Neglected gaps in improving the health, wellbeing, and care for sexual and gender minority young people living in low- and lower-middle- income countries: a scoping review

Background There is a lack of reliable data on the size, characteristics, and experiences of sexual and gender minority (SGM) young people (ages 10–24) in low- and lower-middle- income countries (LMICs). This review examines the research conducted in the last thirteen years with and about SGM young people living in low-income settings and seeks to answer the question: What is known about the mental and physical health needs, safety, and wellbeing of SGM young people living in LMICs? Methods We conducted a scoping review informed by the methodological frameworks put forth by Arksey and O’Malley and the Joanna Briggs Institute. We systematically searched two general social science databases and one topic-specific database for peer-reviewed papers, of any research design, that included SGM young people or explored attitudes toward SGM young people in LMICs. We included papers that reported on factors influencing the health and wellbeing of SGM populations, including physical and mental health, healthcare-seeking behaviors, substance use, experiences of discrimination and/or stigma, experiences of violence and abuse (emotional, physical, and/or sexual), economically motivated paid sex practices, housing or economic security, and attitudes of others toward SGM populations. Results Of the 5,409 unique records identified, 79 papers drawing from data collected from 74 unique studies met the inclusion criteria. Only 50 of the 79 papers included SGM young people as participants, with just 13 focusing exclusively on SGM young people ages 10–24. The included papers were classified into three thematic groupings: attitudes toward SGM populations (n = 26), risks to health (n = 40), and experiences of stigma and discrimination (n = 13). Conclusion The findings indicate that the health and wellbeing of SGM young people in LMICs has been historically under-researched. While SGM young people have received more attention from researchers in recent years, the body of literature as a whole is disjointed and sparse, and often studies are about SGM young people, rather than with and for them. Our review highlights the need for more and better research, more accurate and disaggregated demographic data, and leadership and participation of SGM-led community-based organizations in the co-design of studies that focus on SGM young people.


Background
Totaling 1.8 billion, today's generation of young people (ages 10-24) are the the largest population of young people in history and nearly 60% live in low-and lowermiddle-income countries (LMICs) [1].The percentage of young people who identify as sexual and gender minorities (SGM) 1 globally is unknown, because there is a lack of reliable data on the size of SGM populations [3].Data from the United States, which often serves as the starting point for global models of SGM populations [3], suggests that more than 9.5% of adolescents ages 13-17 identify as SGM [4].
Evidence from high-income countries show that SGM young people are subjected to higher rates of peer victimization, stigmatization, social stress, and family and social rejection compared to their cisgender and heterosexual peers [5].These experiences of discrimination, violence, and prejudice negatively impact the overall physical and mental health of SGM young people [6].An emerging evidence base of meta-analyses and longitudinal studies in high-income countries have confirmed associations between these experiences and the development and maintenance of anxiety, depression, self-harm, and suicidal behavior, as well as poor immune and cardiovascular function [7][8][9][10][11].In general, same-gender and same-sex sexual behavior and gender diverse expression is more aggressively sanctioned in LMICs than high-income countries: it is expressly criminalized in 41 LMICs, and punishable by death in seven [12].In light of recent evidence from high-income countries linking the negative impacts of unsupportive environments (including legislative) to the health and wellbeing of SGM youth [13,14], it is reasonable to suspect that SGM young people in LMICs are also experiencing the negative impacts of unsupportive environments on their physical and mental health.However, to what extent remains unknown due to a dearth of research [15].
To date, only one scoping review has explored survey research with gender minority adolescents in LMICs [16], but no scoping or systematic reviews have explored the full body of research on SGM young people in LMICs.The objective of this scoping review is to address this critical gap by reviewing literature published in the last decade with SGM young people (ages 10-24 as defined by the World Health Organization [17]) living in LMICs, that focuses on the health, safety, or wellbeing of SGM young people, and/or attitudes toward them.The primary research question this review aims to answer is: What is known about the mental and physical health needs, safety, and wellbeing of SGM young people living in LMICs?

Methods
Our scoping review design was informed by the methodological frameworks put forth by Arksey and O'Malley and the Joanna Briggs Institute [18,19].

Exploratory review
A preliminary search of the literature on sexual and gender minority young people living in LMICs was conducted prior to the searches performed for the scoping review.A search of Campbell Systematic Reviews, the Cochrane Library, PubMed, PROSPERO, and JBI Evidence Synthesis revealed that no reviews of this nature had been previously conducted nor were ongoing.Additional exploratory searches were conducted on two general social and behavioral science databases (Pub-Med, Web of Science) and one topic-specific database (LGBTQ + Source) to ensure a robust search.The exploratory review helped to inform the keyword list for our search strategy, refine the research question, and develop the inclusion criteria and objectives.

Study selection criteria
Peer-reviewed papers were considered eligible for inclusion in the scoping review if they: 5. Included a focus on SGM populations OR the focus was on attitudes toward SGM populations; 6. Explicitly focused on any subset of youth, adolescent, young adult, or student populations aged 10-24 OR the mean of the study sample was 9.5-24.4OR the median of the study sample was between 10-24 OR 51% of the study sample was between 10-24 OR data for a relevant outcome (see criteria #7) was disaggregated for any subset of the study sample age 10-24 OR the study retrospectively surveyed adult participants about their experiences during youth or adolescence; 7. Reported on factors influencing the health and wellbeing of SGM populations, including physical and mental health, healthcare-seeking behaviors, substance use, experiences of discrimination and/or stigma, experiences of violence and abuse (emotional, physical, and/or sexual), economically motivated paid sex practices, housing or economic security, and attitudes of others toward SGM populations Of note, we aimed to summarize the factors influencing the health of SGM adolescents beyond their risk for HIV/AIDS, their HIV/AIDS positive status, or engagement with HIV/AIDS testing and treatment services.This body of work has been reviewed elsewhere, with reviews speaking to the emerging sexual health needs of young men who have sex with men (YMSM) [21].While this body of work offers important insights into the health and wellness needs of SGM youth, we sought to focus on themes and outcomes that are often overlooked in the literature on SGM youth.Therefore, we excluded papers with health outcomes exclusively linked to HIV (e.g., HIV/AIDS or STI prevalence, transmission, testing, risk factors, and/or treatment).
In addition, we excluded the following types of studies and publications:

Search methods for identifying studies
In collaboration with an Information Specialist, we developed the search strategy (Appendix) for PubMed and modified it for use in the other databases.Search terms for identifying countries in the Majority World and classified by the World Bank as "low-, lower-middle-, and upper-middle-income countries" were adapted from the EPOC LMIC filters developed by the WHO Library and Campbell Collaboration [22].
Initial searches for articles published between January 1 st , 2010 -December 31 st , 2020 were conducted in February 2021 using PubMed, Web of Science, and LGBTQ + Source.An additional search was conducted in May 2023 to capture newer publications from low-and lower-middle income countries only released between January 1 st , 2021 -May 21 st , 2023.
Using the inclusion criteria described above, title and abstract screening were conducted in Covidence by researchers JD and CG.Full text review of for each publication was conducted by at least two of the three reviewers (JD, CF, CG).Any disputes regarding eligibility were assessed by the reviewer who had not screened the given article for inclusion at the full text stage and were resolved via discussion between all three reviewers.We imported all references into Zotero for citation management.

Data extraction
Three reviewers independently extracted relevant data from eligible studies in Covidence.We extracted data on study characteristics, thematic focus, and study population.The extracted data was imported into Airtable for cleaning and analysis.The dataset generated during the study can be accessed here.

Search results
The PRISMA flow diagram describes the study selection process (Fig. 1).We identified 5,409 records across the three electronic databases.After removing 892 duplicate results, 4,517 unique records remained and were screened for relevance based on a review of titles and abstracts; 3,213 abstracts were excluded based on relevance.The search was designed to return records from low, lower-middle, and upper-middle income countries, however the intent of the current review is to focus on the most resource-constrained environments, therefore records from upper-middle-income countries (669) were set aside for a separate review, leaving 635 records for full text review.Articles were most commonly excluded at the full-text review stage because they focused on adult instead of youth populations (n = 197) or took place in a high income country (n = 159).Ultimately, 79 papers representing 74 unique studies were included in this review (see Table 1).Of these, 50 papers included SGM young people ages 10-24 as participants to some extent, and only 13 focused exclusively on SGM young people ages 10-24.

Key findings by theme
The included papers (79) were classified according to their thematic focus.Across the review, three key groupings emerged: 1. Risks to the health of SGM populations (n = 40) 2. Attitudes toward SGM populations (n = 26) 3. Experiences of stigma and discrimination among SGM populations (n = 13)

Risks to the health of SGM populations
Half of the included papers (n = 40, 50.63%) examined the mental health, sexual health, and resilience of SGM young people, as well as comparative studies that explored the differential health risks that SGM young people are subjected to compared to their cisgender and/or heterosexual peers.[ These 14 papers covered topics such as SGM identity management and the need to conceal SGM identities in many social contexts to feel safe, the impact of religion on internalized homo/transphobia, and experiences of violence.The remaining nine papers were comparative studies that investigated the prevalence of adverse mental health outcomes (i.e., anxiety, depression, and self-harm) and protective factors (i.e., social support) of SGM young people compared to their cisgender and/or heterosexual peers [26,39,43,44,58,59,62,80,81].Three of the nine comparative studies explored the mental health of SGM youth in the Philippines, and found that SGM youth were at increased risk for anxiety, depression, appearance perfectionism, and suicidal ideation compared to their cisgender and/or heterosexual peers [58,62,81].Similarly, a study of Nigerian adolescents (with two publications that explored the same dataset) found that sexual minority individuals reported lower resilience and self-esteem when compared to their heterosexual counterparts [43,44].Quarshie et al. presented only descriptive statistics but also found that Ghanaian SGM youth also had worse mental health outcomes than their non-SGM peers [26].
In contrast, Lian et al. found that higher risk of suicidal ideation among sexual minority adolescents was location-specific and only seen in one of the three southeast Asian cities studied [80].
Sexual health Twelve papers (15.19%) focused on aspects of SGM sexual health, of which nearly all (n = 7) focused on YMSM and/or transgender people (n = 2) within a key populations HIV framework 2 rather than SGM young people explicitly [27,30,50,52,77,83,84,92,96].For example, one study was an evaluation of a harm reduction and sexual health promotion intervention for young male sex workers who have sex with men in Vietnam [84], while another was an assessment of client satisfaction with sexual and reproductive health services among adolescent key populations in Bangladesh [96].Also included in this grouping is a formative study exploring the acceptability of respondent-driven sampling strategies for recruitment of YMSM [50].The remaining three publications explored both the sexual health and mental health needs of SGM young people using a broader SGM framework.For example, Larsson et al. and Agradh et al. 's publications (drawing from the same dataset) used both self-reported measures of sexual attraction and sexual behavior to define and explore the unmet health needs of university students in Uganda [88].Cheng et al. similarly used measures of same-sex sexual behavior and same-sex romantic experience to explore the mental and sexual health outcomes of Filipino young people [75]. 2 The Joint United Nations Program on HIV/AIDS describes key populations as groups defined by their engagement in a specific set of higher-risk behaviors that increase risk of HIV transmission and infection including YMSM, transgender women, sex workers, people who inject drugs, and incarcerated people [102].

Experiences of stigma and discrimination among SGM populations
The thirteen papers (16.46%) under this theme focused on SGM young peoples' experiences of identity-based discrimination throughout the life course, and the impact of living in a society rife with homophobia, transphobia, and the social construct of gender binarism.Nine papers in this category, including a review, focused on gender minority and/or sexual minority populations only [31,46,57,63,66,69,70,73,78] and one explored the experiences of SGM young people in a larger study of school-going adolescents [38].Additionally, three studies focused on young SGM people who sell sex [41] and/or are homeless [37,54].Collectively, these thirteen studies explored discrimination in the context of a wide variety of life experiences, from emotional and sexual to educational and occupational.Internalized homophobia and transphobia experienced by SGM young people, and the role that inter-and intra-personal factors play in negatively impacting mental and physical health outcomes were explored in four qualitative studies [31,69,73,78].These studies highlight the struggles SGM young people face worldwide as they grow up in a global society that emphasizes heteronormativity and cisnormativity.These studies documented a range of harmful experiences, including bullying and lack of support at school [31] and violent treatment by police [69,73].

Discussion
To the best of our knowledge, this is the first review, scoping, systematic, or otherwise, to explore what is known about the mental and physical health needs, safety, and wellbeing of SGM young people living in low-and lower-middle-income countries.Our review shows that there is a lack of critical evidence about the mental and physical health needs, safety, and wellbeing of SGM young people in LMICs.The findings indicate that the research that does exist for SGM young people in LMICs is often about SGM young people, rather than with and for them.While research on SGM young people in recent years appears to be growing, of the 79 papers included in this review, only one-third (n = 29, 34.18%) specifically focused on SGM young people ages 10-24 [26, 28, 30, 35, 38, 39, 41, 43, 45-47, 50, 52, 57, 58, 60, 61, 66-69, 75, 79-81, 83, 96].Research that focused on young sexual minority women or women who have sex with women (WSW) [81] and non-binary adolescents [47] in LMICs was the most lacking in this review, with just one included study each (excluding reviews).Additionally, although this review included extensive search terms for all LMICs (see Appendix)-265 country terms, 31 regional terms, and 54 LMIC text words-only three included papers utilized data from studies conducted exclusively in a low-income country (all from Uganda), with the majority of included papers drawing on data from lower-middle-income countries.Our review highlights the need for more research with and for SGM young people living in LMICs, especially in the most resource-constrained environments.
We also included papers that focused on attitudes toward SGM populations.These made up nearly onethird of all of the papers (n = 26, 32.91%) included in this review [23-25, 29, 33, 34, 36, 42, 48, 49, 53, 64, 71, 74, 79, 82, 85, 89, 90, 93-95, 97-99, 101].The findings from these papers make it clear that discriminatory and hostile homophobic and transphobic attitudes towards SGM young people remain prevalent.While studies focused on attitudes can offer insight into how SGM young people are perceived in different contexts and settings, these studies do not provide information on how these harmful attitudes impact the physical and mental health of SGM young people.Thus, there is a critical need for studies that center the experience of SGM young people themselves.Only thirteen papers explored the differential health risks that SGM young people are subjected to compared to their cisgender and/or heterosexual peers.The limited number of studies identified and their differing findings suggest that more research is needed in order to better understand which adverse health outcomes SGM young people are at a higher risk of experiencing and in which settings [26,26,39,43,43,59,59,62,75,80,81,86,88].

Perpetuating erasure
Throughout the review, data on participants' sexual and gender identity was limited and inconsistently reported.
In order to better understand the needs and experiences of sexual and gender minority young people, demographic data about gender and sexual identity must be more accurately captured and regularly reported [16,103].In addition, there were many studies in this review that set out to recruit young adult populations but defined young people with a larger age band than that set by this review.Despite these larger age bands, age-disaggregated data was only reported in five of these papers [27,77,85,91,92].The lack of age-disaggregated data erases the experiences of SGM youth populations.Age data should be broken out in developmentally appropriate age bands, such as 10-14 for young adolescents, 15-19 for older adolescents, and 20-24 for young adults [104].This is critical for SGM young people (and for all young people in general) to become visible in the data, so their mental and physical health needs can be better understood and met with evidence-based services and programs, and included in global initiatives such as the United Nation's 2030 Agenda and Sustainable Development Goals (SDGs) [105].
That said, we recognize that sample size limitations can preclude age-disaggregation.For example, Johnston et al. 's study was originally focused on recruiting young people ages 15-24 and they report having to increase the age limit to 28 to boost recruitment [76].Additionally, it may not be possible to disaggregate datasets due to the potential risk of individuals becoming identifiable in the data [104].Ramadhani et al. noted that a limitation of their study was the small sample of transgender women participants, ultimately leading to the authors' decision to pool transgender women and MSM survey respondents [27].

A way forward
There is no one-size-fits-all solution to increasing participation of SGM young people in research and safely capturing more inclusive demographic data.However, two strategies adopted by studies included in this review that researchers could consider utilizing are communitybased participatory research (CBPR) approaches and working with local youth networks to co-design research directly with SGM young people (Table 2).For example, Ganbaatar et al. and Meer and Muller, integrated CBPR principles with their qualitative study designs to effectively engage with young SGM populations and shine a light on their lived experiences [45,66].Ganbaatar et al. used photo-elicitation with queer young people in Mongolia to better understand how youth navigate their SGM identities, and Meer and Muller worked collaboratively with SGM youth from Zimbabwe, Kenya, and Botswana to create an anthology of graphic short stories that represented their lived experiences as queer Africans.Additionally, a study on unmet HIV and mental health needs in Southeast Asia was designed to work collaboratively with a local youth network to develop study tools relevant to the lives of adolescents and young key populations, including SGM young people [52].Not only does meaningful involvement of the target population in research design and implementation result in more culturally appropriate survey tools, but it can also promote wellbeing and resilience among its participants [106].Obtaining waivers of parental consent from ethical review boards is also a potential strategy that could increase participation (and potentially safety) of SGM youth in research.This is a strategy that is sometimes necessary in order to safeguard and encourage research informed by SGM young people, mitigate potential risk due to forced disclosure of sexual orientation and/or gender identity, and help to ensure that SGM young people who are at high risk for negative health outcomes are included in critical research [107,108].
Alliance building with SGM-led community based organizations (CBOs) will also be key to continuing research with SGM young people in settings where samesex relations between consenting adults and/or forms of gender diverse expression are criminalized [109].This is more important now than ever given the escalating political volatility towards SGM individuals around the globe [110,111].This review identified 43 papers that draw from data collected in 19 different countries where SGM identities and behaviors are criminalized, 3 demonstrating that it is possible to conduct research on sexual • Conduct risk assessments and develop risk mitigation plans for ensuring the confidentiality and safety of all study participants • Leverage online tools to recruit study participants and/or collect data 3 This is inclusive of six papers that described studies that were conducted in India prior to the 2018 Indian Supreme Court decision that decriminalized homosexuality [112].
Guidance on the ethics of research with young SGM people is needed to increase participation of SGM young people in research.When conducting research in countries with laws that are restrictive or punitive, where there is significant risk, it is paramount that risk assessments are conducted together with local SGMled organizations and groups before, during, and after all studies so that the health and safety of participants can be protected [113].Example tactics, as utilized in a feasibility study with adult MSM in Kenya, Malawi, and South Africa, include developing risk mitigation plans for each study site that outline protocols for ensuring the safety and confidentiality of study participants; requiring study staff and relevant stakeholders to sign confidentiality agreements; and forming advisory committees that include people from the priority population to oversee study implementation [113].
In contexts where internet is accessible, conducting virtual studies may allow for greater participant safety and anonymity [109].There are known risks, however, with relying primarily on social media and chat groups for health information and peer support.Misinformation and cyberbullying can be pervasive, algorithmic biases exacerbate existing gender, class, education, and geographic inequalities, and sharing health information online raises privacy concerns [114].Although researchers should be aware and take precautions against these risks, virtual tools have the potential to increase participation of SGM people who have online access.For example, a recent study with queer women and transgender men in Kenya used online sites and platforms to both recruit participants and conduct one-on-interviews.In order to promote safety of the study participants, interested participants were given an information sheet about online privacy and were asked to complete a self-assessment about potential individual risks [115].Another study with adult SGM participants from Zimbabwe and South Africa involved responding to qualitative study questions using voice notes and/or texts over WhatsApp.The study authors found that the anonymity of participants could be maintained by having the participants send their responses to an intermediary instead of directly to the researchers [116].

Challenges and limitations
This review is not without its own challenges and limitations.While more adolescent-focused HIV research is certainly needed, we chose to focus this review on outcomes not linked to HIV [117].We felt that this was important to shed light on other topics related to SGM health and wellbeing, however, we understand that this has limited the scope of the review and may have left out relevant findings from the HIV-focused body of literature.
Due to time and budget constraints, we prioritized SGM adolescents living in LMICs and therefore limited our focus only to peer-reviewed research from low-and lower-middle-income countries published between 2010 and May 2023.We recognize the need for a larger global review on the health and wellbeing of SGM adolescents.
Additionally, our review was limited to three research databases and papers published in English only, and as a result, we may be missing valuable research published locally in LMICs.We also did not directly reach out to authors of the included publications; this would have provided additional insight into how some of the barriers to conducting studies in countries where same-sex relations and/or gender diverse expression are criminalized were overcome and research was safely conducted with young people.As white researchers based in the United States, we recognize that we live and work within a different cultural context than the populations we are studying.We acknowledge that this lens impacts and limits our work and our understanding of this body of literature.

Conclusion
Our findings demonstrate a clear lack of rigorous research with SGM young people in LMICs.While this topic has received increased attention in the past four years, there is still much that is unknown about the mental and physical health needs of SGM young people in LMICs due to the limited and disjointed nature of the research that exists.We must advocate for rigorous studies with age, sexual orientation, and gender-disaggregated data that are co-designed with SGM young people and SGM-led CBOs from the outset, to not only better understand the experiences of SGM adolescents at various stages of development and across all gender and sexual identities, but also to develop solutions that more accurately identify and meet their needs.

Search Strategy
The search strategy was used to search PubMed, LGBTQ+ Source and Web of Science in February 2021.

Web address Search Field Used
LGBTQ+

Fig. 2
Fig. 2 Included Papers by Country and Income Classification

Table 1 (
continued) c Sexual orientation and risk factors for suicidal ideation and suicide attempts: a multi-centre cross-sectional study in three Asian cities Vietnam, China, Taiwan

Table 2
Recommendations for Research with SGM Young People in LMICs • Develop guidance on the ethics of research with young SGM people to increase participation in research • Adopt CBPR principles and allow SGM study participants to co-develop research aims, tools, and procedures • Partner with local youth networks, influencers, and inclusive CBOs to recruit participants and encourage buy-in • Obtain waivers of parental consent from ethical review boards maldives OR indian ocean OR mali OR malta OR micronesia OR kiribati OR marshall islands OR nauru OR northern mariana islands OR palau OR tuvalu OR mauritania OR mauritius OR mexico OR moldova OR moldovian OR mongolia OR montenegro OR morocco OR ifni OR mozambique OR portuguese east africa OR myanmar OR burma OR namibia OR nepal OR netherlands antilles OR nicaragua OR niger OR nigeria OR oman OR muscat OR pakistan OR panama OR papua new guinea OR paraguay OR peru OR philippines OR philipines OR phillipines OR phillippines OR poland OR polish people's republic OR portugal OR portuguese republic OR puerto rico OR romania OR russia OR russian federation OR ussr OR soviet union OR "union of soviet socialist republics" OR rwanda OR ruanda OR samoa OR pacific islands OR polynesia OR samoan islands OR "sao tome and principe" OR saudi arabia OR senegal OR serbia OR seychelles OR sierra leone OR slovakia OR slovak republic OR slovenia OR melanesia OR solomon island OR solomon islands OR norfolk island OR somalia OR south africa OR south sudan OR sri lanka OR ceylon OR "saint kitts and nevis" OR "st kitts and nevis" OR saint lucia OR st lucia OR saint vincent OR st vincent OR grenadines OR sudan OR suriname OR surinam OR syria OR syrian arab republic OR tajikistan OR tadjikistan OR tadzhikistan OR tadzhik OR tanzania OR tanganyika OR thailand OR siam OR timor leste OR east timor OR togo OR togolese republic OR tonga OR trinidad OR tobago OR tunisia OR turkey OR turkmenistan OR turkmen OR uganda OR ukraine OR uruguay OR uzbekistan OR uzbek OR vanuatu OR new hebrides OR venezuela OR vietnam OR viet nam OR middle east OR west bank OR gaza OR palestine OR yemen OR yugoslavia OR zambia OR zimbabwe OR northern rhodesia