LGBTQ+ Structural Stigma and College Counseling Center Website Friendliness

Prior research indicates that college students with lesbian, gay, bisexual, transgender, and queer, plus other identities (LGBTQ+) are at greater risk of experiencing psychological distress compared with their cisgender and heterosexual counterparts because of minority stress associated with societal marginalization (Effrig et al., 2014; McAleavey et al., 2011; Meyer, 2003; Oswalt & Wyatt, 2011). Specifically, LGBTQ+ minority stress is heightened in hostile and heterosexist campus climates (Hood et al., 2018; Meyer, 1995, 2003; Rankin et al., 2010; Woodford et al., 2014). These conditions, combined with limited social support from peers, and oppressive institutional policies, contribute to anxiety, depression, posttraumatic stress disorder, substance abuse, mental health–related academic impairment, suicide, sexual risk‐taking, and burnout among LGBTQ+ identifying college students (Blosnich & Bossarte, 2012; M. E. Eisenberg & Wechsler, 2003; Hood et al., 2018; Oswalt & Wyatt, 2011; Ridner et al., 2006; Vaccaro & Mena, 2011; Wolff et al., 2016).

College counseling centers are typically the most accessible mental health services to college students, and counseling center websites (CCWs) are likely the first impression students have of the counseling center. CCWs have been explored as a means of marketing affirming services to LGBTQ+ students because they offer convenient and anonymous (McKinley et al., 2014) service. Yet, according to prior research, only 49% of CCWs provided any LGBTQ+ information and fewer than 10% mentioned educational outreach, offered peer support groups, or posted an LGBTQ+ mental health pamphlet (McKinley et al., 2014). Previous research indicates that, in addition to campus climate and LGBTQ+ targeted health information on CCWs, state‐level political friendliness has been associated with well‐being and distress among LGBTQ+ individuals (Hatzenbuehler, 2014). Findings consistently show that lack of visible supports (e.g., LGBTQ+ affirming organizations) and policies that do not provide protections (e.g., sexual orientation nondiscrimination) are associated with detrimental health behaviors and outcomes (Duncan & Hatzenbuehler, 2014; Hatzenbuehler, 2014). In the current study, we examined the relationship between indicators of state‐level structural stigma and CCW content to elucidate a potentially problematic, yet modifiable, contributor to disparities in LGBTQ+ health information.

Campus Climate and Counseling Centers

College campuses are a microcosm of society and have the potential to affect students’ attitudes, behaviors, and mental health. In fact, prior research has documented that a perceived negative LGBTQ+ campus climate has been associated with heterosexist harassment (Szymanski & Bissonette, 2020; Woodford & Kulick, 2015; Yost & Gilmore, 2011). Szymanski and Bissonette (2020) found an association between such a negative campus climate and reports of victimization, poor mental health outcomes, and poor academic outcomes. These findings are consistent with prior research (Hood et al., 2018; Kulick et al., 2017; Rankin et al., 2010; Szymanski & Bissonette, 2020; Woodford et al., 2014). In addition, LGBTQ+ college students report greater unmet needs from existing institutional mental health resources, despite greater utilization of these services, compared with their heterosexual counterparts (Dunbar et al., 2017; D. Eisenberg et al., 2007; Sontag‐Padilla et al., 2016; Williams & Chapman, 2011). The perception of unmet needs may be related to anticipated and/or experienced discrimination, which is damaging to student mental health and academic success in college (Hood et al., 2018; Szymanski & Bissonette, 2020; Vaccaro & Mena, 2011; Wolff et al., 2016). Given that high‐quality communication systems are critical in serving LGBTQ+ students’ needs, CCWs may be an effective and useful tool to communicate to LGBTQ+ students that the college counseling center staff affirm their identities (Marks & McLaughlin, 2005; McKinley et al., 2014; Rankin, 2005).

CCWs and LGBTQ+ Friendliness

University counseling centers play a critical role in maintaining students’ psychological well‐being. Moreover, the use of counseling center services is on the rise: In 2009–2010 and in 2014–2015, counseling centers saw a 30% increase in the number of students seeking services (Winerman, 2017). Also, students have consistently reported that they rely heavily on the resources counseling centers provide for their mental health (Gallagher, 2007; Turner & Quinn, 1999; Wright & McKinley, 2011). Furthermore, using an online mental health service such as a CCW to gather information may be particularly appealing to LGBTQ+ students because it may alleviate concerns related to social stigma, rejection, and harassment compared with in‐person interactions (Kessler et al., 2001; McKinley et al., 2014; Penn et al., 2005).

When students visit CCWs, they encounter content that they may find affirming or rejecting (McKinley et al., 2014). Previous research indicates that the lesbian, gay, bisexual, and transgender (LGBT) information presented on a CCW may be influenced by various characteristics of the school, such as religious affiliation and geographic location (McKinley et al., 2014; Wright & McKinley, 2011). Regarding the significance of these outcomes, researchers suggest that religious institutions provide less support to such students (Love, 1998; Wolff et al., 2016). To our knowledge, only two studies have been conducted that examined CCWs and LGBTQ+ affirming mental health information. Findings indicate that LGBT‐targeted information was limited and inconsistent (Wright & McKinley, 2011). In an important update, McKinley et al. (2014) found that (a) schools did not improve on the frequency of LGBT‐targeted information between 2011 and 2014, (b) religious schools provided significantly less LGBT‐targeted information, and (c) CCWs in the United Kingdom were more likely to have LGBT‐targeted information than those in the United States. However, this update did not consider the link between state‐level structural policies and LGBTQ+ affirming health information on college CCWs. CCWs are an important source of information for students; however, less is known about how factors outside of the university may exert influence on CCW content.

Structural Stigma and LGBTQ+ Health

Structural stigma refers to “societal‐level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized” (Hatzenbuehler & Link, 2014, p. 2). Structural stigma may include social policies, prevalence of neighborhood hate crimes, and community attitudes toward marginalized groups, all of which are associated with health (Hatzenbuehler, 2014). Measures of social attitudes toward marginalized groups have been aggregated to examine how communities differ in their levels of structural stigma serving as reflections of local attitudes and behaviors (Hatzenbuehler, 2016).

Structural stigma, as measured by laws and social policies, has been associated with various health behaviors and health outcomes across cross‐sectional, prospective, quasi/natural experiments, and laboratory designs. For instance, a composite structural stigma measure demonstrated that LGBT youth living in states with high structural stigma were more likely to develop smoking behaviors than LGBT youth in low structural stigma states (Hatzenbuehler et al., 2014). The structural stigma measure used was based on the density of same‐sex couples in the state, the proportion of gay‐straight alliances per public high school, sexual orientation discrimination policies at the state level, and public opinions toward sexual minorities (Hatzenbuehler et al., 2014). Other research has linked structural stigma toward sexual minorities to higher levels of marijuana and other illicit substance use (Duncan et al., 2014; Hatzenbuehler et al., 2015; Heck et al., 2014), tobacco and alcohol use (Hatzenbuehler et al., 2011; Pachankis et al., 2014), alcohol abuse symptoms, and number of sexual partners (Hatzenbuehler et al., 2012). Notably, structural stigma appears to have an effect on health that extends beyond health behaviors. For example, growing up in communities with high levels of structural stigma has been linked to stress response, elevating the risk of future health effects (Hatzenbuehler & McLaughlin, 2014).

Structural stigma has also been positively and consistently associated with deleterious mental health outcomes such as suicide ideations, plans, and attempts (Duncan & Hatzenbuehler, 2014; Goodenow et al., 2006; Hatzenbuehler, 2011; Saewyc et al., 2014). In U.S. counties without inclusive antibullying policies, lesbian and gay youth were 2.25 times more likely to have attempted suicide in the past year compared with their counterparts in counties with such policies (Hatzenbuehler & Keyes, 2013). In states with protective school climates (e.g., safe spaces and gay‐straight alliances), across eight states, the disparities in suicidal thoughts between lesbian, gay, and bisexual (LGB) and heterosexual youth were nearly eliminated even after controlling for known moderators (Hatzenbuehler & Keyes, 2013). A naturalistic study showed that LGB adults in states that passed same‐sex marriage bans saw increases in psychiatric disorders among LGB adults (37% increase in mood disorders, 248% increase in generalized anxiety disorders; Hatzenbuehler et al., 2010).

The goals for our study were informed by the minority stress model (Meyer, 2003). The minority stress model posits that minoritized social status is related to stress processes that in turn are linked to mental health concerns, including depressive symptoms, substance use, and suicide ideation (Cochran & Mays, 1994; D'Augelli & Hershberger, 1993; Diaz et al., 2001; Meyer, 2003; Rosario et al., 1996). Various interrelated factors are proposed as pathways to mental health concerns including distal and proximal processes (Meyer, 2003). The first goal of the present study was to conduct a content analysis of CCWs to determine the frequency of LGBTQ+ affirming information in a nationally representative random sample of colleges and universities in the United States. The second goal was to analyze the association between frequency of affirming information on CCWs and LGBTQ+ state‐level political friendliness. These goals are aligned with the pathways of the minority stress model and represent a departure from local and individual‐level analyses that, although valuable, may obscure the impact of structural stigma. This study closes a gap in the literature by examining structural stigma relative to CCWs, which may influence LGBTQ+ college students’ perceptions of the friendliness of the mental health services available to them.

Method

Sampling

A stratified random sample of U.S. colleges and universities was generated from schools obtained from the National Center for Education Statistics (NCES, n.d.). The inclusion criteria for the search were as follows: public or private, not for profit, 4‐year or above, degree‐granting, institution size of 1,000 or above, and an institutional category of degree‐granting primarily baccalaureate or above. This search generated 1,371 institutions. Nearly 60% of the colleges and universities were public (n = 812) and about 40% were private (n = 559). No private schools were generated for Alaska or Wyoming. The goal was to sample 15% of the schools generated by the NCES search (206 schools) while maintaining the proportion of public and private schools per state. Each school in the population was assigned a unique identification number and selected with a random number generator by state. Nine schools lacked a CCW; thus, the anticipated sample size (N = 221; nPrivate = 134, nPublic = 87) was reduced by nine schools for a final sample of 212 schools (nPrivate = 126, nPublic = 86).

Measures

State‐level structural policies. To assess the political friendliness of each state and the District of Columbia, we assessed the type and extent of structural policy measures that provide legal protections to LGBTQ+ individuals. These measures were well aligned with indicators of distal processes in the minority stress model (Meyer, 2003). The selected structural policy measures included (a) state hate‐crime protection; (b) state employment nondiscrimination, which we chose before U.S. Supreme Court's ruling in Bostock v. Clayton County (2020); and (c) religious exemption, meaning laws that permit certain organizations to seek exemption from providing services that contradict their religious beliefs. Using the Movement Advancement Project's (n.d.) online equality map, we coded each state's political friendliness based on the policy of the state in which the CCW was located. Both state hate‐crime protection and employment nondiscrimination policy were treated as categorical variables with three possible options (states provided the protection for sexual orientation alone, for both sexual orientation and gender identity, or for neither); religious exemption was treated as a dichotomous variable (the state either did [yes] or did not [no] have a form of religious exemption).

CCW friendliness. CCW friendliness items were derived from previous research (McKinley et al., 2014; Wright & McKinley, 2011) and a preliminary scan of websites not included in the sample. CCW friendliness items reflect “circumstances in the environment” that are believed to have a cascading effect on mental health outcomes (Meyer, 2003, p. 679). Each of the 11 CCW friendliness items received a score (0 = website lacked evidence for the variable, 1 = evidence for the variable was observed).

In scoring CCW friendliness, we used the term individual counseling to indicate whether each counseling center had a staff member who listed a specialization in LGBTQ+ issues. Group counseling was used to indicate whether schools offered an LGBTQ+ counseling group facilitated by a counseling center staff member. Couples counseling referred to whether a school stated that it offered couples counseling for LGBTQ+ couples and relationships. Peer group was operationalized as a group of LGBTQ+ students who met on campus to support one another. Educational outreach was used to determine whether a CCW mentioned educational outreach opportunities offered regarding LGBTQ+ issues (e.g., classroom presentation, discussions with student organizations, sensitivity training for faculty). Counselor pronouns noted whether any counseling center staff listed their preferred pronouns (e.g., she/her/hers, they/them/theirs) in their biographies. Support statement indicated that the counseling center would willingly provide services regardless of a student's sexual orientation and/or gender identity (most frequently located in the initial description of services or mission statement). Informational resources was used to gauge whether websites provided a source (e.g., link to LGBTQ+ website, online pamphlet, community referral) for students to gain information, help, or support outside of the university. A counselor training variable was used to gauge how counseling center staff were trained on LGBTQ+ related concerns and sensitivity (e.g., Safezone; see https://thesafezoneproject.com). After hours indicated whether counseling centers stated specifically how LGBTQ+ students could get help outside of normal working hours (e.g., LGBTQ+ counselor on call or 24/7 hotline, such as the Trevor Project [see https://www.thetrevorproject.org]). Last, confidentiality was used to assess whether websites provided any policy information about this subject.

Each school received a sum score (0–11) representing the number of CCW variables for which the school had information on its website.

Results

Frequency of LGBTQ+ Affirming Content on CCWs

We analyzed the data to (a) determine the frequency of LGBTQ+ affirming information on CCWs and (b) create a sum LGBTQ+ friendliness score. With respect to frequency (see Table 1), results showed that information on the confidentiality policy was offered by most websites (89.6%). Other frequently offered affirming information included an LGBTQ+ support statement (37.7% of websites), individual counseling services for LGBTQ+ students (30.7%), a link or referral to LGBTQ+ informational and support resources separate from the institution (29.2%), and information on where LGBTQ+ students could get help outside of regular counseling center hours (22.6%).

Table 1

Counseling Center Website Friendliness Variables

∗p < .05. ∗∗p < .01.

Analyzing the structural policy variables in each school's state (see Table 2), we found that 42.5% of the schools sampled were in states that offered employment nondiscrimination protection on the grounds of sexual orientation and gender identity, 41.5% of schools were in states with hate‐crime protection for both sexual orientation and gender identity, and 53.8% of schools were located in states that did not have any form of a religious exemption law.

Table 2

Frequency of Structural Policy Measures by Level of Protection

Note. N = 212.

Furthermore, when examining differences in CCW friendliness total scores by school type (public vs. private), we found that the mean CCW friendliness total score was significantly higher for public schools (MPublic = 3.5, SD = 2.34) than for private schools (MPrivate = 2.47, SD = 2.18), t(210) = 3.29, p = .001, two‐tailed. Chi‐square tests of each CCW variable indicated that more public than private schools offered information about LGBTQ+ individual counseling, couples counseling, and peer group and had a support statement (see Table 1).

CCW Friendliness and State Policies

We conducted means comparisons (analyses of variance [ANOVAs] and t test) to examine the association between frequency of LGBTQ+ affirming information on CCWs (friendliness), as indicated by the counseling center variables, and state‐level political friendliness, as indicated by the structural policy measures of hate‐crime protection, employment nondiscrimination, and religious exemption.

Results (see Table 3) revealed a statistically significant relation between schools’ CCW sum score and hate‐crime protection levels, F(2, 209) = 9.87, p < .000. Post hoc analyses using Tukey's honestly significant difference test indicated that the mean score for schools in states with full protection (M = 3.66, SD = 2.56) significantly differed from that in states with partial (M = 2.59, SD = 2.25) or no protection (M = 2.14, SD = 1.62).

Table 3

Analysis of Variance Results for Comparison Between CCW Content and State-Level Variables

Note. CCW = counseling center website.

An examination of mean differences between schools’ CCW sum score and employment nondiscrimination indicated that there was a statistically significant difference between the amount of LGBTQ+ affirming information on the CCW and whether that state offered employment nondiscrimination protections (M = 3.69, SD = 2.44) or not (M = 2.29, SD = 1.99), t(168.8) = −4.4, p < .000. The partial employment nondiscrimination group was excluded from these analyses due to the small cell size.

Finally, there was no significant difference in the scores for LGBTQ+ affirming information on CCWs and whether the state had religious exemption laws, F(2, 209) = 2.25, p < .135.

Additional analyses were conducted to examine the relationship between the frequencies of the individual CCW variables relative to the structural policies with significant ANOVA results (hate‐crime laws and employment nondiscrimination). There was a significant association between the presence of hate‐crime laws and the website posting of LGBTQ+ affirming information regarding individual counseling, group counseling, couples counseling, peer group, support statement, informational outreach, and after hours help. Schools located in states that offered LGBTQ+ hate‐crime protections were more likely to have information about those seven CCW variables on their websites. Schools located in states that had employment nondiscrimination policies for LGBTQ+ individuals were more likely to report information regarding individual counseling, group counseling, peer group, counselor pronouns, support statement, informational outreach, and after hours help than schools in states without these protections.

Discussion

The current study addressed two important gaps in the literature: (a) the dearth of information on the frequency of LGBTQ+ friendly content on CCWs and (b) the limited knowledge about LGBTQ+ structural stigma. As suggested by the minority stress model, distal and proximal processes may intersect at multiple levels and exert influence on mental health (Meyer, 2003). In fact, our results showed that structural stigma as measured by hate‐crime and nondiscrimination protections, but not religious exemptions, were associated with LGBTQ+ communication on CCWs. These findings may be used to create inclusive campus climates and provide evidence for the importance of advocating for just state‐level policies.

The findings in the current study illuminate that LGBTQ+ friendliness on CCWs remains low and that little has changed in the frequency of such content in the recent past. In comparison with McKinley et al.'s (2014) investigation, our results showed a slight increase in the frequency of group counseling (21.7% in our study vs. 17.1% in McKinley et al.'s) and educational outreach information (9.4% vs. 7.9%; see Table 1). A larger increase was found in the current study regarding the frequency of campus peer group information (19.8% compared with 2%). Notably, public schools had significantly more LGBTQ+ friendly content compared with private schools in this sample, which may be a function of state mandates and financial incentives.

The results also yielded a significant difference between the amount of LGBTQ+ affirming information on CCWs in states that offered hate‐crime and employment nondiscrimination protections compared with states without these policies. As expected, CCWs in states with hate‐crime protections had significantly more LGBTQ+ communication on their websites commensurate with the level of protection. That is, the LGBTQ+ friendliness mean in states with full protections was significantly higher than the mean for partial protections, which in turn was higher than states with no protections. A similar pattern was observed for employment nondiscrimination between schools with and without protections. Given these findings, it appears that structural stigma and the way that college counseling centers present themselves online are linked. An alternative explanation is that the donor base or local cultural norms may be responsible for the difference in LGBTQ+ CCW communication. No relationship was observed between religious exemption and CCWs, which countered our expectation.

Limitations and Directions for Future Research

The study findings should be considered in light of various limitations. This study did not assess individual LGBTQ+ student perceptions, which limits our ability to assess the combined influence of structural stigma and CCWs. Additionally, it is possible that unmeasured factors may be related to decisions about website content. Communication standards and website design priorities vary across institutions of higher education, which may influence the posting of LGBTQ+ friendly information on websites. The study design limits our ability to make causal inferences regarding the influence of structural stigma on the frequency of LGBTQ+ affirming information on CCWs. Furthermore, state and institutional policies are always undergoing revision.

Future research that collects information on LGBTQ+ student experiences within counseling can paint a better picture as to whether advertised services are truly affirming to their identities. Future research should also consider the audience of a school's CCW and whether its focus is directed toward prospective or current students. In other words, it is unknown whether more affirming services that are not advertised on the website are presented to LGBTQ+ students upon enrolling in an institution. It is possible that some services are not disclosed on websites to avoid accidentally “outing” students; thus, it is worth considering how schools make decisions about what information is included on their websites. Importantly, indicators of structural stigma are constantly changing.

As previously noted, the structural policy variables used in our study were selected prior to Bostock v. Clayton County (2020), which granted employees protection from discrimination on the basis of sexual orientation and gender identity. Future research should assess whether this landmark civil rights case has influenced how CCWs present LGBTQ+ affirming information. Thus, longitudinal study designs that track policy changes are recommended for future research.

Recommendations and Implications

College students rely heavily on college counseling centers for mental health services. Therefore, counseling centers need to provide affirming treatment and implement communications systems that address the unique needs of LGBTQ+ students (Rankin, 2005; Wright & McKinley, 2011). Perhaps the first step institutions of higher education can take is to improve how they advertise the availability of LGBTQ+ affirming mental health resources. Accessible information about counseling services is key because it is unlikely that sexual and gender minority students will assume LGBTQ+ support options are available. In addition to training staff to deliver affirming treatment, counseling center staff should be aware of the impact that structural stigma and campus climate have on LGBTQ+ college students’ mental health. For example, therapists working in university counseling centers can increase their awareness of the LGBTQ+ campus climate at their school and understand how it may contribute to students’ mental health symptoms (Szymanski & Bissonette, 2020).

Institutions of higher education can make a concerted effort to support LGBTQ+ students by understanding the influence of structural stigma; mitigating its effects; advocating for socially just policies and laws; incorporating LGBTQ+ material into curricula; examining retention rates of LGBTQ+ students; and responding appropriately to student, staff, and faculty experiences of discrimination. LGBTQ+ affirmative policies and programs can produce psychosocial benefits such as a sense of community and belonging for sexual minority students on college campuses; hence, it is vital that institutions offer these services and properly advertise them to students (Pitcher et al., 2016; Woodford et al., 2018).

Attending to the influence of structural stigma on CCWs and institutions of higher education is essential to creating inclusive and accessible campus climates. Counseling centers can use these findings to guide improvements to their CCWs and to advocate for inclusive institutional and/or state‐level policies. These findings further elucidate that it is imperative that changes meant to alleviate the mental health burdens LGBTQ+ college students face occur at multiple ecological levels. Counseling center staff treating individual LGBTQ+ students is one level of change, but institutional and social policies must be addressed as well because individual treatment experiences and structural‐level policies exert interlocking powerful influences.

Conclusion

This study updates and extends prior research by examining previously unexplored CCW characteristics and exploring links to state‐level policies (McKinley et al., 2014; Wright & McKinley, 2011). Our analyses indicate that structural stigma may influence how college counseling centers present themselves online. There is still a great need for progress at individual and structural levels to ensure that LGBTQ+ college students are obtaining the support they need from their institutional resources. CCWs can be used to disseminate information in a way that is anonymous and convenient; therefore, they should continue to be examined as a means of marketing information to LGBTQ+ students. However, future research should prioritize examining the relationships among various levels, including individual student experiences within counseling centers and structural stigma, because each of these two areas is influential yet relatively unexplored.