Protective Factors for LGBTI+ Youth Wellbeing: A Scoping Review Underpinned by Recognition Theory

Considerable research has been undertaken regarding the mental health inequalities experienced by lesbian, gay, bisexual, transgender and intersex (LGBTI+) youth as a consequence of societal and individual prejudice, stigma and discrimination. Far less research has focussed on protective factors that promote wellbeing for this population. A scoping review was conducted using a six-stage methodological framework, and is reported in accordance with the PRISMA-ScR statement. This explored the extent, range and nature of the peer-reviewed, published, academic literature on what is known about the protective factors that promote LGBTI+ youth wellbeing. Six databases were systematically searched applying Population–Concept–Context key inclusion criteria, complemented by contact with authors to identify additional sources, reference checks and hand searches. Ninety-six individual research records were identified and analysed, drawing from Honneth’s Recognition Theory. Interpersonal relations with parents (n = 40), peers (n = 32) and providers (n = 22) were associated with indicators of enhanced wellbeing, as were LGBTI+ community relations (n = 32). Importantly, online (n = 10), faith (n = 10) and cultural (n = 5) communities were potentially protective. Content and thematic analysis highlighted the importance of Gay–Straight Alliances (GSAs) (n = 23) offering powerful protective opportunities through intersecting interpersonal, community and legal forms of recognition. GSAs enhance allyship by peers and providers (n = 21), facilitate access to LGBTI+ community networks (n = 11) and co-exist alongside inclusive policies (n = 12), curricular (n = 5) and extracurricular activities (n = 1). This scoping review underscores the need to move beyond the predominant focus on risk factors for LGBTI+ youth, which subsequently inform protectionist approaches. It concludes with an appeal to develop mechanisms to apply recognitive justice to policy, practice and, importantly, future research directions. This emphasises the salience of enhanced understandings of inclusion, which is rights-based, universally available and of potential benefit to all.


Orientations and Identities
The World Health Organization (WHO) describes mental health holistically as "a state of wellbeing" [1]. While the concept of wellbeing is contested, it is used extensively throughout the literature, with less clarity about how this is defined [2,3]. In relation to lesbian, gay, bisexual, transgender and intersex (LGBTI+) populations, the concept of wellbeing has generated considerable research interest over many decades [4]. Defining sexual minority, gender minority youth and those with diverse sex development using the LGBTI+ acronym appears straightforward: "L" equates to lesbian; "G" to gay; "B" to bisexual; "T" to transgender and "I" to intersex. The LGBTI+ acronym comprises three dimensions, sexual orientation, gender identity and sex development, with wide variations and diversity of expression, particularly for youth [5]. Sexual orientation encompasses identification, behaviour and attraction, with suggestions of a greater lifetime prevalence of same-gender behaviour and attraction than identification [6], and higher prevalence of an LGBTI+ identification for youth, with young people more likely to identify as bisexual [7]. Gender identity refers to someone's internal sense of their gender as male, female or non-binary, and may not accord with the sex assigned at birth [4]. Sex development is a spectrum of variations that occur within humanity, including intersex youth [8]. The inclusion of populations with diverse sex development accords with the recent work of the National Academies of Sciences, Engineering and Medicine [9]. Notwithstanding the complexity of youth orientations and identities, "researchers tend to use self-identification as the defining criterion" [4] (p. 13).

Wellbeing and Stigmatisation
There has been much concern regarding youth mental health disparities and vulnerability to psychological distress and suicidality [4,[10][11][12]. This is typically contextualised within a Minority Stress Model, which describes the consequences of discrimination against, and victimisation of, marginalised groups [13]. This is consistent with WHO identification of the negative impact of social exclusion and stigmatisation [14]. Further, structural stigma within systems and enactment of personal stigma at the intersubjective level are acknowledged [15]. Stigmatisation regarding LGBTI+ identities is recognised as impacting negatively on wellbeing, reinscribing normative, binary frames of reference [16]. Such stigmatisation may equally apply to "mental health", regarded as synonymous with ill health, as distinct from positive mental health or social wellbeing [2]. The resultant tendency for young LGBTI+ lives to be represented as universally vulnerable and "at risk", on the basis of their orientations and identities, may lead to protectionist approaches, inadvertently reinforcing underlying inequalities [16][17][18][19][20][21][22][23]. As a consequence, LGBTI+ youth may have increased reluctance to disclose mental health difficulties due to concerns that providers may misunderstand their LGBTI+ identity as the source of mental ill health, or lack understanding and awareness of appropriate language and terminology [24].

Social Justice as a Pre-Requisite for Wellbeing
The WHO makes a further contribution to understandings of wellbeing through the Ottawa Charter for Health Promotion, which emphasises that social justice is a necessary pre-requisite for health, including mental health [25]. While there are multiple definitions of justice, distinctions have been drawn between redistributive and recognitive forms of justice [26]. Honneth concurs, highlighting the importance of recognition and revaluing disrespected identities through promoting cultural diversity and group differentiation [27][28][29]. In particular, Honneth underscores the importance of recognitive justice for emancipation struggles, using this as an example of social justice for LGBTI+ communities, described as: "culturally integrated communities with a common history, language and sensibility" [29] (p. 162). His tripartite framework emphasises three interconnected forms of recognition: interpersonal, community and legal relations [27][28][29]. This extends recognition beyond intersubjective relationships to the structural context through the recognition of universal human rights [27][28][29].

Rationale and Objectives
From our initial analysis and literature research, there is no existing review (narrative, systematic or scoping) on protective factors for LGBTI+ youth wellbeing. The limited research focus on protective factors is noteworthy given that almost two decades have passed since Meyer drew attention to the potential of "stress-ameliorating factors" for mental health [13] (p. 678). Further, a decade ago, Haas et al. specifically recommended that studies should be conducted on potentially protective factors for LGBTI+ populations [4]. The methodological framework for scoping reviews was followed as outlined by Arksey and O'Malley and Levac, Colquhoun and O'Brien [30,31]. The review aimed to: map the concepts, themes and types of available evidence within the existing literature; describe the characteristics of those studies undertaken to date, the various domains assessed and the specific outcome measures used; and to identify research deficits and knowledge gaps [30][31][32][33]. In accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR) reporting statement [34], outlined in Appendix A, a protocol was published a priori (https://hrbopenresearch.org/articles/3-11, accessed on 28 October 2021) [35]. Supplementary Data (see Supplementary Materials) provided with this review, were submitted to the Open Science Framework repository [36]. The overarching objective was to collect and synthesise evidence on the protective factors for LGBTI+ youth wellbeing.
This scoping review has potential to inform policy, practice and research, particularly through mapping a course forward to guide the planning and the commissioning of future studies [30][31][32][33].

Search Strategy
The search strategy was developed by the lead author (N.C.) in consultation with a subject liaison librarian (M.B.), with detailed search terms subsequently generated (N.C. and L.T.). No restrictions on time were placed on the search. With the limited research attention given to the topic, the review focused on published academic, peer-reviewed research articles and review articles in English. The Population-Concept-Context (PCC) approach informed inclusion screening criteria [34]. This was conceptualised as: P-Population: sexual minority, gender minority, intersex and non-binary youth; C-Concept: protective factors that promote wellbeing; and C-Context: any country, with broadly comparable supportive environments, as outlined in the Global Acceptance Index (GAI) [37]. Study selection was based on a priori eligibility criteria as outlined in Table 1.

Search and Study Selection
Studies were identified through electronic academic database searches using a combination of title and keyword terms alongside MeSH headings across six databases: PubMed; CINAHL; PsycINFO; ASSIA, Eric ProQuest; and Academic Search Complete. Prior to searching, the full electronic search strategy for PubMed was deposited in the Open Science Framework repository [36]. Comprehensive searches were conducted across all databases on 21 June 2020 and citations were managed using the bibliographic software manager, EndNote, with duplicates removed and imported into Covidence (N.C.).
All titles and abstracts were screened by two reviewers independently, in two teams (N.C. and O.J.; N.C. and L.T.), using screening tools tested by the team before their use (N.C., O.J., L.T., M.B. and D.C.) [38][39][40]. Disagreements were resolved via discussion, with reference to the a priori eligibility criteria until consensus was achieved (N.C., O.J., L.T. and D.C.). The PCC criteria were applied to the full text by two reviewers, independently (N.C. and O.J.) [34]. Another reviewer was recruited to assist in resolving disagreements (A.K.). CART criteria (Completeness, Accuracy, Relevance, Timeliness) were applied to intervention studies in relation to the research question (N.C. and A.K.) [41]. Following further discussion (N.C., A.K., O.J. and D.C.), records with medical, pharmacological and therapeutic interventions were excluded. While the authors acknowledge that treatment can promote wellbeing, the focus of this review is on protective factors that are health promoting [1][2][3]25]. This process sought to ensure robust, transparent decision-making informed by a clear rationale for selecting sources of evidence [38][39][40]. Follow-up search strategies included contact with 29 content experts, requesting information on relevant published studies, with a reminder sent one week later (N.C.). Over a third of authors responded (34.5%). This was complemented by reference checks for relevant publications and a final hand search of peer-reviewed journals by dissertation author name (N.C.). All identified records were cross-checked against Covidence and independently double-screened (N.C. and A.K.).

Data Charting and Summarising Results
Two study team members designed a template, to confirm relevance and extract characteristics from each full-text record (N.C. and D.C.). A pilot exercise was undertaken to guide the process, as recommended by Levac et al. (N.C., O.J., L.T., M.B. and D.C.) [31]. Based on this preliminary exercise, half of the records identified through database searching were extracted by a single reviewer (N.C.), with the study team completing checks against the original articles (A.K., O.J., L.T., M.B. and D.C.). The data items were compiled by the lead author (N.C.) in Microsoft Excel of the main details and relevant data collection variables (lead author, year of publication, study location, title, methodology and analysis, recruitment, demographic details, protective factors, wellbeing indicators).

Content and Thematic Analysis
Content and thematic analysis was undertaken, as per scoping review guidelines [30][31][32][33]. An inductive approach initially extracted protective factors, with a deductive approach subsequently applied across all records to assess the relevance of Honneth's Recognition Theory [27][28][29]. The first author (N.C.) collated and categorised the records iteratively to summarise the results, with another member recruited to the study team to cross-reference charted data against the original articles (C.B.) [41]. Study team members regularly assessed

Overview of Documented Records
The review identified 96 records spanning just over three decades, from 1989 until 2020. All 96 records are presented in Tables 2-7. While the first identified records date from 1989, it is notable that it was a further ten years before there was an exponential increase in research attention on, or including, factors that protect or promote LGBTI+ youth wellbeing. As such, the first 20 years of this review account for just 10.3% of records, with 89.7% of records published since 2010. An overview of these findings is illustrated in Figure 2.
While 25 countries met context inclusion criteria [37], only the United States (n = 79), Canada (n = 11), Australia (n = 4), Britain (n = 3) and New Zealand (n = 2) were represented. This is consistent with a recent landscape review and research gap analysis identifying the paucity of research, across Europe, of any persuasion, focused on LGBTI+ youth [50]. From the searches, we reviewed quantitative (n = 45), qualitative (n = 34) and mixedmethods research (n = 8) studies, with sample sizes ranging from n = 5 through to n = 4314. Systematic (n = 5) and narrative (n = 4) reviews were also included ( Figure 3). Four of these provide a global perspective. Quantitative research accounts for almost half of the records (46.9%). It is notable that it was not until 2014 that these records included research using large, population-based datasets, with variables on sexual orientation, measuring identification, rather than attraction or behaviour. The emergence of population-based analyses in relation to gender identity is more recent, dating from 2018. Prior to this, studies recruited participants mainly through LGBTI+ organisations, community venues and events.

Orientations and Identities
A fundamental issue across all included sources related to definitions, terminology and self-descriptors used by research participants. Research was predominantly conducted with sexual minority youth populations (72.9%), with studies including transgender and gender minority youth being more sparse (25.9%) (Figure 4). There is a paucity of research with intersex youth and those with variations in sex development (1.2%). One study focused on those who identify with a medical term: congenital adrenal hyperplasia (CAH).
(46.9%). It is notable that it was not until 2014 that these records included research using large, population-based datasets, with variables on sexual orientation, measuring identification, rather than attraction or behaviour. The emergence of population-based analyses in relation to gender identity is more recent, dating from 2018. Prior to this, studies recruited participants mainly through LGBTI+ organisations, community venues and events.  A fundamental issue across all included sources related to definitions, terminology and self-descriptors used by research participants. Research was predominantly conducted with sexual minority youth populations (72.9%), with studies including transgender and gender minority youth being more sparse (25.9%) (Figure 4). There is a paucity of research with intersex youth and those with variations in sex development (1.2%). One study focused on those who identify with a medical term: congenital adrenal hyperplasia (CAH).

Self-Descriptors
There is broad variation in the range of identities and orientations included. Alongside lesbian, gay, bisexual, transgender and intersex from the LGBTI+ acronym, as Figure  3 highlights, the "+" symbol encompasses 57 forms of self-identification: 23 self-descriptors used by sexual minority youth; 17 self-descriptors for those who are transgender; with 16 terms encompassing gender minority identities; and one using medical terminology for variations of sex development.

Self-Descriptors
There is broad variation in the range of identities and orientations included. Alongside lesbian, gay, bisexual, transgender and intersex from the LGBTI+ acronym, as Figure 3 highlights, the "+" symbol encompasses 57 forms of self-identification: 23 self-descriptors used by sexual minority youth; 17 self-descriptors for those who are transgender; with 16 terms encompassing gender minority identities; and one using medical terminology for variations of sex development.

Being "Out"
In relation to identity and orientation, some records highlight that openness regarding sexual orientation and/or gender diversity is critical for positive wellbeing [51][52][53] and is associated with reduced stigma and discrimination [51,52] and increased pride [54]. Sexual minority youth "out" to a larger peer network reported higher levels of support, particularly with longer lapses of time since disclosure [55]. However, both concealment and its opposite, open disclosure of sexual orientation and gender identity, may be equally protective [52,56]. These nuanced findings emphasise that it may depend on who young people disclose to, with both youth who were fully "out" and those not "out" at all having to manage these dynamics least [52,57]. Further, the motivation to conceal may not negatively impact on connectedness, including within LGBTI+ networks [58].

Age
The records included LGBTI+ populations aged between 10 and 24 years, in accordance with the definition of youth [59,60]. Where reported, the mean age, across primary studies, ranged from 14.3 years to 23.4 years. As illustrated in Figure 5, most of the research focus has been with emerging adults, aged over 18, with some focus on adolescents aged 14-17 years. One study that included teenagers noted that there were far fewer younger participants [61]. There was limited research attention on children aged 10-13 years.

Age
The records included LGBTI+ populations aged between 10 and 24 years, in accordance with the definition of youth [59,60]. Where reported, the mean age, across primary studies, ranged from 14.3 years to 23.4 years. As illustrated in Figure 5, most of the research focus has been with emerging adults, aged over 18, with some focus on adolescents aged 14-17 years. One study that included teenagers noted that there were far fewer younger participants [61]. There was limited research attention on children aged 10-13 years. The combined inductive content analysis and deductive thematic analysis found several areas of interest, highlighting the interpersonal, community and legal factors associated with LGBTI+ youth wellbeing ( Figure 6). Key themes included: intersubjective recognition; community connectedness; inclusion through universal rights; and intersecting forms of recognition. These protective factors will now be discussed, before outlining the impact on outcomes and associations with broad indicators of wellbeing. The combined inductive content analysis and deductive thematic analysis found several areas of interest, highlighting the interpersonal, community and legal factors associated with LGBTI+ youth wellbeing ( Figure 6). Key themes included: intersubjective recognition; community connectedness; inclusion through universal rights; and intersecting forms of recognition. These protective factors will now be discussed, before outlining the impact on outcomes and associations with broad indicators of wellbeing.

Intersubjective Recognition
Honneth highlights that recognition through interpersonal relationships with an other whom one mutually recognises supports the development of security and resilience, with an impact on self-confidence [28] (pp. [26][27][28][29]. Intersubjective relations included relationships with parents (n = 40), peers (n = 32) and providers (n = 22), with the proportion of records illustrated in Figure 6. Interpersonal protective factors and the impact on wellbeing are tabulated, in chronological order from the most recent, in Table 2 of the quantitative records (n = 16), Table 3 of the qualitative and other records (n = 9), alongside those captured in Table 7 of the intersecting records (n = 15).

Intersubjective Recognition
Honneth highlights that recognition through interpersonal relationships with an other whom one mutually recognises supports the development of security and resilience, with an impact on self-confidence [28] (pp. [26][27][28][29]. Intersubjective relations included relationships with parents (n = 40), peers (n = 32) and providers (n = 22), with the proportion of records illustrated in Figure 6. Interpersonal protective factors and the impact on wellbeing are tabulated, in chronological order from the most recent, in Table 2 of the quantitative records (n = 16), Table 3 of the qualitative and other records (n = 9), alongside those captured in Table 7 of the intersecting records (n = 15).

Peers
Social support from peers was identified as a protective factor in the lives of LGBTI+ youth (n = 32). A range of peer relationships were identified: close friendships with gender and sexual minority peers [52,53,55,61,62,68,69,[88][89][90][91][92][93][94][95] [52,53,57,61,65,69,72,75,88,90,[93][94][95]102]. Such relationships with peers were regarded as mutually beneficial and reciprocal and of increasing importance as young people became older [72,77,88,92]. Differences were noted, with sexual minority friends described as providing support for coping with both sexuality stress and other problems, while heterosexual friendships provided more non-sexuality support than sexuality-related support [55,89,94]. While being "out" was associated with larger networks and a greater proportion of extremely close friends, it was also associated with a greater loss of heterosexual friendships after coming out, with fears regarding romantic relationships as a consequence [53]. As such, there may be limitations to the emotional support provided by heterosexual peers [102]. However, the promotive benefits of cross-sexual orientation friendships offer the potential for the appreciation of commonalities, breaking down negative stereotypes and increasing the sensitivity of the heterosexual friend to sexual minority perspectives [52,55,95,100,102].

Community Connectedness
Honneth equally emphasises the unique contribution of community members, with the acknowledgment of individual contributions to the collective, enhancing self-worth (p. 30) [28]. Such protective community relations extended to LGBTI+ networks (n = 32), online connectedness (n = 10), faith communities (n = 10) and cultural communities (n = 5). Community protective factors and the impact on wellbeing are tabulated, in chronological order, in Table 4 of the quantitative and mixed-methods research, alongside the systematic review records (n = 12), Table 5 of the qualitative records (n = 17) and the records of intersecting forms of recognition in Table 7 (n = 19).

Online Communities
Online communities may provide important platforms for LGBTI+ youth, particularly those outside urban centres [65,73,103,124,[126][127][128][129][130][131][132]. They appear to facilitate access to LGBTI+-specific social support [103,128,130,132], emotional support [132] and increased connectedness [73,124,126,129,131], as a consequence. This was enhanced when there were no in-person LGBTI+ supports available locally [131]. Access to online LGBTI+ communities provided a source of friendship and support, and offered the potential to find romance and to meet people in person [131,132]. Some online friendships may replace in person friendships [132]. Sexual minority youth were noted to be more adventurous in their online use, meeting people online, including for friendships and relationships, in contrast to their heterosexual peers [132].

Faith Communities
This review identified potential for the presence of accepting faith communities to be a source of support for LGBTI+ youth [68,73,90,114,127,[133][134][135][136][137]. While faith and LGBTI+ identities have often been assumed to be incompatible and mutually exclusive, those religions and communities with supportive attitudes, such as endorsing marriage equality, may enhance the interaction of diverse identities [127,135,137]. Positive acceptance may be promotive of identity development, which, in turn, mediates the relationship between identity integration and wellbeing [114,[134][135][136].

Cultural Communities
An emergent topic area identified as part of this review is the protective potential of cultural communities. Five records identify the potential for LGBTI+ identification and cultural identification to be mutually enhancing [70,73,103,106,125]. The interaction of these diverse identities provided support from peers and the inspiration of role models [70,106,125], resistance to cultural stigma and prejudice related to intersecting identities [103] and affirmation through the value of such unique and multifaceted identities [70,106]. Further, strong cultural and familial ties enhanced personalised coping strategies [125] and challenged the "at risk framing" of cultural messages [103].

Inclusion through Universal Rights
Honneth underscores that recognitive justice necessarily requires legal relations, i.e., recognition of universal rights and inclusion, which promotes empowerment and selfrespect [28] (pp. [26][27][28][29]. The scoping review highlights the importance of the structural context, beyond the broader social acceptance through legislative measures, captured by the GAI [37]. Documenting protective legal relations highlighted educational settings, in particular, with Gay-Straight Alliances (GSAs), also known as Gender-Sexuality Alliances, offering inclusive spaces. GSAs (n = 23), alongside inclusive policies (n = 23), curricular (n = 11) and extracurricular activities (n = 4) were all promotive of wellbeing. Such protective climates highlight the powerful protective potential of GSAs. These protective factors, and the impact on wellbeing, are tabulated in chronological order, from the most recent, in Table 6 of the legal relations and Table 7 of the intersecting protective factors.

Gay-Straight Alliances/Gender-Sexuality Alliances (GSAs)
GSAs are student-run organisations that unite LGBTI+ young people and allies by providing support, opportunities to socialise, information and access to resources. This review found that the presence, alone, of GSAs in schools was protective [87,91,101,105,108,111,122,[138][139][140][141][142][143]. This promotive benefit was enhanced through involvement and participation [64,87,105,111,139,140,142]. Further, greater levels of engagement were associated with greater benefits [64]. Even moderate levels of peer and significant other support appear to play a protective role [91]. GSAs may also facilitate access to LGBTI+ community networks [64,68,75,83,90,101,104,120,140,142,143].

Policies
A number of policy factors, particularly in the school context, that promote LGBTI+ wellbeing were documented. While there was some reference to anti-discrimination measures [75,110,141,144], this review noted the presence of inclusive policies, as a means to influence overall school climates. Such policies were applied universally across the school and extended to administrative measures to provide for chosen name and use of pronouns [106,107,109,110,120,144], inclusive bathroom access [75,[144][145][146], alongside all-gender dress codes, such as uniforms [75,109].

Curricular
This scoping review highlights the importance of a comprehensive and inclusive education curriculum [65,68,75,83,120,147,148]. While these findings largely relate to the secondary school context, an inclusive curriculum includes, but is not limited to, puberty, sexuality and relationship education [120,123,141,147,148]. In addition, curricula should have broader relevance to sexual minority youth, gender minority youth and youth with diverse sex development. As such, curricular education offers potential to extend beyond health, to ensure the representation of LGBTI+ lives throughout the humanities and sciences [68,70,75,93,111,123].

Extracurricular Activities
Alongside inclusive spaces in schools for LGBTI+ youth, curricular provision may also co-exist alongside extracurricular activities, offered through school and outside educational contexts [65,120,147,148]. This included welcoming same-gender partners at school events, alongside the partners of staff and family from sexual and gender minority backgrounds [147]. There was specific mention of involvement in creative pursuits, such as music, art, dance and drama, alongside sports participation [120]. It is noteworthy that there was only one record that specifically mentioned creative and sporting extracurricular activities [120].

Intersecting Forms of Recognition
Honneth's Recognition Theory outlines an intersecting, tripartite framework that underscores the co-existence and interconnection between interpersonal, community and legal forms of recognition. In particular, GSAs appear to offer powerful protective potential through the intersection of these forms of recognition. These promotive benefits are illustrated in Figure 7.
All quantitative studies used self-report scales for depression, including the Center for Epidemiologic Studies Depression Scale (CES-D); the Beck Depression Inventory; the Diagnostic Interview Schedule for Children; Brief Symptom Inventory subscales for depression; the 2-item Patient Health Questionnaire-2; a single item from the WHO Composite International Diagnostic Interview Short Form; a combination of CES-D items with the Structured Clinical Interview for DSM-IV and Schedule for Affective Disorders and Schizophrenia for School-Age Children; and a question asking whether participants felt very "trapped, lonely, sad, blue, depressed, or hopeless about the future". Internal consistency, measured by Cronbach's alpha for the depression scales, where reported, ranged from .70 to .94. Some studies dichotomised scores to differentiate between depressive symptoms that were clinically significant. Qualitative studies garnered perceptions of self-reported, psychosocial consequences of supportive and unsupportive behaviours. As such, GSAs may enhance allyship by peers and providers (n = 21) and facilitate access and connectedness to LGBTI+ community networks (n = 11). Positive affirmation of identities and orientations, and allyship by peers [64,68,73,83,90,100,110,123,140], alongside that of providers [64,67,68,73,75,83,90,100,101,104,110,123,[140][141][142][143], may enhance and promote advocacy at both the individual and collective levels [64,69,70,83,85,[105][106][107]109,110,120,123,138,140,141]. Advocacy, in turn, may promote activism, with strong associations with wellbeing [64,67,70,98,110,119,120,138,[140][141][142][143]. Additionally, GSAs may facilitate and strengthen the development LGBTI+ community networks, enhancing community relations [64,68,75,83,90,101,104,120,140,142,143]. Further, the presence of GSAs was associated with the increased likelihood of co-existing inclusive policies (n = 12), inclusive school curricular (n = 5) and extracurricular activities (n = 1). These findings are tabulated, in chronological order from the most recent, in Table 7.

Indicators of Wellbeing
Of the 96 records included in this review, interpersonal relations, community connectedness, legal inclusion through universal rights and the intersecting tripartite forms of recognition were found to be associated with enhanced LGBTI+ youth wellbeing. This accords with Honneth's Recognition Theory [27][28][29]. In particular, significantly better psychological outcomes were noted (n = 36). These included lower levels of depression [53- Measures for anxiety used the 21-item Beck Anxiety Inventory; the Brief Symptom Inventory subscales for anxiety; and a question asking whether participants were "anxious, nervous, tense, scared, panicked, or like something bad was going to happen". Where reported, the coefficient alpha reliability estimate was α =.95.
Measures for psychological distress included the Brief Symptom Inventory; the Brief Hopelessness Scale; short form of the Global Appraisal of Individual Needs; the Emotional Symptoms Index of the Behavior Assessment System for Children; and the General Well-Being Schedule with a question measuring stress and despair. Where reported, the Cronbach's alpha ranged from .80 to .94.
The amelioration of the negative effects of victimisation was also identified [57,62,63,66,87,88,91,96,[138][139][140]. Measures included the Scope and Prevalence of Anti-Lesbian/Gay Victimization; family victimisation related to sexual orientation; bully victimization in the past 30 days; experience of violence at school in the past 30 days; a 10-item lifetime victimization on the basis of LGBT identity scale; an adapted scale of the California Healthy Kids Survey measure on violence, safety, harassment and bullying; a 10-item measure of the frequency of LGBT victimization; at-school victimization adapted from the Bullying and Victimization Scale; and experience of school victimization based on sexual orientation.
Decreased odds of non-suicidal self-injury were noted [61,62,66,67,93,109,113,120,133,134,141,147]. There were also reduced odds of suicidal thoughts, symptoms and attempts [62,63,[65][66][67]78,81,87,91,93,105,109,120,133,134,139,141,147]. These positive impacts were associated with interpersonal, community and legal protective factors. For example, an increase by one context-be it interpersonal, within the community or enshrined in policy-supporting chosen name use, predicted a decrease in depressive symptoms, suicidal ideation and suicidal behaviour [109]. Further, disparities in suicidal thoughts were nearly eliminated in US states with the most protective school climates [141].
Measures of suicidality included questionnaire items on self-harm or self-injury that was non-suicidal in intent (NSSI). This was dichotomised regarding frequency and/or recency. Experience of suicidal ideation and attempt in the past year was also measured, with a single-response question and indicator of frequency.
It is critically important that over a third of records (37.5%) noted such reductions, given the concern at the higher prevalence of psychological distress and suicidality for LGBTI+ youth populations [9][10][11][12]15]. This underscores the resonance of Meyer's call for research attention on "stress-ameliorating factors" [13] (p. 678). This also accords with Honneth, who emphasised that recognition extends beyond the interpersonal and community level, highlighting that recognitive justice exists within broader structural contexts [27][28][29]. A broad range of wellbeing indicators, associated with holistic forms of recognition, were mapped onto Honneth's tripartite framework, as illustrated in Figure 8. This is consistent with the WHO constitution, which notes that health is more than the absence of disease [1]. consistent with the WHO constitution, which notes that health is more than the absence of disease [1].

Consultations
There was broad consensus of these findings through the stakeholder consultation, complemented by online discussions with LGBTI+ youth and peer allies. Presentations of the preliminary findings were followed by dialogue and feedback [43]. Stakeholder discussions were guided by the policy-makers and researchers in attendance, and focused on the challenges in capturing the breadth of diversity within identities and orientations, especially for quantitative studies, with particular reference to appropriate question wording for the inclusion of non-binary and intersex youth. The LGBTI+ acronym has particular resonance in the Irish context, with the inclusion of intersex evolving iteratively through research and policy-making processes [24,149]. A more comprehensive qualitative study is being conducted with LGBTI+ youth, living in Ireland, and includes consultation on the phrasing and placement of demographic questions, with the potential to in-

Consultations
There was broad consensus of these findings through the stakeholder consultation, complemented by online discussions with LGBTI+ youth and peer allies. Presentations of the preliminary findings were followed by dialogue and feedback [43]. Stakeholder discussions were guided by the policy-makers and researchers in attendance, and focused on the challenges in capturing the breadth of diversity within identities and orientations, especially for quantitative studies, with particular reference to appropriate question word-ing for the inclusion of non-binary and intersex youth. The LGBTI+ acronym has particular resonance in the Irish context, with the inclusion of intersex evolving iteratively through research and policy-making processes [24,149]. A more comprehensive qualitative study is being conducted with LGBTI+ youth, living in Ireland, and includes consultation on the phrasing and placement of demographic questions, with the potential to influence future waves of longitudinal data collection. Findings from this research will be published in a follow-up manuscript.
During consultations with LGBTI+ youth and peer allies, the critical role of interpersonal relations with parents, peers and providers was reiterated. In particular, affirming and accepting behaviour (especially from family) was recognised as extremely protective. Young people confirmed that broader LGBTI+ communities and, especially, connectedness to gay, lesbian and transgender communities, play an important role, including as chosen families. The young people were initially surprised by the potential of faith communities to be protective. With further discussion, they suggested that such communities may be supportive of LGBTI+ identities because of, rather than despite, their faith. Within the study team and with the stakeholder and youth consultations, intergenerational differences were noted in relation to online communities. While the full study team were aware of potential harm from online activity, including cyberbullying [150], younger team members and consultations with youth concurred with the description of online communities as a "safety net" [132]. Young people also understood the broad lack of awareness of this promotive impact-for example, the potential of having an avatar online that appropriately reflects a young person's self-expression [129]. This is, perhaps, reflected in the differences reported between sexual minority youth and their heterosexual peers [132]. The young people commented that for transgender and gender minority youth, in particular, such online communities are "literally lifesaving," due to geography and population size.
Stakeholder and youth consultations confirmed the importance of GSAs. This reflects the nationwide youth consultation conducted for the Irish LGBTI+ National Youth Strategy, with young people calling for the introduction of such alliances in Irish schools [149]. This attests to the idea of "learning with" LGBTI+ youth [47], and suggests that young people are engaged and aware of what is happening for LGBTI+ communities globally.

Discussion
Holistic, and deliberately broad, conceptualisations of wellbeing, underpinned by the WHO, and complemented by Honneth's Recognition Theory, informed this scoping review. The findings underscore the nuance and breadth of factors that may potentially promote LGBTI+ youth wellbeing. The critical importance of family and friends is highlighted, including LGBTI+ chosen families, and extending to online networks. Community connectedness with faith and cultural communities emphasises the need to acknowledge that young LGBTI+ lives are intersectional, with multi-faceted, diverse identities. Protective school climates that are inclusive appear to have an important promotive role. This review notes the powerful, protective potential of GSAs. The creation of such safe spaces may be particularly important for youth who are exploring their orientations and identities, offering the potential for peer and provider allyship.
The size and breadth of the records included in this review indicates an exponential increase in research attention on this topic, particularly in the past decade. This, perhaps, reflects the call by Hass et al. for an increased focus on protective factors [4]. However, it is in stark contrast to the extensive research focus on psychological distress and suicidality [10][11][12]. There is a pressing need for increased research attention on protective factors that promote LGBTI+ youth wellbeing. The more recent availability of populationbased datasets that facilitated representative and generalisable analyses is welcome, and the prioritisation of secondary analysis and further comparative research is recommended. While not comparative, the quantitative records included in this review capture a wealth of experiences, with a continued need for such research. The rich nuance of the qualitative studies emphasises the need for an increased focus on these methods, while the paucity of mixed-methods research calls for greater investment in these methodologies. Convenience, purposeful and snowball sampling via LGBTI+ organisations, community venues and events seems appropriate, given the importance of such communities. This could be further enhanced by increased attention to alternative forms of recruitment [95].
The authors call for continued research with sexual minority youth, an increased research emphasis with transgender and gender minority young people and the urgent prioritisation of research attention for youth with variations in sex development [9,15]. However, it is recognised that the inclusion of intersex, within the broader LGBTI+ acronym, continues to generate discussion. For example, the recent Australian human rights commission report, while using this acronym, noted that the needs and context for intersex youth are unique, and are not encompassed by terms related to sexual and gender minority populations [151]. This accords with the recent work of the National Academies [9]. It is acknowledged that the challenge posed for practitioners, policy-makers and researchers is not insubstantial in relation to the call for continued and increased attention on sexual and gender minority youth, and the pressing need for the prioritisation of focus on populations with diverse sex development. However, this offers rich opportunities to explore the breadth and depth of LGBTI+ youth's lived experience. This is now discussed in relation to the nuance in these findings regarding multi-faceted orientations and identities; broadening understandings of family; the salience of community connectedness; shifts from protectionism to rights-based, universal inclusion; and mental health beyond a dichotomy.

Multi-Faceted Orientations and Identities
Social acceptance and increased visibility may facilitate broader understandings of sexual orientation, gender identity and sex development [37]. The authors call for increased attention to disaggregating data on sexual orientation, with particular attention given to bisexual youth, due to prevalence [6,7], alongside concerns that the protective factors identified in this review may not have the same promotive benefits. As Figure 3 highlights, young people perceive sexual orientation and gender identity as dynamic and are comfortable and confident with a myriad of forms of self-identification. It appears that a proportion of young people no longer assume rigid sexual orientation labels and binary gender identities [152]. While this raises challenges for researchers in relation to measurement [9], it offers opportunities for "learning with" LGBTI+ youth, alongside those who identify beyond this acronym, and their peer allies [47,48]. This reinforces the need for preliminary, participatory research to understand appropriate self-identifiers as part of survey design and development. This necessarily extends to attending to possible non-medical self-descriptors for youth with diverse sex development [8,9].
Sparse research has included younger populations. In this regard, measuring attraction in relation to sexual orientation, rather than identification, may be of increased importance [6,7]. One study noted children's early knowledge that they were not heterosexual, with an average age of 10.3 years for boys and 12.2 years for girls [53]. The Health Behaviour in School-Aged Children may provide an example of measuring attraction, with a pilot conducted across eight European countries [153]. While this offers potential, it poses additional challenges as measures of sexual orientation may assume a gender binary. An additional complexity, specific to LGBTI+ identities and inclusions, is the issue of parental consent for children and adolescent research participants [154]. However, some research ethics processes can accommodate passive parental consent, or waive this requirement [52,62,66,68,81,113,127,133,141,145].

Broadening Understandings of Family
The powerful protective role of family accords with research that identified the importance of "One Good Adult" [155,156]. This can be a family member, provider (in both formal and informal roles) or non-parent adult-someone who is available to the young person in times of need [155,156]. As such, caring adults within LGBTI+ communities may also form chosen family, alongside, or in lieu of, parents and adult family members [57]. In light of the pervasive and dominant focus on risk factors, it is, perhaps, understandable that supportive adults have concerns about LGBTI+ youth mental health distress. This may inadvertently lead some adults to seek to prevent young people from expressing their identities and orientations, in a mistaken belief that this may be protective [157]. It is recommended that a realist review, underpinned by the methodology outlined by Pawson and Tilley, be undertaken, predicated on complexity, rather than seeking to isolate social interactions [158]. This type of review could be contextualised within the work of organisations, such as the Family Acceptance Project, which, alongside demonstrating the benefits of affirming behaviours, offers insights into working with rejecting families and assisting them to support their children (see https://familyproject.sfsu.edu/, accessed on 28 October 2021).
Within broader understandings of family, although after the date that the search was run, an emergent topic area suggests companion animals, particularly family cats and dogs, can promote LGBTI+ youth wellbeing [159,160]. This may indicate the promotive effects of human-animal bonds [47]. The authors concur that this topic warrants further research.

Salience of Community Connectedness
This review highlights the importance of community, with a sense of connectedness via an LGBTI+ identity associated with collective self-esteem and positive selfidentification [54,77,83,98,106,111,116,121]. This extends beyond Honneth's concept of recognition of the individual contribution of community members [27][28][29], to acknowledgment of the importance of the wider contributions of LGBTI+ communities. As such, policy investment in LGBTI+ community endeavours and initiatives is of critical importance. In the current problem-focused funding climate, LGBTI+ community groups have been placed in an invidious position and may find themselves reinscribing a risk-based, deficit focus in order to maintain and secure further funding [23]. In particular, the benefits of involvement in LGBTI+ sporting, creative and social groups warrants further research attention, in light of the positive impact on wellbeing for adult members of LGBTI+ communities [161,162]. It is recommended that further investigation be undertaken to determine whether involvement in extracurricular activities through groups, by and for LGBTI+ communities, could be supportive for LGBTI+ youth. The authors extend this to online fora, and connectivity, via gaming and social networking.
The concept of a singular readymade "community", which assumes an inevitable sense of belonging, is contested and the use of "communities" more appropriately reflects the diversity "within and between" those who identify as LGBTI+ [163]. The findings regarding faith communities and cultural communities counter the assumption of mutually exclusive identities. This has important implications and prompts practitioners, policymakers and researchers to ensure that LGBTI+ youth's lived experience is contextualised within intersectional understandings of the salience of identities that include sexual and gender minority orientations and identifications, alongside faith, ethnicity and cultural diversity [164]. The nuance regarding the potential promotive benefit of religious belief and spirituality is captured in the systematic review by McCann et al. [135]. Understanding of these contexts may be enhanced with reference to institutional allyship, beyond interpersonal allyship by members of faith communities, to those embedding institutional allyship, predicated on values of social justice, equity, diversity and inclusion [165]. This review calls for a greater focus on the promotive benefits of ethnic and cultural communities for LGBTI+ identified young people. This accords with recent research highlighting the importance of community belonging for Black LGBTQ adult mental health and wellbeing [166]. Further research may be strengthened with reference to Indigenous peoples' understandings of the fluidity and blurring of sexual minority and gender minority identities beyond the LGBTI+ acronym [167,168].

Shifts from Protectionisism to Rights-Based, Universal Inclusion
Much of this review has focused on the educational context, in light of the ages encompassed by the term "youth", which encompasses those aged 10-24 years and therefore likely to experience primary and secondary education, and possibly higher education contexts [59]. The authors call for greater research into all aspects of legal relations. Protective school climates appear to be critically important, beyond a focus on protectionist approaches, which inform anti-discrimination measures and seek to address bullying [16][17][18][19][20][21][22][23]. Rather, this review highlights the potential benefit of strengths-based policy measures of provision for all students for chosen name and pronoun use [109]; inclusive access to allgender bathrooms and changing rooms [169]; and inclusive dress codes, such as all-gender uniforms [75,109]. This extends to policy and curricula, with recommendations for puberty, sexuality and relationship education [170], inclusive education [171] and embedding an ethos of diversity and inclusion within schools, with potential promotive benefits for all [172][173][174].
The powerful, protective potential of GSAs is noted. The creation of such safe spaces may be equally important for youth who are "out", those exploring their orientations and identities and those who do not disclose. This accords with findings that being completely "out" or completely "in" may be protective [51][52][53][54]. The design of GSAs, with allyship central to these alliances, appears to facilitate participation without young people being required to declare their identities or orientations. GSAs may potentially provide an inclusive space to challenge rigid, binary conceptualisations of gender and sexuality, explore ambiguities and ensure the visibility of a diverse expression of identities and orientations [152]. This may foster a sense of connectedness and school belonging. While inclusive provision may seek to address the needs of LGBTI+ self-identified students, the benefits appear to be far-reaching, with a suggestion of potential promotive benefit to all. The authors suggest that a realist review is undertaken to determine what works, for whom, in which contexts, in relation to the impact of GSAs, and resultant policies of inclusion, across multi-faceted, intersecting identities, including sexual orientation, gender identity, faith, ethnicity, socio-economic status and ability. While such alliances and policies are predicated on rights-based, inclusive provision that is universally available to all students, it is important to establish how this is extended to youth with multiple marginalised identities. Further, peers and providers are uniquely positioned to advocate for the importance of inclusive policies, including the provision of GSAs. As role models, informal mentors and allies, through advocacy and activism, may foster optimism and instil hope for the future, including future possible selves. Such allyship, at the interpersonal, intergenerational and institutional level, is associated with promoting LGBTI+ youth engagement, involvement and participation [149,152,175]. A systematic review on interpersonal, intergenerational and institutional allyship, provided by peers and providers, within the policy context may yield important insights [165,175,176].

Mental Health beyond a Dichotomy
The concerns regarding mental health disparities for LGBTI+ youth are well established [4,[10][11][12]. While it is essential that the immediate and lasting factors that negatively impact on LGBTI+ youth wellbeing are not diminished or underrepresented, it is perhaps understandable that research attention has focused on mental health disparities [13]. However, this review identifies potentially "stress-ameliorating factors" [13] (p. 678), with interpersonal, community and legal factors associated with reductions in psychological distress and suicidality, alongside increased wellbeing. As such, experiences of mental ill health do not preclude experiences of mental wellness. Equally, it is important that the concept of resilience is not suggested as a solution to experiences of prejudice, discrimination and victimisation, exacerbating mental health stigma as a consequence [16]. This underscores the importance of strength-based approaches, predicated on nuanced conceptualisations of mental health beyond a binary of illness and wellness as dichotomised and mutually exclusive [1][2][3]. This has implications for policy, practice and research, beyond deficit-informed and protectionist approaches. In turn, needs assessments can explore strengths within young people's lives, providing a basis for determining the protective potential of intersubjective, community and legal factors, those which can be enhanced, alongside factors requiring additional scaffolding. Such approaches recognise youth social and cultural capital and may connect young people to their own sense of competence and agency [47]. The authors call for a greater emphasis on broader conceptualisations of LGBTI+ youth wellbeing and recommend that equal priority is given to research on protective factors.

Limitations
The authors are heartened by the exponential increase in research focused on, or including, factors that protect or promote LGBTI+ youth wellbeing, particularly within the last decade. As Figure 2 illustrates, the number of records doubled in 2010 and again in 2016, with this trend also reflected in publications from 2020. The Figure 1 flowchart captures the many recent, relevant studies forwarded by context experts, outside the date that the search was run and not included in this review. Further, as this review focused on peer-reviewed, published, academic literature in English, it is possible that some records may not have been identified, particularly if studies were not indexed at the time of search, or used terms not included in the search string. While the review intended to include dissertations, due to embargo and repository restrictions, these could not be retrieved. This highlights the critical importance of publication that enhances the more rapid dissemination of research in a field where gaps in the literature remain pervasive. This review focused specifically on self-identification in relation to sexual orientation, with studies including measures of attraction and recoded for identification excluded from this review. We further acknowledge that the use of terms relating to resilience is both limited and limiting, particularly in light of the experience of victimisation and stigmatisation for LGBTI+ youth. These findings may have been further enhanced by attention to the wealth of grey literature, including books, book chapters and reports. The authors recommend further scoping of this literature, particularly as it appears that policy-makers and practitioners may have already adopted strengths-based approaches. This highlights the importance of practitioner-informed research as an essential component of a virtuous research cycle. No studies on interventions were included and the authors recommend that a systematic review is conducted of educational, community-based, psycho-social, psychological, pharmacological and surgical interventions.
While the concept of recognitive justice remains contested, particularly in light of the importance of redistributive forms of justice [29], Honneth's Recognition Theory provides a useful framework for scoping such tripartite, protective factors [26][27][28], with their interconnection illustrated in Figure 5. This also underscores the importance of attending to intersectionality, particularly that of LGBTI+ orientations and identities alongside socio-economic status [164].
Despite these limitations, this scoping review provides a nuanced, comprehensive overview of this body of literature.

Conclusions
The findings contained in this scoping review demonstrate that, rather than an LGBTI+ identity being assumed as a proxy for risk, there is a pressing need to attend to specific psychosocial strengths rather than the predominant focus on stressors for this population. The de-pathologising of LGBTI+ identities may be reflective of increased recognition, beyond the interpersonal and community level. Bringing a social justice perspective to this review, underpinned by Honneth's Recognition Theory, is of critical importance, given the broad consensus of the elevated risk of psychological distress, self-harm and suicidality for LGBTI+ youth populations. It is with some urgency that this review concludes with an appeal for research funders and policy-makers to move beyond the dominant discourse focused solely on LGBTI+ youth's mental health risk, which subsequently informs pro-tectionist approaches. These findings have important practice and policy implications, highlighting the broad applicability of strengths-based approaches in assessment and the crucial need to develop mechanisms, underpinned by recognitive justice, to herald a change in the funding of future research directions. This emphasises the salience of enhanced understandings of inclusion, which is rights-based, universally available and of potential benefit to all.
Supplementary Materials: The following are available online at https://www.mdpi.com/article/ 10.3390/ijerph182111682/s1, Final PubMed search string; Flow chart overview of inclusion and exclusion criteria for title and abstract screening; Inclusion and exclusion criteria; Screening template using PCC criteria and inclusion criteria.  Informed Consent Statement: Written informed consent was obtained for consultations with LGBTI+ youth and peer allies; no identifying information is included in this review. A blank copy of the consent form was forwarded to the assigned Assistant Editor for IJERPH for their records.

Objectives 4
Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.

3
Protocol and registration 5 Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number. 3 Eligibility criteria 6 Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale. 3 Information sources 7 Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed. 4 Search 8 Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated. 4 Selection of sources of evidence 9 State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review.

3-4
Data charting process 10 Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.

Data items 11
List and define all variables for which data were sought and any assumptions and simplifications made. 4 Critical appraisal of individual sources of evidence 12 If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate