How Intersectional Are Mental Health Interventions for Sexual Minority People? A Systematic Review

Introduction

Worldwide, sexual minority people (i.e., people who identify as lesbian, gay, bisexual [LGB], asexual, pansexual, queer, or engage in sexual activities with same-sex others) report disproportionately higher rates of mental health risks compared to their heterosexual counterparts, due to pervasive and multilevel stigma directed at them because of their sexuality.^1,2 Other than identifying factors responsible for the mental health disparities, a growing body of research, as well as theoretical frameworks, have contributed to the development of clinical therapies and social services to effectively address sexual minority people's exposure to psychological risks. In a systematic review that aimed to scope distinct approaches of mental health interventions for sexual minority people, Chaudoir et al.³ identified an array of programs, which differed in their goals, structures, and contexts, yet, proved to be efficacious in either reducing stress or enhancing coping resources among sexual minority individuals.

Despite the emerging and promising evidence for the efficacy of existing interventions, these reviewers called for a departure from the current focus on sexuality-based stigma alone as a root cause of psychological distress endured by sexual minority groups, to develop interventions that consider the “intersecting effects” (p. 609) of multiple and systematic disadvantages.³ The American Psychological Association's guidelines for working with sexual minority people urge mental health professionals to “understand the different ways in which multiple minority statuses may complicate and exacerbate the difficulties their clients experience.”⁴ (p. 20) In view of the complex consequences of intersecting discrimination and the ascending quest for intersectionality-informed practices, exploring whether existing mental health interventions for sexual minority people respond to their multifaceted needs and experience of intersecting disadvantages is therefore critical. This systematic review addresses this question by examining current interventions through an intersectional lens and seeks to identify the intervention components that have the potential to take account of intersectionality.

Intersectionality

Intersectionality theory is primarily concerned with “the interaction between gender, race, and other categories of difference in individual lives, social practices, institutional arrangements, and cultural ideologies and the outcomes of these interactions in terms of power.”⁵ (p. 68) At the center of intersectionality theory lies a critique of the long-held focus on a single social position⁶ and responses to intersectional inequalities. On an epistemological level, intersectionality theory aligns with critical realism⁷ in rejecting the quest for a universal pattern of inequalities; rather, intersectionality researchers seek to unpack the social processes of perpetuating inequalities, in particular sites, and to uncover the subjective meaning of living in an intersectional position.^8–10 Notably, although intersectionality theory was advanced by Black feminist scholars and activists to simultaneously account for the multiple forms of subordination in legal and political domains, intersectionality has gained increasing prominence in mental health care for various groups who are impacted by structural oppression or marginalization, directing our attention to within-group variations, complex structural inequalities, and between-group commonalities.^11,12

In keeping with intersectionality theory, mental health practitioners should remain open to understand the experience of target populations and examine power relationships operating at individual, interpersonal, and structural levels.^13,14 Instead of treating social identities as fixed properties, intersectionality theory reminds practitioners to understand social identities as social processes that generate inequalities and calls for actions to challenge oppressive institutions.¹⁰ Some scholars have recognized the value of the intersectional perspective in creating uniquely tailored, culturally appropriate services to meet clients' specific, yet complex, needs.^11,15,16 Taken together, intersectionality theory can guide professional practice to address the simultaneous social forces, decenter the exclusive primacy of a single dimension of disadvantage, and avoid simplifying people's experiences of being marginalized.^13,17

In practice, intersectionality theory questions the “one-size-fits-all” approach¹⁸ and encourages the development or modification of intervention programs to address clients' needs embedded in interlocking social locations.^19,20 Intersectionality research also sheds light on intersectional stigma and resilience. Recent studies with sexual minority people living with HIV have documented the operation and consequence of intersectional stigma constituted by HIV-related stigma, gender, race, sexual orientation, involvement in sex work, and socioeconomic status.^21–23 Their findings hence highlight a need for researchers and service providers to adopt an intersectional and multileveled approach to mitigate the effect of intersectional stigma. Notably, researchers who study stigma also draw a conceptual distinction between perceived and enacted forms of social stigma²⁴ and note that there may be occasions when an individual internalizes multiple forms of stigma (i.e., intersectional internalized stigma).^25,26 Although intersectionality theory has enriched knowledge about stigma, the responses of available interventions seem limited.³

Although intersectionality theory emphasizes the voice of people experiencing interlocking disadvantages, its critical feminist underpinnings also foreground the subjectivity and resilience among the oppressed.^8,9 With regard to Black women's experiences, Wing thus wrote “our essence is also characterized by a multiplicity of strength, love, joy, … and transcendence that flourishes despite adversity.”²⁷ (p. 196) From an intersectional perspective, Rice et al.²² offered strength-based accounts of how women living with HIV were afflicted with intersectional stigma while maintaining an optimistic outlook for the future and actively seeking resources and support such as self-affirmation, mental health services, and solidarity with peers having similar lived experiences. Likewise, in a study guided by intersectionality theory to explore the experiences of Chinese immigrant gay men living in Canada, a participant remarked on his unique intersectional position: “If you think you are a minority … then you will really stand in a lower position…we all have some strengths.”²⁸ (p. 34) In this view, intersectionality theory does not confine research and practice focus to the experiences of suffering and oppression, but rather leads to the identification of resilience and resources existing in an intersectional social location.²³

Intersectionality-informed practice

Several scholars^29,30 have recommended that an intersectional consideration can render interventions more culturally appropriate and responsive to clients' unique needs. Although the application of intersectionality in research across disciplines and statistical modeling is growing,^31–33 the integration of intersectionality into clinical interventions remains in its infancy.¹⁷ Hankivsky³⁴ contends that a major challenge for those who aspire to utilize the intersectionality framework in health and mental health contexts lies in translating this theory into directives for clinical practice or interventions.^32,35

To this end, several researchers have offered advice on moving toward intersectionality-informed practice. Focusing on children exposed to intimate partner violence, Etherington and Baker¹⁷ suggested integrating the intersectional perspective into the process of practice, including agenda setting, evaluation, accessibility and inclusion, reflexivity, and education. Some researchers^17,36 consider an explicit use of intersectionality terms and framework to be a hallmark of intersectionality-informed practice. Weber suggests that an intervention to address health disparities is intersectional in nature when it seeks to (1) eliminate societal inequities; (2) uncover multiple forms of dominance; (3) attend to fluidity and contextual specificities of power hierarchies; and (4) address power and oppression at both micro and macro levels.⁸ Meanwhile, according to Weber, “intersectional and other critical power-based research approaches seek a collaboration that privileges and supports the voices, insights, and actions of multiply subordinated groups.”⁸ (p. 44) These works provide useful directions for intersectionality-informed practice.

The current study

Little research has investigated the extent to which mental health interventions for sexual minority people are informed by intersectionality. To the best of our knowledge, only two review studies^17,36 have examined whether an intervention was guided by intersectionality, both of which only considered an intervention to be guided by intersectionality if it explicitly used the intersectionality framework or terminology. In contrast, this review views the incorporation of intersectionality as a gradient (i.e., low, medium, and high) and develops intersectionality criteria to rate the degree to which a clinical intervention responds to participants' intersectional needs. This review aims to (1) assess how interventions for sexual minority people are informed by the intersectionality framework, and (2) identify the intervention characteristics that are instrumental in incorporating intersectionality theory.

Methods

Eligibility criteria

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance, which requires a systematic review to demonstrate transparency and rigor by reporting a set of checklist items and a flow diagram to illustrate the rationale and process of the literature search.³⁷ To locate eligible academic journal articles, three inclusion criteria regarding types of reports, participants, intervention, and outcome measures were applied to screen the title and abstract of publications that (1) reported on a mental health intervention program for sexual minority people; (2) were published in a peer-reviewed journal; and (3) were published in English. Meanwhile, studies were excluded from the analysis if they (1) were review articles; (2) did not involve an intervention; (3) did not report empirical data on the outcomes; (4) only reported the process of intervention development; (5) did not assess psychological well-being as intervention outcomes; or (6) were conducted as case studies with small sample sizes. Given that the primary objective of this review was to investigate the degree to which intersectionality was integrated into an intervention, we included articles of diverse study designs, analytic techniques, and evidence quality.

Information source

The procedure of literature retrieval and selection is illustrated in a PRISMA diagram (Fig. 1).³⁷ We conducted a literature search using PsycINFO and PubMed. Previous analyses have identified PsycINFO as one of the principal databases through which to retrieve reports on high-quality psychological treatments^38,39 while PubMed is considered a useful database to identify literature concerning health interventions.⁴⁰ The combination of two reputable databases meets the guidelines of Assessing the Methodological Quality of Systematic Reviews critical appraisal tool⁴¹ and yielded a significant volume of eligible literature.

Study selection and search strategy

According to a recent systematic review on interventions for sexual minority people,³ the first intervention study was published in 2001. Thus, 2001 was designated as the start year for the literature search. Three sets of keywords were used in the literature search to specify (1) our population of interest (i.e., LGB, GLB, gay, lesbian, bisexual, homosexual, sexual minority, men who have sex with men [MSM], pansexual, asexual, queer, and questioning); (2) interventions (i.e., treatment, practice, intervention, counselling, psychotherapy, and therapy); and (3) mental health outcomes (i.e., mental health, mental disorder, depression, anxiety, psychological well-being, subjective well-being, self-esteem, and quality of life). In addition, the reference lists of reviewed publications were inspected manually to locate pertinent primary research which had not already been identified in our search; this procedure identified three additional publications.

A total of 2640 articles were found and screened by 2 independent reviewers to determine the relevance of the title and abstract. Seven hundred and sixty-three duplicate articles were found during the screening process and 1825 were excluded due to their study or intervention characteristics. Fifty-two articles were initially judged as eligible, although nine of these were subsequently excluded after discussion between the two reviewers for one of the following reasons: (1) they described intervention protocol; (2) they illustrated the process of developing an intervention without reporting empirical data; (3) they were case studies; (4) their sample was not exclusively sexual minority people; or (5) the primary objectives were irrelevant to mental health. Forty-three articles were therefore included for analysis.

Data collection process and data items

As a review of preexisting study reports, this review was deemed by the Ethics Review Board of the University of Hong Kong to be exempt from ethical approval. Data collection took place in July 2019. The following information from the included articles was collected and tabulated: authors, a brief description of the intervention, study site, study design, inclusion criteria, sample size, and intervention outcomes. Data extraction was carried out by one of the reviewers under the supervision of the team's principal investigator.

Analytic strategy

The included studies were analyzed by two independent coders to assess the incorporation of intersectionality. A coding framework (Table 1) was developed to evaluate each study. The operational logic of this coding framework regarded the recruitment of participants with diverse social identities as a potential for an intervention to be intersectional; however, an intervention could be regarded as truly intersectional only if the concept of intersectionality was integrated throughout the intervention process.^17,42 Specifically, in addition to the recruitment of participants with intersecting positions, the criteria for high intersectionality covered the following: (1) addressing the effects of intersecting positions in the intervention; (2) discussing the effects of intersecting positions in the study report; and (3) explicitly using “intersectionality” and some derivative of it as a theoretical framework.

Applying these criteria, the two coders labeled each article as low (i.e., only including a homogenous group of participants), medium (i.e., reporting on participants' intersecting identities, yet without addressing the intersecting inequalities), or high (i.e., recruiting participants who occupied intersecting social positions and giving adequate attention to the social process of intersectional marginalization) in terms of adoption of the intersectional principle. In the initial coding process, the discrepancy rate between the two coders was 26.6%. All disagreements were resolved by the coreviewers through discussion and reexamination. The agreed coding results and summary of each article are presented in Table 2.^43–85 Each high intersectionality study is illustrated in detail in the Results section.

Results

Study characteristics

A majority (n = 36) of the 43 reported interventions designed to address sexual minority people's mental health were conducted in North America,^{43–46,48–63,66,67,69–73,75–82,85} 3 in Europe,^47,65,84 and 1 each in Australia,⁷⁴ China,⁸³ New Zealand,⁶⁸ and South Africa.⁶⁴ The study designs ranged from 21 (48.84%) studies^{45,53,54,56,57,59,61,62,64–68,70,72,73,75,77,78,80,84} reporting on within-group changes without a control group, 19 (44.19%) randomized controlled trials,^{43,44,46–52,55,58,63,69,74,76,81–83,85} 2 (4.65%) quasi-experimental studies,^60,71 and 1⁷⁹ (2.33%) examining the correlation between the number of sessions attended and changes in the outcome variables (i.e., posttest only, no control group). The sexual minority sample sizes were between 7 and 762. In addition to LGB participants, some studies included participants who self-identified as asexual,⁸⁰ queer^{53,59,60,66,67,70,73,75,79} pansexual,^59,66,70,80 or questioning.^{60,70,73,79,81}

Result of intersectionality coding

Thirteen (30.2%) studies^{53,55,57,59–61,64–67,69,72,75} were coded as low intersectionality because participants in these interventions were presented as homogenous sexual minority groups. Twenty-three (53.4%) studies were classified as medium because they added a recruitment criterion other than sexual orientation (HIV positive = 16^{43,44,46–49,51,52,54,58,63,74,76,77,83,85}; age = 5^{70,78–80,84}; substance use = 2^50,54; and cancer diagnosis = 1⁴⁵), but the interventions were designed as only focusing on stressors commonly endured by sexual minority clients, whereas the intersecting positions were relegated to descriptive demographics. Seven (16.3%) studies showed a high level of intersectionality to account for the intersection between membership as a sexual minority and HIV-positive status (n = 3)^56,62,82; age (n = 3)^56,68,73; disability (n = 1)⁷¹; homelessness (n = 1)⁷³; or rurality (n = 1).⁸¹

Description of intersectionality-informed interventions

In this section, we described in greater detail the interventions that were rated as high intersectionality. Addressing the mental health outcomes and HIV sexual risk behavior among gay and bisexual men ages 40 and older, the intervention, 40 & Forward,⁵⁶ was designed to address their unique need for social support and to compensate for their experiences of social isolation, depression, and anxiety caused by the intersection of internalized ageism and sexual minority stress. In addition to the intervention's promising efficacy, participants also expressed their appreciation that the service catered to their unique social support needs as “single guys in our forties.”⁵⁶ (p. 538).

In the Helping to Overcome Problems Effectively (HOPE) intervention,⁶² although the initial objective was to mitigate unemployment among African American gay men living with HIV/AIDS, the research team also identified an array of challenges confronting this community, including low levels of job-seeking skills, lack of on-site support, inadequate treatment compliance, stigma and workplace discrimination, mental and physical health concerns, and lack of social support and public assistance. By addressing the intersection of these needs and marginalization, the HOPE intervention went beyond the employment issue to respond extensively to participants' diverse concerns arising from their intersecting positions.

Rainbow SPARX (smart, positive, active, realistic, x-factor thoughts) is a computerized cognitive behavioral therapy intervention that took account of “the unique sociopolitical and interpersonal challenges” (p. 203) faced by sexual minority youth.⁶⁸ Specifically, the program developers argued that young people were more likely to encounter anti-LGB attitudes and may feel that disclosure to their family renders them particularly vulnerable. They highlighted the advantages of this intervention specifically for sexual minority youth, including protection of privacy and overcoming geographical and social isolation.

In a study of a mindfulness program designed to improve mental health among lesbian and bisexual women, Ingraham et al.⁷¹ explicitly recognized the “particular intersectional oppression of race/ethnicity and sexual orientation, [so the program] added a group specifically for women of color. … Women who experience multiple forms of oppression may be particularly suited to a nonjudgmental, body acceptance approach to health.”(p. S59) The researchers suggested that future interventions should pay attention to the intersectional needs of lesbian and bisexual women of color and with disabilities.

The iTEAM program⁷³ was developed for homeless LGB, transgender, and queer/questioning or straight-allied youth who were at greater risk for drug abuse, victimization, truancy, and housing problems. The service developers recognized the necessity of “a sensitive, coordinated, and effective system of care to address the constellation of issues they face.”⁷³ (p. 182) Researchers attributed the success of the iTEAM with regard to acceptability, retention, and efficacy to the effective responses to participants' complex needs.

Targeting rural sexual and gender minority people, a peer advocate intervention was implemented to address the social isolation stemming from the intersection of geographic distance, conservative gender norms, limited socialization opportunities, and identity concealment.⁸¹ Viewing societal institutions as a source of minority stress, especially for rural sexual and gender minority people, a distinctive characteristic of this intervention was its advocacy orientation and training of peer advocates to effect changes for this community. This intervention addressed issues other than HIV and responded to different needs within rural sexual and gender minority communities.

Bogart et al.⁸² reported on an intervention, Still Climbin’, aimed at enhancing the coping abilities of Black sexual minority men living with HIV. The intersectional orientation of this intervention is evident from addressing multifaceted discrimination due to the “intersectionality of multiple stigmatized identities.”⁸² (p. 542) Notably, the intervention emphasized the development of flexible and contextual coping strategies to respond to distinct forms of discrimination across diverse situations. Moreover, the authors highlighted that “structural-level interventions are needed in tandem that address social determinants of health disparities.”⁸² (p. 549).

Community-based participatory research

All high intersectionality interventions involved close collaboration with diverse community partners. The development of the 40 & Forward program benefited from “obtaining community advisory board and consumer input.”⁵⁶ (p. 527) In the HOPE program, “CBPR partnership members, including African American gay men living with HIV/AIDS, were directly involved with development of the intervention and the section of the study design” (p. 410)⁶² The development of Rainbow SPARX also featured collaboration between researchers, clinicians, and sexual minority youth.⁶⁸ The mindfulness intervention program, Doing It for Ourselves, was “developed using principles of community-based participatory research.”⁷¹ (p. S55) Partnership between agencies and the research team enabled the iTEAM project to address “the unique, varied, and complex needs” of homeless LGB, transgender, queer/questioning, or straight-allied youth (p. 186).⁷³ In the peer advocate intervention for rural sexual and gender minority people, community-based participatory research (CBPR) proved instrumental in maintaining the intersectionality approach by involving community members “who have close knowledge of local social realities, and can improve access to quality of care for underserved populations.”⁸¹ (p. 396) Finally, the program Still Climbin’ was a cognitive-behavioral therapy adapted through “an iterative community-engagement process” with input from community stakeholders⁸² (p. 543).

Discussion

This review provides an overview of clinical interventions for sexual minority groups and suggests directions for future service development and research to move toward intersectionality. The review suggests a need to develop evidence-supported programs to assist sexual minority individuals in mitigating intersectional risks for mental health. The appraisal of intersectionality identified noticeable variability among the reviewed studies. Nearly one third of the reviewed studies were deemed to lack intersectionality because they neither addressed nor reported intersecting identities of the participants, thereby treating them as a homogenous group. Although 53.4% of the studies paid attention to the role of intersectional social positions in shaping participants' mental health, the presence and impact of intersectional disadvantages was not well considered. Moreover, a closer examination suggests that the majority of these medium-intersectionality interventions focused mainly on the interplay between sexual minority identity and HIV-positive status. Since disproportionate attention to HIV/AIDS has been criticized for reifying the stigmatization of sexual minority people,⁸⁶ future research and interventions should consider other social factors.¹²

Seven (16.3%) interventions that were examined demonstrated a thorough incorporation of intersectionality throughout their planning, implementation, and evaluation stages. Although their primary goal was to reduce sexual orientation-related disparities in mental health, the adoption of intersectionality theory along with CBPR afforded a critical space for their participants to highlight other types of disadvantage in their lives, thereby allowing the intervention to respond to their intersectional positions and unique needs. It is also important to note that the community engagement process of seeking participants' voices and concerns resonates with the empowering and strength-based principles inherent in intersectionality theory by privileging the perspectives of subordinate groups.⁸

Implications

Although emerging work has suggested useful strategies to collect and analyze empirical data using an intersectional approach,^17,32,87 there has been relatively little discussion on incorporating intersectionality into actual services.⁸⁸ Arguably, this stagnation of translating intersectional theory into clinical interventions may originate in the salience of establishing internal validity especially when mental health promotion for specific communities remains at a nascent stage.⁸⁹ Specifically, to determine whether an intervention yields intended effects on a prescribed set of needs for a target group, an intervention should be built upon a specific theoretical framework to pinpoint the causes of and possible solutions to a certain problem so as to be precise and parsimonious in its treatment component and participation criteria.^12,90 This quest for accurate identification of intervention effects in turn guides a researcher to recruit a homogenous sample to “reduce confounding factors that might affect the dependent measures.”⁴⁴ (p. 377) Given that “in its very definition intersectionality demands complexity,”³³ (p. 455) to fully consider the multiple forms of marginalization could inadvertently become counterproductive to the quest for internal validity by rendering an intervention and subsequent evaluation complex and unpredictable.

Intersectionality theory helps research, policy, and clinical interventions tackle the complexity of health inequalities.^7,91 As Dhamoon⁹² suggests, intersectionality brings to the fore inherent instability and irreducibility in human behavior and experiences. Garran and Werkmeister Rozas¹³ likewise mark intersectionality's dynamic, ambiguous, and open-ended properties as its core theoretical insights. In evaluation science, most researchers are invested in testing intervention efficacy (i.e., internal validity) through randomized controlled trials and usually call for further endeavor to establish generalizability (i.e., external validity) by recruiting a heterogeneous sample. However, these dominant implementation and evaluation strategies could counteract the development of intersectional, power-oriented, and community-based research. Weber also contends that from an intersectional perspective, the social processes of engendering health disparities are simultaneously dynamic and context-specific and can be best captured through the engagement of participants.⁸ In this light, incorporating an intersectional approach entails a methodological shift and CBPR proves instrumental in ensuring intersectionality.

In practice, an intersectionality-informed intervention acknowledges multiple social determinants of health and avoids reducing a target population to unidimensional categorization. To this end, McCall delineates three complementary intersectional approaches that can be adopted in an intervention: (1) an intercategorical approach focuses on the combined influences and interactions of multiple identities; (2) an anticategorical approach follows a deconstructive method by questioning the universal representation of any identity categories and relies more on personal narratives and interpretations of a mental health problem to inform the design of clinical interventions; and (3) an intracategorical approach operates through cross-classification to identify subgroup differences.⁹³ These distinct orientations enable researchers and clinicians to challenge the single-identity model and respond to the intersectional processes of marginalization. Importantly as well, the utilization of intersectionality should also guide us to unravel the coexistence of advantages and disadvantages, and challenges and resources that an individual possesses through intersecting social positions. However, this strength-based perspective has not been widely incorporated in the current body of literature on people facing intersectional marginalization.⁹⁴

As elucidated by this review, several scholars have reiterated how community members' active engagement throughout the phases of intervention and evaluation can better ensure that clients' complex lived experiences and mental health needs are addressed holistically.^8,12,89 Despite substantial investment and prolonged commitment, CBPR allows us to strike a balance between delivering effective interventions and fully appreciating participants' concerns. Such insight can also contribute to the development of guidelines for intersectionality-informed practice and research.

Limitations

Some study limitations should be noted. The first limitation pertains to reliance on two databases only as the literature sources. Although these two databases provided a significant number of eligible articles, this study cannot be used as a scoping review because a minimal risk of omitting relevant studies still exists. Future reviews of mental health interventions for sexual minority people could extend to other databases to locate additional interventions⁹⁵ and to cover books, clinical guidelines, and training materials. Second, the coding framework used by this review was designed specifically to capture clients' characteristics and program components presented in the reports to determine their intersectionality. The noticeable intercoder discrepancies might be symptomatic of ambiguity inherent in this coding guideline; this, therefore, should be clarified and revised. Future studies can also consider establishing a broader set of criteria to increase correspondence with intersectionality theory. Finally, although this review focused on interventions for sexual minority individuals, participants in these interventions were diverse in their sexual and gender identities. This within-group diversity necessitates caution in interpreting the results of this review and warrants attention to the intersection of sexual and gender minority status in future research.

Conclusion

In this review, a promising progression toward intersectionality-informed intervention emerged as researchers and practitioners have become increasingly aware of the irreducibility of the experiences and complex needs of sexual minority individuals. Admittedly, the logic of well-defined grouping is important for intervention design, delivery, and evaluation. However, viewed through an intersectionality lens, a deliberate response to the nuances and the complex social forces in an individual's experience best enables an intervention to address entrenched health disparities and larger structural inequalities. Ongoing engagement in intersectionality, promotion of a community-based participatory approach, and concrete guidelines for intersectional intervention and evaluation represent vital steps forward.

Disclaimer

The content is solely the responsibility of the authors.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Y.T.M. and this study are supported by Research Grant Council Early Career Scheme number 27616418.