Service provider views on issues and needs for lesbian, gay, bisexual, and transgender youth.
Article Type: Report
Subject: Gay teenagers (Sexual behavior)
Gay teenagers (Health aspects)
Gay youth (Sexual behavior)
Gay youth (Health aspects)
Community health services (Evaluation)
Social workers (Beliefs, opinions and attitudes)
Teenagers (Sexual behavior)
Teenagers (Surveys)
Authors: Travers, Robb
Guta, Adrian
Flicker, Sarah
Larkin, June
Lo, Chase
McCardell, Sarah
van der Meulen, Emily
Pub Date: 12/22/2010
Publication: Name: The Canadian Journal of Human Sexuality Publisher: SIECCAN, The Sex Information and Education Council of Canada Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2010 SIECCAN, The Sex Information and Education Council of Canada ISSN: 1188-4517
Issue: Date: Winter, 2010 Source Volume: 19 Source Issue: 4
Topic: Canadian Subject Form: Teenage sexual behaviour
Product: SIC Code: 8399 Social services, not elsewhere classified
Geographic: Geographic Scope: Ontario Geographic Code: 1CONT Ontario
Accession Number: 253926193
Full Text: Abstract: Lesbian, gay, bisexual, and transgender (LGBT) youth require appropriate, effective, and accessible sexual health services. Sexual minority youth living in large urban, multicultural cities have a complex range of service needs. As part of the Toronto Teen Survey, focus groups were conducted with 80 service providers from 55 agencies in the Greater Toronto Area to elicit their input concerning the changing service needs of LGBT youth, their increasing complexity as a client group, and obstacles to working effectively with them. Issues that arose in the focus groups included addressing the needs of LGBT youth across a large city that includes suburban areas, the need to address the specific service needs of transgender youth, and the intersection of racial and ethno-cultural diversity with sexual orientation. Service provider recommendations focused on the need for improved education and training and policy change at the agency level.

Introduction

The present study used data from the Toronto Teen Survey's (TTS) service provider focus groups to investigate current issues, needs, and challenges facing lesbian, gay, bisexual, and transgender (LGBT) youth in Toronto. We did so with a focus on the social and demographic changes that have taken place since the first author left the sector in 1998 (Travers & Paoletti, 1999). The greater acceptance of LGBT people in Canadian society is in part evident by the increasing visibility of LGBT characters and actors in mainstream media, and popular television shows (Gross, 2001). During this same period, the Canadian government enacted the Civil Marriage Act on July 20, 2005 making Canada the fourth country in the world (at that time) to legalize same-sex marriage. Canada is widely known as a leader in LGBT rights; Toronto was a site of early feminist and gay liberation movements and consequently continues to possess a highly visible and increasingly diverse LGBT community and social infrastructure (Smith, 2005). As such, the city is a principal centre for LGBT migration from both within and outside of Canada, and is a common destination for youth seeking to escape homophobia from families, communities, or

religious institutions (Travers, Scanlon, Carolo, & O'Brien, 2004). Consequently, youth bring a greater complexity of service needs that reflect changing demographics and greater visibility. In this study, we ask whether, in the the last decade, these increasing needs have evinced a corresponding increase in appropriate services and support for LGTB youth. What becomes apparent is that while much has changed, more has stayed the same. Despite the increasing acceptance of LGBT people in society, and the growing visibility of LGBT youth, such gains have not necessarily translated into appropriate, effective, and accessible services to meet their needs.

Background

Lesbian, gay, bisexual and transgender youth (LGBT) are characterized as engaging in higher-risk taking behaviours, and having complex health and psychosocial needs. Specifically, they are said to initiate sexual relationships at an earlier age (Saewyc et al., 2006), have more sexual experiences (Goodenow, Netherland, & Szalacha, 2002; Rosario, Meyer-Bahlburg, Hunter, & Gwadz, 1999; Saewyc et al., 2006), and are more likely to use drugs and alcohol which may interfere with safer sex practices (Newcomb, Clerkin, & Mustanski, 2010). LGBT youth are disproportionately burdened by familial and peer rejection, academic underachievement, violence, substance use, depression, emotional distress, and suicidal ideation (Almeida, Johnson, Corliss, Molnar, & Azrael, 2009; Gilliam, 2002; Scott, Pringle, & Lumsdaine, 2004). Compounded by a dearth of social supports and resources, these youth constitute a disproportionate number of all runaway, homeless, and street-involved young people (Smith et al., 2007). Unfortunately, the focus on specific negative health outcomes for LGBT youth may be detracting from research on service needs in the LGBT community (Addis, Davies, Greene, MacBride-Stewart, & Shepherd, 2009). The need is evident when drawing on the broader LGBT health literature, where findings suggest a range of health and service providers are not effectively trained or competent to work with sexual minorities (Eliason, 2000; Logie, Bridge, & Bridge, 2007; Rondahl, 2009; Sanchez, Rabatin, Sanchez, Hubbard, & Kalet, 2006).

Few research studies have explored the health service needs of LGBT youth. In a recent study on healthcare preferences of LGBT youth, respondents wanted providers to address health risk, but also wellness and health promotion, and to be considerate of home and family and aware of cultural and developmental differences (Neal, Katherine, & Stephanie, 2009). While supportive therapeutic and clinical models of care have been proposed (Gilliam, 2002; Langdridge, 2007; Mayer et al., 2008), they may not be relevant to, or address intersections between, addictions, housing, immigration, child protection, etc. Moreover, it is unclear whether or to what extent youth are actually receiving services, or whether they experience barriers even earlier in the service seeking process. In other words, do they make it past the front door? Previous studies on LGBT youth identified the prevalence of homophobia and heterosexism as pervasive in social service agencies (Travers & Paoletti, 1999; Travers & Schneider, 1996, 1997). Overall, we know little about the barriers experienced by LGBT youth in accessing and negotiating care settings and about the care they receive.

Service providers (SPs) have insights and experience that can inform policy and practice in the provision of sexual health-related services for youth. This qualitative study used selected findings from the Toronto Teen Survey as a stimulus for SPs to reflect on the changing needs of LGBT youth, their increasing complexity as a client group, obstacles to working effectively with these youth, and to suggest possible changes for service improvements. Recommendations for system-level change are also offered.

Methods

The methods described here are as in another TTS article on service providers (van der Meulen, Oliver, Flicker, & Travers, 2010) with some adaptations consistent with the different focus of the current study.

Participants

In 2008, the TTS team coordinated 13 focus groups with 80 service providers (Table 1) representing 55 agencies in the Greater Toronto Area. Service providers who hosted TTS survey sessions were contacted and invited to participate. Additionally, information about the study and the focus group sessions was posted on a variety of listservs; interested SPs were instructed to contact the TTS Research Coordinator. SPs who participated were primarily front line workers who assisted individual youth and youth in groups (generally aged 13 to 18 years). Service providers had diverse experiences both working within a range of services (for example, health clinics, workshops, and drop-ins) and working with diverse populations (for example, immigrant youth, sexually diverse youth, and youth with various disabilities). We held one over-subscribed focus group for service providers who worked specifically with LGBT youth, although issues of sexual orientation and diversity came up in all focus groups.

Focus groups

The primary objective of the SP focus groups was to identify the needs and concerns of workers who work with youth in a variety of capacities. In these focus group sessions, selected survey findings (Flicker et al., 2009) were presented to participating SPs who were then asked for their comments and insights. Each focus group lasted approximately two hours and provided an opportunity for SPs to respond to key survey findings and to provide input into the development of recommendations for change. Each participant provided information on the type of work they did, the specific youth populations worked with, and the services offered. Many respondents checked more than one item in each of these categories (Table I) reflecting the scope of their work experience.

Data Analysis

All focus groups were audio-recorded and transcribed. Prominent themes were garnered from the literature to develop a preliminary initial coding framework. Once the focus groups were completed, the verbatim transcripts were uploaded into NVivo, a data management software package for qualitative data. Coding and analysis of data commenced using the constant comparative method outlined by Strauss and Corbin (1990). The coding framework was revised to incorporate themes generated through an adaptation of the constant comparison method used in grounded theory (Strauss & Corbin, 1990: Taylor & Bogden, 1998). The Investigators Team collaboratively designed the coding scheme and Youth Advisory Committee members contributed to the analysis.

Results

Service providers identified a range of barriers to providing adequate support for the complex needs of diverse LGBT youth, including: addressing the needs of youth across a big city; the needs of transgender youth; intersecting identities; and homophobia within service agencies (Table 2). They spoke of the clustering of sexual health services in downtown Toronto and the relative lack of available resources in the city's large and expansive suburbs. Connecting youth to services in the city centre can be challenging due to distance and time in a city as big as Toronto. They also said that services targeted to LGBT youth may be avoided by youth. The heavy service focus on sexual health and HIV prevention may preclude discussion and support on the other complex social issues facing this population, e.g., isolation, homophobia. Service providers raised concerns about the ways that supposedly inclusive programs are funded and organized and that new programs were being developed outside of the downtown core in agencies that didn't necessarily have the capacity to deliver them.

In addition to geographic complications, SPs identified a lack of evidence-based information about how best to meet the needs of transgender youth. Indeed, the experience of accessing services can also raise unique concerns for transgender youth. For those "living stealth" (hidden) and for those who have not physically transitioned, or don't intend to, service encounters may invoke considerable emotional vulnerability. Two key challenges were raised related to the appropriateness and relevance of services for trans youth. First, including trans youth under the auspices of LGB services was considered problematic by some SPs, while others felt that the provision of services to trans youth in LGB organizations might actually serve as a barrier to their receiving services.

Diverse cultural backgrounds and differing religious beliefs also present as barriers to sexual health service provision and community outreach. SPs serving newcomer youth explained how issues of sexuality are deemed taboo and inappropriate for discussion. Similarly, for Black LGBT youth, there are also unique issues related to intersecting identities. Service providers who work with Black youth identified the conundrum facing Black LGBT youth, who experience racism in the mainstream gay community and homophobia in their own communities. Another significant challenge that SPs raised was the pervasive denial among many settlement organizations that LGBT youth exist in their communities. This denial makes it very difficult to even begin the process of opening up space for dialogue and ensuring that there are appropriate referrals being made.

In addition to barriers related to intersecting identities, SPs discussed a number of ways that homophobia impacts their ability to provide appropriate and quality services to LGBT youth. First, they described reluctance on the part of their LGBT colleagues to be "out" in their own agencies, and the pressures faced by allies. A different situation was experienced by LGBT service providers who were "out" at work. They faced the expectation of being an "expert" on LGBT issues and the resulting responsibility of having to manage all of the complex needs of vulnerable LGBT youth clients. Service providers situated these significant and ongoing challenges within concerns over institutional homophobia. For example, many SPs were concerned about the quality of care being offered in their agencies and described the ongoing reliance on hidden referral networks of trusted LGBT staff and allies in other agencies. A consequence of this invisibility or falling "below the radar," is that systems-level changes become more difficult to implement when youth are being ushered through informal channels.

Recommendations

Service provider recommendations for improved service delivery and programming for LGBT youth generally conformed to one of two broad areas: The need for training; and the need for agency policy change (Table 3). Training staff about sexual orientation issues was regarded as one important means of enhancing service access for LGBT youth. While SPs saw the value in targeted services for LGBT youth, they also believed it imperative that all youth-relevant agencies strive to make their services accessible to these youth. Service providers also identified additional and on-going training as an important issue, however, they were cognizant of its limitations, regarding it as but one piece of a more complex and holistic approach to institutional change. Moreover, SPs recommended system-level change so that all youth-serving agencies see it as their ethical responsibility to serve all youth who present with needs. The "specialized agency" approach was regarded as out-dated and ineffective for meeting the needs of an increasingly large number of very vulnerable youth with broad needs.

Discussion

Simultaneous to the growing visibility of LGBT people in the media, Toronto's LGBT youth communities are becoming more diverse and reflective of the city's changing composition. In the last two decades, Toronto has witnessed striking demographic changes due to a relatively large number of newcomers (as well as migrants from other parts of Canada) choosing the city as their home. Toronto is home to more than 200 distinct ethno-racial groups speaking over 140 different languages (City of Toronto). New immigrants, the majority of whom belong to a visible minority group (Hou & Picot, 2004), account for 45.7% of the city's entire population (Statistics Canada, 2007). These changes have been accompanied by a greater acceptance and visibility of LGBT people in Canadian society, prompting many youth to come out at younger ages. Consequently, LGBT youth presenting for services bring considerably greater diversity in age, race/ ethnicity, and newcomer status, than they did 10 years ago.

Another significant change is the increased visibility of transgender people in society; trans youth are transitioning at younger ages, also presenting for services. Service providers struggle to meet the needs of these clients facing both a sea of misinformation in addition to a lack of evidence-based information to guide them. Services established primarily to deal with "coming out" and self-acceptance issues, are now finding themselves dealing with a broader array of complicated determinants of health and well-being. For example, LGBT youth newcomers will have needs related to "settlement" including housing, employment and income, and social support. These are further complicated by the intersections of new and old culture, and homophobic attitudes in ethnic enclaves and situated agencies. Changing the landscape of services will require a concerted effort and patience. Given the number of newcomers to Toronto, it may be especially important to reach out into settlement programming, ESL classes, and other services targeting immigrants and other newcomers.

The findings presented here are surprising, as the original intent of the SP focus groups was to have participants speak back to the TTS survey data. That is, we were looking for context in which to frame the qualitative phase of the TTS. Although SPs provided confirmation that the TTS findings reflected the realities seen in their practice, the discussion quickly took a different direction as SPs used the focus group sessions as an opportunity to express their frustration and anger. These providers are embedded in a service climate where agency attitudes and resources have not kept pace with advancements in social attitudes, and legal rights for LGBT individuals. The focus groups provided an opportunity to speak out about these issues in a way they had not been able to at their agencies. Finally, these focus groups illustrate the disjuncture between public health's focus on mitigating individual risk behaviours and the much more challenging context of providing appropriate services in the face of larger and inequitable systemic and structural forces.

Acknowledgements: This study was supported by grants from the Ontario HIV Treatment Network, the Canadian Institutes of Health Research, the Centre for Urban Health Initiatives, and the Wellesley Institute. It was hosted by Planned Parenthood Toronto. We want to thank the entire Toronto Teen Survey Research Team for all their help in gathering, managing and analyzing the data: Susan Flynn, Crystal Layne, Dr. June Larkin, Dr. Jason Pole, Hazelle Palmer, Adinne Schwartz, Kristin McIlroy, Roxana Salehi, our exceptional students, research assistants and our youth advisory committee. Finally, we want to express gratitude to the community partner agencies that hosted workshops, and the youth and service providers who participated in our research.

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van der Meulen, E., Oliver, V., Flicker, S., Travers, R., and the Toronto Teen Survey Team. (2010). Obstacles to sexual health services for youth: Service providers' perspectives. The Canadian Journal of Human Sexuality, 19, 185-190.

Robb Travers (1,2,3), Adrian Guta (3), Sarah Flicker (4), June Larkin (5), Chase Lo (4), Sarah McCardell (4), Emily van der Meulen (2), and the Toronto Teen Survey Team (6)

(1) Department of Psychology, Wilfrid Laurier University, Waterloo, ON

(2) Centre for Research on Inner City Health, St. Michael's Hospital, Toronto, ON

(3) Dalla Lana School of Public Health, University of Toronto, Toronto, ON

(4) Faculty of Environmental Studies, York University, Toronto, ON

(5) Women and Gender Studies/Equity Studies, University of Toronto, Toronto, ON

(6) Planned Parenthood Toronto, Toronto, ON

Correspondence concerning this article should be addressed to Dr. Robb Travers, Department of Psychology, Wilfrid Laurier University, Waterloo, ON N2L 3C5. E-mail: rtravers@wlu.ca
Table 1 TTS Service provider demographics

                                                Total     %

Type of worker
  Front line                                      43     54
  Youth outreach                                  16     20
  Health care provider                            17     21
  Manager or provider                             13     16
  Government employee                              6      8
  Other                                           23     29

Work with youth
  Individually                                    17     21
  In groups                                       22     28
  Both                                            40     50
  No response                                      1      1

Specific populations of youth worked with
  Refugee & newcomer youth                        33     41
  Immigrant youth                                 49     61
  First generation Canadian youth                 33     41
  Youth living with physical disabilities         15     19
  Youth living with cognitive disabilities        20     25
  Youth with addictions                           33     41
  Youth with mental health disabilities           31     39
  Lesbian, gay, bisexual and/or transgender
    (Sexually diverse youth)                      51     64
  Youth in the foster care system                 26     32
  Street-involved or homeless youth               32     40
  13-to 14-year-olds                              43     54
  15- to 16-year-olds                             54     68
  17- to 18-year-olds                             54     68
  Other                                           33     41

Services offered
  Health clinics                                  43     54
  Youth drop-ins                                  33     41
  Regular youth group                             36     45
  Sexual health workshops                         47     59
  Peer-led programming                            38     48
  School-based programming                        38     48
  Summer Camps                                    15     19
  Other                                           16     20

Table 2 Service provider perspectives

Addressing the    "My agency is pretty progressive, especially with
needs of youth    our LGBT programs. They're sort of letting us do
across a big      whatever is new. Like we're giving them proper
city              information. The only, thing that I would find is
                  because we're [suburban] and a lot of the sexual
                  health centres are downtown, I'll take a lot of
                  individual youth downtown. But it's hard to connect
                  them with a service."

The needs of      "...we don't have a good plain answer for a lot of
transgender       things around any sort of physical sexual health, in
youth             particular with trans youth rights. Like, how do we
                  know for sure about HIV and STI transmission? That I
                  find a real struggle when anybody asks you a
                  question. It's just like this is the best answer I
                  can give you but I can't really give you a good
                  answer because it doesn't exist in terms of a
                  knowledge base and that's a struggle."

                  "... I've gone to hospital with trans youth who are
                  terrified ... they don't care what else the doctor
                  wants to do, just 'don't let them take my pants off
                  because there's humiliation, there's being exposed."

                  "Really this lack of a distinction drawn between
                  issues of sexuality and issues of gender identity.
                  For the most part, trans issues have been taken up
                  as sort of an addendum or an appendix to queer
                  organizations in service delivery so that they've
                  been assumed within this larger LGB, hence LGBT,
                  group of service delivery."

                  "... [LGB services] aren't necessarily meaningful or
                  reflective of the majority of trails-identified
                  people who are straight identified ... But some
                  trans people may be reticent to access queer spaces
                  ... and if someone is not queer identified, what is
                  the relevance or what are the tensions that sort of
                  happen when you're doing that kind of work?"

Intersecting      "The South Asian group I did, it was all youth and
identities        things that come up are domestic violence, gender,
                  sexuality. These things are not talked about, and
                  when an outside professionals come into that culture
                  and speaks about these things, it is seen as a very
                  violent sort of interjection because they say, 'the
                  Canadian state is trying to come in and interfere
                  with our lives, our culture here, and we don't speak
                  about this in our culture."'

                  "The question is, do you get ostracized in the black
                  community or the queer community? So it's not to say
                  that you abandon your home ties for a community that
                  does not respect you. For all of those reasons, a
                  lot of young black queer youth will not seek
                  information because they are not out."

                  "With queer black youth who come to the group, they
                  may say that they're not "out" but they're coming to
                  this group. There is this fear amongst the group.
                  The majority of the youth say that the reason
                  they're not coming out is because of family. They
                  don't want to be disowned by their family, whether
                  the family is here or somewhere else."

                  "I've had one settlement worker tell me that 'oh, we
                  don't have any issues ... we don't need the
                  workshops ... and we don't have any gay immigrants.'
                  Like you'll hear that too ..."

Table 3 Service provider recommendations

The need for      "I think a lot of the wants really speak to the need
training          to educate service providers about working with LGBT
                  youth. Some of us do that specifically but also the
                  agencies that don't specifically or even primarily
                  serve LGBT youth, how many of the wants and how many
                  of the needs are being met and how could that be
                  increased through training?"

The need for      "People will call me and say, 'Can you do an LGB
agency policy     training for 45 minutes' and I'm like, 'No, I can't,
change            sorry.' I think people don't have a clue, and they
                  kind of think it means that we have a 2 hour
                  training and that we're good."

                  "I think organizations need to do their work to be
                  LGBTQ positive and it's not just training. It's
                  looking at policy. It's looking at every sort of
                  aspect of the service."

                  "Also taking this work beyond the responsibility of
                  the LGBT agencies and making it really clear that
                  it's the responsibility of all agencies and that all
                  its staff within those agencies. So instead of being
                  the one person who's supposed to take care of all of
                  these issues, or the one agency that's supposed to
                  take care of all of these issues, how do we make
                  that more widespread and how do we work to make
                  public health safe for LGBT youth?"
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