Coping Strategies to Enhance the Mental Wellbeing of Sexual and Gender Minority Youths: A Scoping Review

Robust population-based research has established that sexual and gender minority youths (SGMYs) are at an increased risk of mental ill-health, but there is a dearth of literature that seeks to explore how to best support SGMY mental wellbeing. This scoping review aims to identify findings related to coping strategies and/or interventions for building resilience and/or enhancing the mental wellbeing of SGMYs. PRISMA extension for scoping review (PRISMA-ScR) guidelines was utilized for this review. Studies were included if they were peer-reviewed papers containing primary data; reported psycho-social coping strategies for SGMY; were conducted with SGMYs in the adolescent age range; and were published in English. MEDLINE, Embase, and PsycINFO databases were searched. Of the 3692 papers initially identified, 68 papers were included with 24 intervention-focused studies of 17 unique interventions found. The most commonly cited therapeutic modality was cognitive behavioral therapy (CBT) (n = 11 studies). Despite the need to support the mental wellbeing of SGMYs, few interventions focused on this area and unique populations have been reported upon in the peer-reviewed literature. As a result, there is considerable potential to develop supports for SGMYs.


Introduction
Sexual and gender minority youths (SGMYs) include the young people who identify as lesbian, gay, bisexual, transgender/trans, and queer, as well as all other sexual and gender minority (i.e., LGBTQ+) youth. It is estimated that up to 10% of the adolescent population are SGMYs, based on the results of a range of population-based studies [1,2]. Prior research has indicated that SGMYs are more likely to experience mental health problems in comparison to their peers who are heterosexual and cisgender (i.e., not transgender). For example, a systematic review and meta-analysis of population-based studies reported sexual minority youths had three times the risk (odds ratio = 2.9) of depression in comparison to heterosexual youths [1]. Estimates of depression for gender minority youths indicate even greater mental health needs, with a nationally representative population-based estimate from New Zealand reporting gender minority youths had almost six times the odds (odds ratio = 5.7) of depression when compared to their peers who are cisgender [3].
The elevated rates of mental health problems frequently experienced by SGMYs are hypothesized to be largely driven by minority stress. The effects of the stigma, discrimination, or victimization that SGMYs can experience in their everyday lives, and the high and chronic levels of stress they face, place them at an increased risk [4,5]. In short, ". . . it is toxic social environments that place SGMY at elevated risk of mental ill-health" [6] (p. 6). Logically more needs to be done to improve these challenging social environments, over and above the work LGBTQ+ organizations have engaged with over many years to bring about positive change. Improving the overall milieu for SGMYs is therefore important, and some further efforts are underway to address these challenging environments, for example, the work associated with the UK's "LGBT Action Plan 2018: Improving the lives of Lesbian, Gay, Bisexual and Transgender people" [7]. However, overall progress seems out of step with the relative size of the SGMY population, as well as the considerable mental health needs of SGMYs. For instance, there appears to be limited interventions specifically designed to support the mental health of SGMYs, as highlighted in three systematic reviews that sought to identify such resources [8][9][10].
Fortunately, considerable evidence is already available on how to treat commonly occurring mental health problems, such as for depression and anxiety in young people generally. For instance, the use of cognitive behavioral therapy (CBT) has been recommended for children and young people with mild through to severe depression in the UK's influential National Institute for Health and Care Excellence/NICE treatment guidelines [11]. However, sexual and gender minority (SGM) people have not been well served by the mainstream health and social care services that are evidence-based [12][13][14]. For example, when Foy et al. [12] surveyed sexual minority adults about their treatment experiences, which frequently included CBT, half (52.2%) highlighted that services should be improved for sexual minority clients. Common issues identified by participants included their therapist's lack of awareness and understanding of sexual minority identities and community-specific challenges, with distrust, disillusionment, and exclusion being common therapy experiences [12]. Furthermore, previous work has reported that the clinical outcomes from mainstream therapy services for SGM individuals are poor relative to those of their heterosexual cisgender peers [13,14]. This is especially the case for lesbian women and bisexual adults [13], as well as gender minority adolescents [14].
Given that mainstream services appear less acceptable and effective for SGM adults and gender minority youths, an investigation of the therapeutic potential and usefulness of supports for SGMYs more generally is warranted. However, internationally, only 24 such interventions have been identified and most of these (n = 17) have a sexual health focus [8]. SGMYs have highlighted a preference for digital psychosocial supports [15]. However, given the results of the reviews to date, few such digital interventions have been developed specifically to meet the needs of SGMYs [8][9][10]. We identified several broadly related literature reviews associated with the efforts to support SGMYs, but none had a focus on the specific coping strategies and/or interventions for building resilience and/or enhancing the mental wellbeing of SGMYs. For instance, there have been reviews with an emphasis on defining resilience, either for young people generally [16] or SGMYs more specifically [17]. Reviews have also described the SGMY inequities context [18] and have assisted our understanding of the overall methods that should be employed when working with SGMYs, including strength-based approaches [19]. However, it appears that there is scant evidence and explanations pertaining to the specific psycho-social skills or resources used within interventions that build resilience or promote mental wellbeing and coping strategies for SGMYs, either digitally or in-person. This gap in the knowledge-base is likely to go some way to explain the lack of tools being developed and offered for SGMY mental health promotion.

Rationale
As a study team, we are in the process of creating a bespoke digital intervention. This new resource is intended to build the resilience skills and enhance the mental wellbeing of SGMYs [6]. We have decided to conduct a scoping review to support us in developing this intervention for two key reasons. Firstly, because the digital intervention field is a fast-moving area, this time-efficient overarching review methodology is especially useful. Secondly, there is a gap in the literature in relation to what appears effective and acceptable for SGMYs in terms of evidence-informed psycho-social coping strategies and/or interventions.

Objective
Our objective is to identify the scope of evidence for the recommended psycho-social coping techniques or strategies for building resilience and/or enhancing the wellbeing of SGMYs in the adolescent age range.

Protocol and Registration
The reporting of this scoping review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist [20]. Given that we have time limited funding to design, co-create, and evaluate a new web-based intervention (by the end of 2022), this scoping review was not registered prior to being conducted.

Eligibility Criteria
The eligibility criteria for our scoping review, from database inception to January 2022, were as follows. Publications were included if they were: • Peer-reviewed papers containing primary data (using quantitative, qualitative, or mixed-methods research designs); • Papers that reported on what is considered effective or useful in terms of psycho-social coping strategies for SGMYs; • Studies that were conducted with SGMYs in the adolescent age range, which could potentially include participants as young as 10 years and as old as 19 years (i.e., the World Health Organization/WHO definition of adolescence), or where the sample included adults (or children) then more than 50% of the study's participants are adolescents; • Were published in English.

•
Publications were excluded if they were: • Studies where adolescent data were not presented separately from adult or child data; • Literature reviews; • Opinion pieces, commentaries, or theoretical pieces (i.e., the publication did not contain original data); • Conference abstracts (i.e., only a brief summary of the research conducted); • Dissertations.
We excluded papers that did not focus on adolescents as we aimed to create a developmentally appropriate resource for SGMYs. Moreover, we only included original data from peer-reviewed papers, as we are interested in summaries of the empirical research and what has been concluded based on that data.

Information Sources and Search Details
Three databases were searched, specifically MEDLINE, Embase, and PsycInfo from their inception to 19 January 2022. The searches across the three databases were based on the search terms used for MEDLINE. The search strategy for MEDLINE was built by three of the authors (i.e., M.F.G.L., R.S., and K.A.R.) and was then reviewed and refined by the remaining authors (i.e., A.N.-G., L.M.W., and K.E.B.) before the full search was conducted. For MEDLINE, the searching was from the database's inception (which was in 1946) to 19 January 2022 (for the specific search terms used, see Appendix A). The same electronic limits were applied to all three databases, specifically that all papers were to be published in the English language, involved humans, and had adolescent participants.

Selection of Evidence and Data Processes
M.F.G.L. screened all the titles and abstracts from the papers initially identified. The full-text papers were all checked by both M.F.G.L. and A.N.-G. and any disagreements about their inclusion were resolved via discussion with R.S. and K.A.R. Nine articles were identified by checking the reference lists of the included studies. Where it was not clear whether or not a paper should have been included, due to a lack of demographic information in the actual paper, the corresponding author was contacted. All data extraction and reporting were conducted by M.F.G.L. and independently checked by A.N.-G. Key information collated included details about the author(s); year of publication; study location; the sample size; how the target population was defined; the salient features of psycho-social coping techniques or strategies for SGMYs identified; and (where applicable) the format of the intervention. Given the diverse ways in which SGMY populations are described, the language as utilized in the individual papers was employed when the paper was summarized.

Appraisal of Individual Sources of Evidence and Synthesis of Results
Prior to commencing this work, we initially debated focusing our review exclusively on trials of mental health interventions conducted with SGMYs. However, it was apparent during the early stages of developing our search terms that such a restrictive focus would be counter-productive, due to the small number of trials identified in the reviews already conducted. A conventional critical appraisal of the quality of the evidence was outside the scope of this review, which was designed to identify the key psychosocial techniques that have been employed for and by SGMYs. Consequently, we have taken a more descriptive approach, as recommended by Arksey and O'Malley [21], where we have not rated the evidence per se, but have outlined the common focus, features, and format of interventions; the standardized assessments used; and the significant clinical or other outcomes reported. We also sought to summarize the expert by experience insights into potentially effective strategies that were provided by SGMYs, as outlined in a range of qualitative studies. Arksey and O'Malley's [21] framework informed the overall process and synthesis of the review, using their five stages of identifying the research question; identifying relevant studies; study selection; charting the data; and collating, summarizing, and reporting the results.

Selection of Sources of Evidence
The initial results yielded a total of 3692 articles that were from: • MEDLINE = 1100 articles; • Embase = 1226 articles; • PsycInfo = 1366 articles.
Once the duplicates were removed, there were 2801 articles identified for title and abstract screening. Of these articles, 2689 were excluded and 112 were identified for a fulltext review, 59 of these full-texts were included in this review and an additional 9 papers were identified after reviewing the reference lists of the included full texts. As a result, 68 papers were included in our review (see Figure 1 for details).

Overall Characteristics of the Sources of Evidence
In total, 68 studies were included in this review. The research in the field is fairly recent, as the oldest papers date from 2008 and more than half of the studies have been published from 2017 onwards (n = 35 studies). Most studies involved fewer than 50 participants (n = 40 studies). North American research predominates, with over two-thirds of papers consisting of participants from the USA (n = 47), including five studies where the participants were from both Canada and the USA. Other studies were conducted in a single country, specifically Canada (n = 5), the United Kingdom (n = 4), New Zealand (n = 4), and Australia (n = 2), with one study each conducted in South Africa, Belgium, Puerto Rico, Israel, and Norway. One study drew participants from across ten African countries (i.e., [22]). There was no uniform focus on the LGBTQ+ sub-populations of interest, but the studies could be broadly categorized into one of three main groups: 1. Those that consisted of LGB (or sexual minority) youths (n = 26 studies). 2. Those that consisted of LGBTQ/+ (or sexual and gender minority) youths (n = 28 studies).

Overall Characteristics of the Sources of Evidence
In total, 68 studies were included in this review. The research in the field is fairly recent, as the oldest papers date from 2008 and more than half of the studies have been published from 2017 onwards (n = 35 studies). Most studies involved fewer than 50 participants (n = 40 studies). North American research predominates, with over two-thirds of papers consisting of participants from the USA (n = 47), including five studies where the participants were from both Canada and the USA. Other studies were conducted in a single country, specifically Canada (n = 5), the United Kingdom (n = 4), New Zealand (n = 4), and Australia (n = 2), with one study each conducted in South Africa, Belgium, Puerto Rico, Israel, and Norway. One study drew participants from across ten African countries (i.e., [22]). There was no uniform focus on the LGBTQ+ sub-populations of interest, but the studies could be broadly categorized into one of three main groups:
The majority of studies (n = 41, 60.3%) provided details of the funder/s of the research (e.g., government ministries, individual universities, and research funding councils); the remainder did not explicitly acknowledge a funder or funders.

Appraisal of the Intervention-Focused Studies (n = 24)
Of the 68 papers, 24 were intervention-focused. Of these, more than half (n = 13 studies) included SGMY/LGBTQ+ youths and the remainder either focused on sexual minority/LGB young people (n = 9 studies) or gender minority/trans young people (n = 2 studies). Table 1 provides an overview of these 24 studies (which represent 17 unique interventions). Of the 17 unique interventions, most were primarily psychotherapeutic in nature (n = 12). A smaller number were, broadly speaking, preventive or universal interventions (n = 5), which were designed either for SGMYs specifically or for all young people more generally.
Most of the interventions were provided in-person (n = 14 studies) in either individual or group formats, with four being delivered in schools (i.e., [24,[27][28][29]). Five interventions (n = 9 studies) were provided digitally, in synchronous (e.g., for "Q-Chat Space") or asynchronous formats (e.g., for "Singularities"). One study explored the potential of a yetto-be-created intervention, and, as such, it was yet to be determined whether the eventual intervention would be delivered digitally (i.e., [30]). Two of the interventions delivered digitally (n = 5 studies) were provided in serious game formats (i.e., "Singularities" and "SPARX/Rainbow SPARX").
Most commonly, the study designs were pilot studies (n = 9) and only one was a randomized controlled trial (i.e., [31]). The focus of the pilot studies was predominantly testing the acceptability, feasibility, and/or preliminary effectiveness of the interventions. A range of standardized assessments were used across the pilot studies, such as measures of depressive symptoms (e.g., the Beck Depression Inventory). Given the design of these studies (i.e., small-scale open trials/pilots), it is unknown if any of the interventions are effective, although acceptability data appear positive based on the feedback from SGMYs.   This summer camp intervention includes free-choice programs (e.g., hiking with a counselor), workshops (e.g., "Self-Love 101" p. 371), build-on programs (e.g., writing a skit), and Brave Trails' social entrepreneurship course (i.e., articulating a "story of self" for use to promote social change or advocacy). Five themes-"Program Structure", "Program Facilitator", "Support", "Education", and "Sharing Stories" (e.g., hearing stories from others or sharing their own). Value of connecting with other SMYs reinforced.
No standardized assessments Not applicable  Content included relaxation training, "do it" (e.g., behavioral activation), "sort it" (e.g., social skills training), "spot it" (recognize or name cognitive distortions), "solve it" (problem solving content), and "swap it" (e.g., cognitive restructuring  Those attending for 1-6 or >6 months reported higher social support, which was associated with improvements (e.g., decreased depression scores). a LGBTQ+ terminology varies across papers; we cite the language and/or abbreviation adopted in the individual papers. LGB = lesbian, gay, and bisexual. LGBT = lesbian, gay, bisexual, and transgender. LGBTQ = lesbian, gay, bisexual, transgender, and queer. LGBTQ+ = lesbian, gay, bisexual, transgender, and queer others who are a gender and sexual minority (i.e., +). RCT = randomized controlled trial. SGMYs = sexual and gender minority youths. b Where a mean age was not provided or could not be calculated, the age range reported or confirmation from the paper's corresponding author was used to determine that the mean age was ≤19 years. Table 2 provides an overview of the therapeutic content or coping strategies that were common across the interventions. These could be broadly categorized as cognitive/emotional or cognitive (n = 6), environmental/social (n = 5), or behavioral (n = 2). Many were evidence-based techniques adapted for SGMYs. For instance, CBT techniques, such as cognitive restructuring, where the "ABCD" cognitive restructuring method (as outlined in "AFFIRM") was applied, in particular, where this method was then linked to salient experiences with accompanying suggested responses for SGMYs, such as in this example:

Relaxation exercises [behavioral]
A mental health promotion program (i.e., [24]), "SPARX" and "Rainbow SPARX" Relaxation exercises included "diaphragmatic breathing and progressive muscle relaxation" [24] (p. 11), although the exercises were not adapted in any way to better meet the needs of SGMYs.

Building family relationships [social/environmental]
An attachment-based intervention (i.e., [26]) and "Familias con Orgullo" An example included parents using ". . . newly learned communication skills and practice with adolescents by discussing a relevant issue in the youth's life related to being a sexual minority" [40] (p. 7).

Educating families [social/environmental]
An attachment-based intervention (i.e., [26]), "Familias con Orgullo", and an unnamed intervention [30] Importance of education reinforced, such as having ". . . written material that the parents could read to educate themselves about many different aspects of sexual minority life, including things as simple as definitions and as complicated as legislative issues. . . " [30] (p. 184).
Public narratives [cognitive and social/environmental] "Brave Trails" and "Rainbow YOUTH workshops" Developing and sharing narratives (e.g., coming out experiences) to support positive change seen as especially useful: ". . .
[An] exercise in public narrative[s], that is, articulating a "story of self" to promote social change or advocacy goals" [39] (p. 371).
Peer support for SGMYs [social/environmental] "AFFIRM", "ASSET", "Brave Trails", "Q-Chat Space", and "Hatch Youth", as well as an unnamed intervention and evaluation of LGBT-related school interventions/resources (i.e., [25,29] Of note, all the interventions were affirming of SGMYs' identities. Although not a technique per se, the instillation of hope for SGMYs was recognized as important, for instance, in "AFFIRM" [34] and "Rainbow SPARX" [42]. Where the latter stated to users of the program: "The other message in the game [Rainbow SPARX] was about having hope. It's good to repeat these simple messages: "I won't always feel this way"; "Things will get better"; or "It can be hard not being straight, but I know I can handle the challenges that come my way." "These statements are true and thinking them can make you feel a little better almost instantly, even if you don't believe them at first" [42] (p. 206). Table 3 summarizes the methods and key findings obtained from the non-interventionfocused studies, which frequently drew upon the expert by experience perspectives of SGMYs in regard to psycho-social coping techniques or strategies. Repeatedly, in the included studies, the ability to obtain support and a connection with other SGMYs was seen as important (e.g., [46][47][48][49][50][51]). The opportunity to meet people "like me" was seen as especially useful. This point was reinforced by a participant who highlighted: ". . . being surrounded by so many LGBTQ community members and allies convinced me that I can one day feel as happy, safe, and loved all the time" [48] (p. 55).

Appraisal of the Non-Intervention-Focused Studies (n = 44)
The Internet was frequently seen as an important way in which SGMYs could achieve a connection with other SGMYs for support purposes (e.g., [52][53][54][55][56][57][58]). The Internet was even described as "life saving" for SGMYs [59]. This point was reinforced by an SGMY who stated: "There's a supportive community out there online and they mean the world to me-they've saved my life" [59] (p. 37). However, the Internet could also be problematic for SGMYs [56,60]. For example, SGMYs could be exposed to mistreatment online, with one adolescent noting: "It's [social media] public. Which is both a blessing and a curse because you can connect with all these people but also you are open to a lot of hate" [56] (p. 278). Even social media groups, specifically for SGMYs, could be a source of discrimination and stigma [55]. For instance, certain SGMYs expressed racist or transphobic views or engaged in exclusionary behavior within a group, expressing sentiments such as: "you cannot be in here, you are not gay enough" [55] (p. 426). As a result of online issues, SGMYs are required to be skillful users of the Internet, such as when they use certain platform features to protect themselves (e.g., by utilizing blocking and privacy settings for safety reasons) [60].
SGMYs also sought to "escape" from challenging environments (i.e., [51,59,65]) and they created "pockets of safety" [61] for themselves. They used cognitive strategies to manage negative messages, such as those of a religious nature [52,61,66]. An example is when an SGMY reflected: "Because I believe God made everybody, so if God didn't want people to be gay, then God wouldn't have made them gay" [52] (p. 7).
Being "out" in terms of one's sexuality and/or gender identity proffered both potential wellbeing benefits and challenges. In some instances, "learning to hide" [67], as it was described in South Africa, or being "being closeted", as cited in Belgium [68], could be adaptive given the potential negative reactions of others towards "out" SGMYs. This meant that SGMYs used ". . . a closed visibility management strategy in specific social situations that are perceived as risky" [68] (p. 697). A similar point was also made by Rubin and McClelland [69] in their research on queer American women of color, where concerns about possible homophobic comments from peers meant that deleting their social media profile was an adaptive way to maintain personal safety. By contrast, being out has the potential to increase the amount of support that SGMYs receive (i.e., [61]). This can be the case, despite the "many cultural and familial taboos" SGMYs can experience [61] (p. 628).
Certain behavioral techniques were described as being valuable in terms of supporting mental wellbeing, including diversionary activities (i.e., [70,71]). For example, Strauss and colleagues [70] noted that amongst trans and gender diverse young people, being distracted by social media, games, or watching online media ". . . took their minds off their concerns, at least momentarily" [70] (p. 5). Physical exercise was also cited as important (i.e., [71,72]), especially during the COVID-19 pandemic where exercise and outdoor activities provided benefits to mental wellbeing. As noted by an SGMY, ". . . the lack of sports has really had a negative impact on me [during the pandemic]. It's hard to motivate myself, but I always feel better after exercising" [72] (p. 1055). These activities were not merely distractions, but could also provide a way to feel more positive about their identity [71], as demonstrated by an SGMY in relation to going to the gym as a coping strategy. He did this when confronted with anti-LGBTQ+ experiences, stating: "I feel the frustration, the anger-it's like the fuel for me to work out and push harder. It kinda turns into a positive. I feel better." [71] (p. 145).
SGMYs can engage in coping strategies usually viewed by others as problematic, in particular, self-harming (i.e., [60,73,74]). However, for some LGBTQ+ participants, their self-harming was perceived to be a positive coping strategy [75]. Other coping strategies that caused harm and/or serious risk to the young person included suicide attempts, risky sexual practices, and excessive drinking and recreational drug-taking [22,62,74].
Certain psychological strategies were also described. For example, in terms of coping with victimization, participants described using mindfulness and emotional regulation strategies; cognitive reappraisals; assertive communication techniques; and questioning and resisting rigid culturally bound labels [57,71,76]. Some used apathy as a response to emotional pain (i.e., [52,77]). Avoidance-both psychologically and physically-was also a perceived coping strategy (i.e., [50,60]). Regarding emotional avoidance, participants suppressed emotions as a means to block these challenging feelings, in an attempt to avoid pain and humiliation [67]. Ignoring or avoiding certain people or behavior was a strategy utilized to reduce the likelihood of distress, and hence preserve emotional energy [78]. For instance, as highlighted by an SGMY: ". . . I know when to just drop it and walk away/block them when they aren't open to learning. Negative comments online are inevitable and they can be hurtful. . . You have the opportunity to teach them but if they aren't open minded, you can simply ignore them. . . " [60] (p. 170).  LGB youths handle the visibility of their minority status differently, depending on the context. Being "closed" can reduce ". . . external stressors, such as verbal aggression and discrimination. . . " (p. 692), but then risks exposure to internal stressors, such as the fear of being "caught" and feeling dishonest. Anti-homosexual religious messages focus on "creation, sin, and afterlife" (p. 2189). Coping strategies (cognitive)-using religious identity material or sexual minority identity content to reduce the negative impacts, adding new information to invalidate the messages, and distancing oneself from or rejecting the actual message.
Goldbach and Gibbs (2015) [52] The study aimed to identify the coping strategies, responses, and resources of sexual minority adolescents (SMAs) in terms of stress management (qualitative study) n = 48
Goldbach and Gibbs (2017) [53] An exploration of whether the minority stress theory applies to sexual minority adolescents (SMAs) (qualitative study) Coping varied from ". . .
LGBT connections (e.g., going to LGBT pride events, using LGBT online resources, going to an LGBT youth center, becoming involved in a gay-straight alliance) to conforming to heteronormative behaviors (e.g., dating individuals of the opposite sex. . . ." p. 42). The more gender non-conforming a young person is, the more abuse they receive. Higher self-esteem, a higher sense of personal mastery, and greater perceived social support predicted positive mental health outcomes for transgender youths.

Higa et al., (2014) [83]
To determine the factors associated with LGBTQ youths' wellbeing from the youths' perspectives (qualitative study) To cope with parental rejection, some participants described engaging in self-harm behaviors. When trans adolescents have parents exhibiting rejecting behaviors, family work will be important, and if not viable then ". . . attempts should be made to connect youth to other forms of social support. . . " (p. 167).

Kuper, Coleman and Mustanski (2014) [78]
To examine how racial-ethnic minority LGBT youths cope with both racial-ethnic as well as LGBT-related stresses (mixed methods) n = 213 Adolescents and young adults (16-20 years) LGBT youths of color Multiple cognitive and behavioral strategies identified, e.g., "preparation for future bias or harassment", being "cautious, guarded, or less trusting", attempt to "ignore or not be affected by other's views or reactions", "be or focus on oneself", and "take care of self and problems" (p. 712).
Madsen and Green (2012) [71] To better understand the specific ways gay adolescent males successfully cope with prejudice, discrimination, and stigma (qualitative study) Coping themes related to thoughts and feelings (e.g., "Regulation of immediate emotional reaction in context of situation" p. 146 and "Analysis of the anti-LGB incident for personal relevance and severity" p. 147) and actions or behaviors (e.g., engaging in distractions, such as sports and music). LGBT Common strategies to manage mistreatment included ". . . routinization and minimizing of homophobia; maintaining individual 'adult' responsibility; and constructing "proud" identities. . . ." (p. 820). Self-harming, in particular, cutting, could be perceived as a coping strategy for when individuals are very distressed.
McInroy (2020) [64] To investigate online fandom communities as supports for SGMYs, and their potential to contribute to the resilience and positive adjustment of SGMYs (mixed methods) Key strategies used during COVID-19-"relationships" (e.g., spending time with others online), setting "routines", "body and mind" (e.g., exercise and meditation), "rest and reset" (e.g., art and reading), and "tuning out" (e.g., binge-watching TV) (p. 1053). Alcohol and drugs also cited as a strategy. Rubin and McClelland (2015) [69] To explore the phenomenon of sexual identity management and the psychological costs of monitoring Participants developed relationships and support via Facebook, which requires sharing (e.g., thoughts, behaviors, and ideas), but, at times, they needed to hide and silence their emerging sexuality. The tempering of self-presentation, to offset possible social exclusion, was ongoing and perceived as treacherous. LGBT Coping strategies were categorized as resilient (e.g., drawing strength from resisting discrimination), managing ambivalence (e.g., being ". . . "out and proud", but also simultaneously uncomfortable with their sexuality or despising aspects of gay culture" p. 332), and engaging in self-destructive behavior (e.g., cutting).  We're strong and we're powerful" (p. 11).
Winskell and Sabben (2016) [22] To identify the contextual factors that inform sexual stigma and the cultural meanings that underpin this stigma (qualitative study) LGBT youths displayed rainbow symbols to disclose their community affiliation to others (e.g., to family members and authority figures). This symbol was associated with positive emotions, memories, and aspirations. There were learned meanings associated with rainbow symbols and these assisted them to navigate toward supports. a Where a mean age was not provided or could not be calculated, the age range reported or confirmation from the paper's corresponding author was used to determine that the mean age was ≤19 years. b LGBTQ+ terminology varies across papers; we cite the language and/or abbreviation adopted in the individual papers. ESMG = ethno-racial and sexual minority girls. GBQ = gay, bisexual, and questioning. GLBT = gay, lesbian, bisexual, and transgender. GLBTQ = gay, lesbian, bisexual, transgender, and queer. LGB = lesbian, gay, and bisexual. LGBTQ = lesbian, gay, bisexual, transgender, and queer. SMA = sexual minority adolescents. SMYs = sexual minority youths. TGDs = transgender and gender diverse youths. TGE = transgender and gender-expansive. TGNC = transgender and gender non-conforming.

Discussion
The issues SGMYs face, from physical violence to unsupportive families, have been well documented in the literature, but there is much less research on how SGMYs can best cope with environments that are often hostile to them. The present scoping review supports the earlier findings highlighting the relative paucity of interventions designed to support the mental wellbeing of SGMYs, including those that are web-based in format [8][9][10]. However, a UK Department of Health commissioned report highlighted SGMYs' strong preference to access help on the Internet, whereby 82.3% (n = 572) of SGMY participants reported that they would be "likely" or "very likely" to select help in this format [89]. Prior reviews have not delved into the therapeutic content of interventions, or the specific strategies designed to be effective in supporting the mental wellbeing of SGMYs, which represents a key strength of the present review.
Our current review indicates that a range of techniques or coping strategies have been considered as effective across cognitive or cognitive/emotional, environmental/social, and behavioral domains. When incorporated within interventions, the majority have been provided in-person. Therefore, there exists an untapped potential in adapting successful psychotherapeutic techniques to a Web-based format, in line with SGMYs' preferences. In relation to the intervention-focused studies, many of the techniques or strategies were evidence-informed and adapted to meet the needs of SGMYs. For example, the CBT techniques of cognitive restructuring and behavioral activation, adapted to be usefully applied to the lives of SGMYs, are adaptations that have long been advocated by psychotherapy experts in the field of SGMY mental health (i.e., [90,91]).
The review findings suggest some challenges for the developers of Web-based interventions for SGMYs. For instance, the ability for SGMYs to connect with other SGMYs has been reinforced as particularly important in regard to supporting the mental wellbeing of these young people. However, this connecting requires careful considerations if provided online, given the feedback provided earlier by both professionals and SGMYs about the risks [15]. Specifically, there are risks concerning online stranger connections, and Internet safety and security issues, including the risk of SGMYs being outed on the Web or specifically targeted for sexual exploitation. There are also serious challenges associated with how suicidality is safely managed in a Web-based context [15]. Another salient challenge is ensuring that interventions do not neglect the needs of SGMYs with other socially disadvantaged characteristics, such as minority race/ethnicity, disability, or female sex. Therefore, future interventions should represent multiple identities by fully acknowledging the intersections between SGM status [65], and other minority characteristics. In part, this could be achieved by using authentic portrayals of LGBTQ+ people, as suggested by Davis and colleagues [80], which would ensure that people with multiple identities are included.
Many simple strategies should be straightforward to embed in future Web-based and other interventions, such as psychoeducation pertaining to minority stress and its impact on SGMYs, as well as basic behavioral techniques, such as relaxations exercises. Youth-friendly and inclusive language adopted in interventions should also be easy to apply and readily adopted in future Web-based interventions, specifically the promotion of inclusivity by using an SGMY's preferred name and pronouns to model transgender supportiveness in resources. Interventions should also strive to use developmentally appropriate language, so that the terminology employed is easily understood by younger SGMYs. Therefore, therapy jargon and psychological concepts will need to be outlined suitably and acceptably to SGMYs.

Strengths and Limitations
To the best of our knowledge, the present review is the first to identify the recommended psycho-social coping techniques or strategies for building resilience and/or enhancing the wellbeing of SGMYs, based on the primary data published in peer-reviewed papers. A drawback of this approach is that we did not explore the gray literature and could have potentially missed relevant findings as a result. Our analysis of the included studies consisted of a narrative synthesis, as outlined by Arksey and O'Malley [21], which was required in this review due to it focusing on investigating the types of psychosocial techniques reported in the previous research, rather than quantifying the quality of the included studies or their success. In particular, given the diverse nature of the research reported upon, which included quantitative, qualitative, and mixed-method studies, a conventional sensitivity analysis (similar to those frequently applied to quantitative studies) was not possible. Moreover, given the heterogenous nature of the existing literature and the lack of intervention trials, a critical appraisal of the clinical outcomes associated with the intervention-focused studies is currently premature. As is commonplace, we only included papers published in the English language, due to our limited resources [92]. That this scoping review only included studies published in English means that the potential insights from papers written in all other languages will have been missed. Studies from a range of countries were included, such as research conducted in South Africa, Israel, and Puerto Rico. However, over two-thirds of the studies were from a single high-income Western nation, specifically the USA. American predominance in psycho-social research is not new [93], but this focus on the USA does create a bias we would like to acknowledge. Of relevance to the research on LGBTQ+ people is that studies will likely be absent in countries where social environments make basic survival challenging for SGMYs, such as in the countries where there is a death penalty for "homosexual acts". By contrast, across a range of more progressive countries, there has been considerable social progress for LGBTQ+ individuals (e.g., marriage equality). However, many SGMYs continue to face challenging social environments, which need to be improved. Whilst the focus of this review was on the coping strategies SGMYs could employ themselves, subsequent work should explore what is likely to be effective in regard to improving social environments for SGMYs. Fortunately, related work is underway, such as a PROSPERO registered review entitled "A realist evidence synthesis of mechanisms by which school-based interventions may widen or reduce inequalities in LGBT adolescents' mental health". We set our inclusion and exclusion criteria to emphasize an adolescent sample of SGMYs and we were holistic in terms of what was to be included regarding a study's design and particular focus. Others may have decided to make different decisions in shaping a comparable review; nevertheless, we strove to be transparent and have provided details around our searching of the literature and our rationale.

Conclusions
For years now, the unique issues and mental health challenges that SGMYs commonly face have been evidenced in considerable depth in the research literature. It is now timely to start developing robust and evidence-informed interventions that seek to assist SGMYs best manage their adolescent years, which are often experienced in unsupportive environments. This review provides an overview of the coping strategies designed to enhance the mental wellbeing of SGMYs, and, as such, it can be used to support efforts in assisting SGMYs to thrive. A range of strategies and interventions appear promising for use in Web-based tools, in order to support the mental wellbeing of SGMYs. However, issues around appropriately managing peer-to-peer online interactions and inclusion, especially for youth who experience multiple social disadvantages, will require careful consideration.

Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.

Data Availability Statement: Not applicable.
Acknowledgments: The authors would like to thank the stakeholders, organizational partners, and academic advisors for this project, such as our partner LGBTQ+ (lesbian, gay, bisexual, trans, queer) organizations and third-sector service providers. The authors also thank their other partners, which include two local authorities' public health departments, and the Centre for Policing Research and Learning (at The Open University). They also acknowledge their other advisors and the youth e-therapy research team in New Zealand.

Conflicts of Interest:
The authors declare no conflict of interest. The funder had no role in the design, collection, analysis, or interpretation of the data; writing of the manuscript; or the decision to submit this scoping review for publication.

Appendix A. Databases, Search Terms, and Search Results
Appendix A.1. Medline Search period: From inception in 1946 to 19 January 2022 Electronic limits: "Humans", "Adolescent (13 to 18 years)", and the "English" language Results: 1100 articles

Appendix A.2. Embase
Search period: From inception in 1980 to 19 January 2022 Electronic limits: "Humans", "Adolescent (13 to 17 years)", and the "English" language Results: 1226 articles AND coping*.mp. OR cope.mp. OR adapat*.mp. OR "Self Care"/OR self management.mp. OR "Mental Health"/OR resilience.mp. OR "Psychological Well-Being"/OR mental well?being.mp. OR "Self Help"/OR "Psychotherapy"/ Note: * The truncation symbol; ? The wildcard symbol; " "/ A subject heading within the database; .mp. The searched term can be identified from multiple places, for example, the paper's title, abstract, subject headings, or keywords.

Appendix A.3. PsycInfo
Search period: From inception in 1806 to 19 January 2022 Electronic limits: "Humans", "Adolescent (13 to 17 years)", and the "English" language Results: 1366 articles OR "Resilience (Psychological)"/OR "Psychotherapy"/OR "Well Being"/OR "Self-Help Techniques"/ Note: * The truncation symbol; ? The wildcard symbol; " "/ A subject heading within the database; .mp. The searched term can be identified from multiple places, for example, the paper's title, abstract, subject headings, or keywords.