health interventions could improve HIV testing rates in young MSM [
Comparatively, few interventions were targeted toward improvement of mental or physical health issues; however, the interventions that did exist in this sphere were more targeted and overlapped less in scope. With the exception of an expressive writing intervention [
Given that the majority of the interventions included in the review were multimedia in some form, it was not possible to draw conclusions about the delivery aspects that would most reliably effect change in outcomes. Furthermore, and importantly, given that the overall quality of the interventions included in this review was suboptimal, their effectiveness must be viewed in light of limitations associated with methodology and reporting.
Overall, digital health interventions were generally acceptable to LGBTIQ+ young people, and there were some clear themes in aspects of these interventions that determined users’ level of interest. Gamification stood out as a component of interventions that tended to be highly regarded by participants. Information presented with brevity and in a relatable way tended to receive greater ratings of acceptability from users and, although infrequent, social aspects of interventions, such as the ability to share experiences with others, were generally highly rated as well. Common concerns raised about the interventions included information being too text heavy, patronizing or contrived, and tasks feeling too laborious or
Regarding the feasibility of the interventions, measures of engagement and adherence were often not reported by the included studies; however, those that did report levels of use (eg, screen time, clicks, communication with other users) appeared adequate, given the intended scope of the intervention. One study that included an in-person component (collecting rewards earned in the web-based component) reported low user engagement with this feature (5%-27%). Overall, rates of attrition among the included studies were low, with several interventions reporting retention rates of 90% to 100% in their trials [
LGBTIQ+ young people have a substantially higher risk of a range of health difficulties than the general population [
In addition to showing potential for effectiveness, the interventions were found to be generally acceptable and feasible overall. Acceptability appeared closely linked to collaborative intervention design development with LGBTIQ+ young people and the digital modality of delivery. Notably, one study, which had regular check-ins with a clinician, found that participants were in fact deterred by this contact, citing difficulty scheduling and desire to remain discreet [
Overall, the results of this review are therefore promising for the continued development of digital health interventions for LGBTIQ+ young people, and there are some clear paths forward for how this field of research could be developed further. Most of the interventions included in this review have thus far only been evaluated in terms of usability, acceptability, and preliminary efficacy, and due to the preliminary nature of most of these studies, when efficacy was evaluated, aspects of methodology such as randomization and blinding were often lacking in rigor. The findings of this review are therefore consistent with others in the literature that frequently report low quality of evidence associated with digital health interventions [
Outside of these methodological concerns, there is also notable progress in terms of expanding the scope of the digital health interventions that exist for this population. Most of the interventions identified in this review were directed toward improving the health of young men who identify as gay, bisexual, and queer and largely within the scope of improving sexual health–related concerns alone. Given the high rates of mental and physical health difficulties in LGBTIQ+ people, resources should be directed toward the development of digital health interventions targeting these issues, commensurate with the attention being given to STI and other sexual health–related concerns. The health concerns faced by LBTIQ+ women, trans and gender-diverse people, and people with intersex variations demand attention as well. Trans and gender-diverse people in particular face increased and wide-ranging health difficulties and barriers to health care access, even when compared with other members of the LGBTIQ+ community [
This review is the first to provide a wide overview of digital health interventions for LGBTIQ+ young people, enabling gaps such as these to be highlighted. However, the review is limited in several ways. Owing to the restrictions placed on the degree of human guidance permissible for inclusion in the review, telehealth interventions are notably absent from those discussed here. The review also did not cover interventions for which their development has been documented but has not yet been evaluated in some respects, and the review also did not include studies documenting the effectiveness of nontargeted interventions for LGBTIQ+ young people. Furthermore, the requirement for included studies to be published in the English language may have resulted in a biased sample, potentially excluding reports on interventions published in other languages. Finally, it is possible that limiting the search to studies published after January 1, 2000, may have excluded relevant studies; however, given that the earliest published study identified in the review was not until 10 years later, this is unlikely to have been the case. The review therefore largely covers the scope of interventions that accumulate an evidence base but should not be taken to cover any and all digital health interventions that may benefit the health of LGBTIQ+ youth.
Although not sought out specifically in the process of conducting this review, many protocols have been identified for continued research into the development of digital health interventions [
Search strategy for PsycINFO (Ovid).
Summary of digital sexually transmitted infection risk reduction and management interventions for LGBTIQ+ young people.
Summary of interventions.
human papillomavirus
lesbian, gay, bisexual, transgender, intersex or queer
mixed methods appraisal tool
men who have sex with men
pre-exposure prophylaxis
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Prospective Register of Systematic Reviews
sexually transmitted infection
This work was funded by the Giorgetta Charity Fund. DG and HM are supported by Research Training Program Stipends funded by the Australian Government. Associate Professor AL is funded by a National Health and Medical Research Council Career Development Fellowship (#1148793). Dr YP is supported by a fellowship from the Giorgetta Charity Fund.
DG developed and executed the search strategy, co-screened the papers, co-assessed their quality, extracted and interpreted the data, and contributed to writing and editing the manuscript. HM co-conducted the screening process, assessed the quality of the papers, and contributed to writing and editing the manuscript. Associate Professor AL contributed to the interpretation of the data and to writing and editing the manuscript; Dr YP conceived and coordinated the study, advised on the development of the search and screening processes, and contributed to writing and editing the manuscript. All authors have read and approved the final manuscript.
None declared.