Accepted for/Published in: Journal of Medical Internet Research
Date Submitted: May 6, 2025
Open Peer Review Period: May 6, 2025 - Jul 1, 2025
Date Accepted: Sep 6, 2025
(closed for review but you can still tweet)
Intersectional disparities in digital health and mental health service use among U.S. youth during COVID-19: Cross-sectional analysis of a national survey
ABSTRACT
Background:
Sexual minority youth (SMY), particularly SMY of color (SMYoC), report elevated mental health challenges and persistent barriers to care. The COVID-19 pandemic exacerbated these disparities and catalyzed a shift to digital health (DH) and digital mental health (DMH) services. This rapid transition has made it challenging to understand digital exclusion and the digital divide.
Objective:
This cross-sectional study identified prevalence of DH and DMH service use among U.S. adolescents during the COVID-19 pandemic and examined heterogeneity by sexual orientation, race/ethnicity, and their intersection.
Methods:
The sample included participants of the 2021 Adolescent Behaviors and Experiences Survey (ABES), a nationally representative survey of U.S. adolescents (N=7,705). Unweighted frequencies and weighted percentages for demographic characteristics were calculated and differences were compared using Chi-square (χ2) tests. Weighted distributions of DH and DMH use were calculated and logistic regression models compared odds of DH and DMH use by sexual orientation, race/ethnicity, and their intersection. All regression models adjusted for age, sex, mental health need, and device/internet access.
Results:
SMY had significantly higher odds of DMH use than heterosexual peers (All SMY: OR=2.90; lesbian, gay, and bisexual (LGB): OR=3.10; sexually diverse: OR=2.75; all p≤0.05). This pattern held among white, Black, and Multiracial SMY relative to heterosexual participants of the same race/ethnicity. However, inequities in DMH use by race/ethnicity were evident: Black, Hispanic/Latino, and Asian participants had lower odds of DMH use than white peers across the full sample (Black: OR=0.67; Hispanic/Latino: OR=0.52; Asian: OR=0.39; all p≤0.05) and among SMY (Black: OR=0.53; Hispanic/Latino: OR=0.29; Asian: OR=0.20; all p≤0.05). Among LGB (Hispanic/Latino: OR=0.46; Other-race: OR=0.09; all p≤0.05) and sexually diverse participants (Black: OR=0.29; Hispanic/Latino: OR=0.13; Asian: OR=0.08; all p≤0.05), racial/ethnic disparities were pronounced compared to white counterparts. Meanwhile no differences in DMH use were observed by race/ethnicity among heterosexual participants. In contrast, DH use did not differ by sexual orientation. However, Black, Hispanic/Latino, and Other-race participants had lower odds of DH use than white peers, in the overall sample (Black: OR=0.70; Hispanic/Latino: OR=0.72; Other-race: OR=0.45; all p≤0.05) and within sexual orientation subgroups, including SMY (Hispanic/Latino: OR=0.66; Other-race: OR=0.16; all p≤0.05) and heterosexual participants (Black: OR=0.64; Hispanic/Latino: OR=0.74; all p≤0.05).
Conclusions:
Digital platforms offer promise for expanding access to mental health care among SMY but persistent inequities, particularly at the intersection of sexual orientation and race/ethnicity, must be addressed. Co-creation with lived-experience experts may be critical to ensure digital services are trusted, inclusive, and accessible for all youth. Clinical Trial: N/A
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