Understanding the processes underlying self-harm ideation and behaviors within LGBTQ+ young people: A qualitative study

Abstract Objective This study aims to understand the processes underlying self-harmful thoughts and behaviors, with and without suicidal intent, among LGBTQ+ young people. Method Nineteen semi-structured interviews took place between October 2019 and May 2020. Participants were aged between 16 and 25 years, had experiences of self-harm ideation and behaviors, and were part of the LGBTQ+ umbrella. A range of sexualities and gender identities were represented: eleven participants were cisgender, six were transgender and two were non-binary. Interviews were transcribed verbatim and anonymised. Thematic analysis and reflective member-checking were used to develop a thematic framework. Results Three themes were developed from the interviews and evaluated by four participants who engaged with reflective member-checking. Findings indicated that internal processes and external responses to being LGBTQ+ resulted in self-harmful thoughts and behaviors. Alongside these, additional stressors related to being a young person were led to difficulties with self-harm. Conclusions Findings from this study indicate that young people often struggle with accepting their LGBTQ+ identity for a number of reasons, whether this is due to access to a resource or their own feelings about their identity. These negative self-perceptions can be enhanced by poor responses from others and additional life stressors which impact their self-esteem or self-perception. HIGHLIGHTS Understanding and accepting that one is LGBTQ+ is not always a simple process, struggling with these thoughts can influence self-harm. Lack of LGBTQ+ terminology hinders self-acceptance and caused young people to engage with self-harm. Peers and family members responses to a young people’s LGBTQ+ identity is highly significant and can directly led to self-harmful thoughts and experiences.

INTRODUCTION Self-harm, the self-injury or poisoning irrespective of suicidal intent (NICE, 2011), is a crucial issue impacting young people (Geulayov et al., 2018).
LGBTQþ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning) youth are particularly vulnerable (Liu et al., 2019). Given self-harm ideation and behaviors (SIB) are the strongest predictor of suicide attempt and completion (Hawton et al., 2012(Hawton et al., , 2020, this is particularly worrying. Among LGBTQþ youth, SIB is around 30-50% more likely (particularly in trans people, those who do not identify their gender with the sex assigned at birth) than among cisgender (individuals who identify as the sex they were assigned at birth), heterosexual peers (Liu et al., 2019;Marshal et al., 2011). Given these significant disparities between LGBTQþ youth and cisgender, heterosexual youth in SIB, it is crucial to explore processes that underlie these experiences. Among LGBTQþ youth, SIB has been linked to high rates of mental health difficulties, victimization (Williams et al., 2021), interpersonal problems, lower self-esteem (Arcelus, Claes, Witcomb, Marshall, & Bouman, 2016), difficulties with self-concept integration and social comparison (Taylor, Dhingra, Dickson, & McDermott, 2020). The Minority Stress Theory (MST; Meyer, 1995Meyer, , 2003Hendricks & Testa, 2012) suggests that mental health is affected by proximal (internally orientated processes) and distal (objective, external events) stressors based on one's minority status. These adverse experiences negatively impact SIB (Arcelus et al., 2016;Shilo & Mor, 2014;Taylor et al., 2020;Williams et al., 2021;Wilson & Cariola, 2020) and explain some of the disparity seen between LGBTQþ youth and cisgender, heterosexual peers.
Minority stressors within the LGBTQþ umbrella can include internalized and external homo-and trans-phobia McDermott, Roen, & Scourfield, 2008;McDermott, Hughes, & Rawlings, 2017;McDermott, Hughes, & Rawlings, 2018;Puckett et al., 2017), body and gender dysphoria (Bailey, Ellis, & McNeil, 2014;Wilson & Cariola, 2020), or impact of transition (social or medical) among others (Beek, Kreukels, Cohen-Kettenis, & Steensma, 2015;Coleman et al., 2012;Wylie et al., 2016) In order to reduce SIB, it is key to understand what these shared stressors are and how they relate to being part of a minority group. This is particularly important to be studied among young people as their identity develops when moving from childhood to adulthood.
While there is some consideration given to underlying processes which lead to selfharm across LGBTQþ young people in qualitative research (McDermott et al., 2018;McDermott, Roen, & Piela, 2015;McDermott et al., 2008), this is still a relatively small pool. Research is often split by identity (Dunlop et al., 2021) or by aspect of self-harm, e.g., non-suicidal self-injury (Jackman, Edgar, Ling, Honig, & Bockting, 2018) or suicidal intention (Hunt, Morrow., & McGuire, 2020;Rivers, Gonzalez, Nodin, Peel, & Tyler, 2018). This study aims to extend the literature in this area by looking across LGBTQþ identities and the dimensions of self-harm. Sexual orientation has been grouped with gender identity in this study as both are part of a minority group at a time when their identity is developing. By having these broad categories for self-harm and LGBTQþ identities, it is thought that this research will have utility across research, clinical and third-sector services and well help us to understand the interaction between SIB and being part of a minority group. Furthermore, by adopting the NICE (2011) definition of self-harm, findings can give insight into how particular experiences can influence the transition from SIB to suicide attempts in young people. Therefore, the aim of this study is to explore the views of young LGBTQþ people's regarding the factors that influence their SIB using a dimensional approach of self-harm to include experiences with and without suicidal intent.

Design
A cross-sectional qualitative study using semi-structured interviews considering experiences of self-harm ideation and behavior among young people who self-identified as part of the LGBTQþ umbrella. This study was granted ethical approval by the Science, Technology, Engineering and Mathematics review committee at the University of Birmingham (ERN_19-1032). A COREQ checklist can be found in the Supplementary materials 1.

Participants
Nineteen participants were interviewed between October 2019 and May 2020, through online, physical and snowballing recruitment strategies (see SM2 for more information). These participants were from the U.K. (n ¼ 16), U.S.A (n ¼ 2), and Israel (n ¼ 1). Participants held a range of gender identities; 11 being cisgender (1 male; 10 female), 6 transgender (4 trans male; 2 trans female) and 2 who were non-binary (people who identify outside of male or female). These individuals also held a variety of sexual orientations (Table 1). Ages ranged from 16 to 25 (M: 21.2, SD: 2.7).

Procedure
The interview schedule was developed with input from an advisory group of LGBTQþ young individuals who had experience of SIB and piloted with two individuals. The interviews broadly discussed SIB, and how this may link with being LGBTQþ, finishing by asking about help-seeking and recovery. The semi-structured nature of the interview allowed reflexivity and flexibility (Mason, 2002). All participants were interviewed by AJW, who has previous experience of qualitative interviewing and lived experience of these phenomena. These were single interviews, with only the primary researcher and participant present. Personal reflexivity of the researcher can be found in Supplementary materials 2. Participants were encouraged to use the language which they felt was appropriate for them to describe their SIB. Field notes were taken during the interviews, which acted as question prompts and highlighted points of relevance within the interview. The interviews lasted a mean of 63 min (45 0 to 89 0 ) and were audio recorded and transcribed verbatim with identifying information removed for confidentiality. The majority of participants had experiences of SIB, with just under half discussing at least one suicidal attempt. One participant withdrew from the study as they had not realized that the main topic of the interview were SIB experiences instead of mental health generally.

Analysis
As all interviews and transcription were completed by AJW, the researcher was immersed in the data from collection. Initial coding of interviews began during data collection and was ongoing to ensure that data saturation was achieved before recruitment was ceased (Guest, Namey, & Chen, 2020). Following transcription, data was imported into NVIVO12, and inductively thematically analyzed following steps by Clarke (2006, 2019). Extensive coding of topics, content and context was performed. Similarities and differences among the codes were identified in order to develop preliminary subthemes within the data. These subthemes were continuously viewed in relation to the interviews, allowing for reflective consideration and critical discussion between all authors. AJW and JA refined subthemes to move forward the strongest identified. Notes and discrepancies were evaluated to enhance the accessibility of subthemes and regrouped to make major themes. This framework was then evaluated and discussed by all authors to create a full thematic framework.
While transcripts were not return to participants, to enhance the accuracy and validity of this framework, participants who had expressed interest in being involved in member checking were contacted. These participants engaged with member checking (Harvey, 2015). Member-checking supported the proposed framework with minor adjustments (language used in theme descriptor).

RESULTS
Three major themes were identified; (i) Struggling with processing and understanding one's own LGBTQþ identity; (ii) Negative responses to being LGBTQþ; and (iii) Life stressors. Each theme is described in further detail and supported by participants' quotes. The thematic framework is presented in Table 2, with theme and subtheme prevalence. Theme prevalence is offered for an insight into the generalizability of themes across participants. However, it is important to note that not every participants' experiences are the same and lower prevalence does not indicate the importance of a specific experience to an individual.

Struggling with Processing and Understanding one's Own LGBTQ1 Identity
Participants discussed at length their internal self-evaluation in relation to their LGBTQþ identity and how this led to SIB with and without suicide intent. Multiple aspects fed into this process; not having the appropriate language to explain their thoughts and feelings even to themselves, hating their LGBTQþ identity, coping with gender dysphoric feelings and the difficulties of medical transition. These aspects negatively influenced participants' self-acceptance, which led to self-harmful thoughts, behaviors and occasionally suicide attempts. During member checking one participant described how "self-acceptance is an ongoing process and can fluctuate for some folks" (Trans man, Bisexual, P4), which indicated that understanding and accepting one's LGBTQþ identity is often not a linear process.

Not Having the Words to Describe Feelings and Thoughts Associated with
LGBTQþ Identity During early adolescence, self-harm was often related to working out one's sexuality and gender identity. Participants typically felt that their sexual attractions or gender identity were somehow different from their peers but did not have the words to describe what was going on for them; I think that was very much there but I probably I didn't have the terminology to understand erm, myself or that you could have a life anything other [than heteronormative relationship] (Cis woman, Lesbian; P12).
The word trans was not something I heard until I was like 20 so, erm I didn't think it was a possibility and I didn't really connect me not liking my male body to me wanting to be a girl. (Trans woman, Polysexual, P5) By lacking this terminology, participants described how they were confused by their feelings and thoughts of being LGBTQþ, and often tried to suppress these which ultimately caused distress and SIB.
Internalized Hatred Relating to LGBTQþ Identity Young people often struggled with accepting that they were LGBTQþ, leading to selfstigma and internalized hatred. Participants described feeling as though they were unable to think about being LGBTQþ or imagine a future where this was the case, therefore believed that they deserved to be in pain due to their sexuality and/or gender identity which could make them engage with SIB; for some resulting in a suicide attempt; "I didn't allow myself to accept or think about at that time that I was gay" (Cis woman, Lesbian, P12).
I think it was a lot of me feeling like I deserved it [self-harm]. Erm and that it was again a form of punishment for me because I genuinely thought that what I was feeling was sinful and that I needed to get it out for me. (Trans man, Queer, P19) While for some internalized hatred was part of the journey toward accepting themselves, other participants still felt very negatively about their LGBTQþ identity and were unable to accept this aspect of themselves, this was a key factor leading to their selfharm. In particular, one participant spoke at several points about not wanting to stand out or be considered different in anyway which transcended into their early adult life. Coping with Gender Dysphoria Among transgender and gender diverse participants, an important cause for SIB was experiencing difficulties with their bodies and others using the wrong pronouns; this was described under the umbrella of gender dysphoria. Young people explained how the mental distress caused by gender dysphoria led them to feel that they should hurt themselves and was an ongoing issue, as their bodies did not represent their true gender and were triggering their pain.
if I was already in a bad place you know something just as small as one pronoun would just sort of send me into a spiral … . Yeah I'd say especially like dealing with like gender dysphoria, you know, it feels you know kind of natural to take those feelings out on your body when it feels like it shouldn't even be yours. (Trans man, Gay, P2) For some, this resulted in very specific, localized self-harm.
Hurt myself in my biceps or where I'm muscular. And when I was younger, so I would hurt, I would disproportionally get hurt in my testicles a lot. Erm like I tried to, I tried to castrate myself sort of (Trans woman, Polysexual, P5)

Difficulties of Medical Transition
Participants discussed the financial costs of medical transitioning to some degree, and the stress due to waiting time for NHS trans health services, which occasionally forced young people to buying gender affirming hormone therapy online. Interestingly, participants from the U.S.A and Israel had been able to begin transition legally prior to the interviews and so much of their discussions were retrospective. UK-based transgender participants were all still on waiting lists and dealing with these issues at the time of interview. They (Gender Clinic) sent me back a letter a couple of months later saying "18 months, see you a year and a half from now." And then when that year and a half came they'd delayed it another year or so, and at that point I've just spent 2 years of my life waiting to get care so I can make the decision and when it got pushed back that's when I got suicidal because I just needed the help there and then. (Trans woman, Pansexual, P16) The long waiting times for transitional appointments caused distress and self-harm as participants felt as though they would never be seen by professionals resulting in thoughts of hopelessness about their futures. Further concerns shared among participants included that they would age out of a particular service before receiving treatment or that they might need to take on private services, which would increase the financial burden. One participant discussed how this pushed back further life experiences, such as attending university, as young people were trying to deal with medical transition first.

Negative Responses to Being LGBTQ1
A common theme which dominated the interviews was how others had and might respond to young people disclosing their LGBTQþ status or outwardly presenting as LGBTQþ. The fear and experience of rejection was frequently stated as a perceived cause of self-harm. This often furthered any negative perceptions the young person held of themselves and intertwined deeply with their self-esteem.

Peer Abuse and Bullying
Some participants spoke about how peers at school who knew or suspected their sexuality would react, and that this made them a target for insults, bullying and abuse.
I had probably about at least half, 150 people being "oh [name] dirty lesbian" coming into my classrooms, I had people throwing balls of yarn covered in piss, piss, urine, didn't ever hit me. Queer,P11) Once their peers knew about their non-heterosexuality, changing rooms were a place for discrimination and bullying. Several young people spoke about how they were accused of looking at others while changing or otherwise invading others' privacy. This caused violence for some, while others isolated themselves to avoid confrontation. everyone would be like "ew she's going to be looking at us" like "aw I bet she fancies us kind of thing," like I felt better being away from everyone else which it didn't feel great that I had to kind of go somewhere else from other people [ … ] I think definitely the discrimination I got when I was younger from other girls, that definitely impacted it [selfharm and suicidal thoughts] because it added to that low mood and just not feeling accepted. (Cis woman, Bisexual, P15) Subsequently, young people were anxious about sharing their LGBTQþ identity and would keep it hidden. This, however, resulted in participants feeling they were not being their "true selves" causing emotional turmoil, ultimately leading to self-harm and sometimes suicide attempts. I felt like anger for like how other people had treated me but I didn't know how to express that anger in a healthy way towards the actual reasons I was feeling angry and so it became self-directed anger and kind of felt like I should punish myself. (Cis woman, Bisexual, P1)

Unaccepted and Unsupported by Family
Commonly, these negative responses to LGBTQþ status came from family members. For transgender and gender diverse youth this could be that their family invalidated their gender identity and desire to transition. This had a detrimental impact on the relationship between the young person and their family. my mum basically used to send me loads of like articles to read and she was all for "oh you know you need to look at the other side and stuff" but they were all really like blatantly transphobic articles and one of them was so bad I had a panic attack really bad. (Trans man, Gay, P3) my mum has just refused to call me [name] or use my pronouns. Despite coming to the clinic, sitting down with professionals being told "your daughter needs to hear this from you." And she just wouldn't (Trans woman, Pansexual, P16) Participants describe the experiences above as isolating and caused a huge amount of distress which resulted in self-harm. Even if a parent or family did accept their child as being LGBTQþ, this did not always result in the young person feeling as though their identity was supported which could influence their own self-acceptance journey.
Sometimes still with my family, especially with my mum, even though I feel that she accepts that I'm gay she still tries to get me to be someone that I'm not [ … ] And I struggle with that, that she doesn't just, that there's not this acceptance of this is who I am, don't try and change me. (Cis woman, Lesbian, P12) One participant noted that their parents not accepting that they were a lesbian caused them to feel "like I needed to change myself or be someone that I wasn't to make my parents happy and then I just ended up disliking myself" (Cis woman, Lesbian, P12), which ultimately caused them to suppress their identity and limit disclosure. For this individual, this ended with them attempting suicide several times.

Life Stressors
This was the final theme which was developed to convey young LGBTQþ people's narratives of difficult experiences that they had faced. These experiences, while not always explicitly related to the individual's LGBTQþ identity, often shaped other elements of their coping mechanisms or self-perception which impacted self-harm.

Abusive Experiences
Several young people experienced some form of abuse. For most, this abuse was emotional, however one participant experienced multiple types of abuse from her parents and brother.
My dad physically, emotionally and sexually abused me throughout my life.
[pause] Erm and my mother physically and emotionally abused me. I was on child protection when I was a child. And then my brother, I was his punching bag from around the age of 2 onwards … (Cis woman, Lesbian, P17).
For participant 17, she began self-harming at a young age and was sectioned several times following suicide attempt. Primarily she associated SIB with her abusive experiences and bullying from peers related to her abusers. Another participant spoke in depth about their experience of being sexually assaulted while hitchhiking which caused them to completely shut down their internal dialogue and progress regarding their sexuality and gender identity. She discussed how SIB was a tool for communication and coping with their experience.
… then one of those times when I was hitchhiking I was assaulted and kind of regressed everything. I went into a depression afterwards and kind of didn't leave my house a lot [ … ] My problem was trauma. But it wasn't self-harm, self-harm was the way I dealt with it. But I did have, in some ways self-harming was a way to get people to notice that there was a problem. (Trans woman, Polysexual, P5)

Stress of Feelings Responsible for Others
Stress was often related to feeling responsible for others' either physical or emotional health. Several participants had caring duties for people within their families or foster family and felt it was their responsibility to look after the person who was disabled or ill. This led to them feeling overwhelmed, and engaging with self-harm.
I was doing sort of like night shifts just learning how to be a proper carer, like you know he [foster brother] had seizures, epilepsy, and you probably don't know what it is but chronic seizures. They're erm. And I was only doing it for a little while but it was really a lot to process, you know, like obviously his [foster father] daughter had been brought up with it because he was, he was about 24 now I think but you know. It's terrifying seeing that you know. And he was really ill, really ill. Queer,P11) Other participants spoke about how they were emotionally supportive for friends. Often, the case was that the participant was the person that many people came to discuss their own problems with, including mental health. Because of this, the young person felt they were unable to disclose their own struggles without burdening their friends, and that it was their priority to care for their friends over their own wellbeing. As young people were looking after others, this meant their own SIB was pushed aside and caused them not to seek help, as they felt their own feelings were not a priority. the problems with my friends, my friends were going through depression and stuff. And having stuff going on in their lives, and I was always the one who was like helping them out. And it got to a point where it was just too much for me, I just started cutting and stuff … (Cis woman, Lesbian, P9)

Difficulties Relating to Physical Injuries and Illnesses
A number of participants also dealt with ongoing physical injuries or illnesses which caused them great stress. "I have chronic back and neck pain after fracturing my spine [ … ] I would say [pause] it affects my mood a lot and it can affect the self-harming aspect as well." (Cis woman, Lesbian, P6). Another participant discussed at length how their physical illness, caused them to isolate themselves from others, question their sexual orientation due to a fear of being intimate with others and described how it left her feeling hopeless. "it (self-harm) was to do with a physical health thing that I had going on that I felt really embarrassed about and didn't tell anyone about and yeah. I didn't really have any hope for the future" (Cis woman, Bisexual. P14).

Academic Pressures
Finally, participants discussed how they were concerned about their academic performance, that they were perfectionists, and that they could not live up to their own expectations. For some, pressure also came from their parents to succeed but mainly the young people discussed the pressures which they put on themselves. These pressures led to feelings of anxiety particularly in relation to exam periods, such as A-levels, or in the first year of university.
So with the end of first year just before like probably 2 months before first year exams things just got really, really bad. Erm, and I'd yeah, it was, it was like a daily every minute just thinking I'd be better off dead. (Cis man, Gay, P3) One of the participants stated how academic pressures tend to "affect everyone a lot more directly, and I feel it is something which contributes, is affected by and is at the center of a person's life at this age." (Trans man, Bisexual, P18). This highlights the key position of school, college or university plays within many young people's lives.

Discussion
Our findings extend the knowledge regarding the etiology and maintenance of SIB among gender and sexual minorities young people. At a time when a person moves from childhood to adulthood the sense of belonging is important (Corrales et al., 2016), hence being part of a minority group is particularly hard McCallum & McLaren, 2010). People from the sexual and gender minorities share the experiences of being different, of not being accepted in a big part of society, of living against many religious believes, and of experiencing discrimination and abuse (McDermott et al., 2018;D'Augelli, Grossman, & Starks, 2006;Meyer, 1995). As a consequence, is not surprising that SIB is high among this population. Aiming at understanding the interaction between SIB and growing up as part of a minority group, this study provides interesting findings. Firstly, the study confirms the influence of accepting one's self as part of the LGBTQþ umbrella in SIB. Secondly it highlights the important role of peers and family and the influence of not being accepted by them in SIB. These findings allow for an in-depth understanding of how different groups can influence SIB by overt and indirect actions. Furthermore, this selfexploration and acceptance of being LGBTQþ may act as a representation of proximal stressors while distal stressors are represented by others' attitudes and responses. This is consistent with prior research, which indicates that minority stressors are influential to self-harmful thoughts and behaviors, with and without suicide intent among LGBTQþ young people (Wilson & Cariola, 2020;Rivers et al., 2018;McDermott et al., 2008;McDermott et al., 2017;Meyer, 1995).
Understanding and processing one's sexuality and or gender identity is an ongoing journey, and self-acceptance is many times the longest and painful, complex process. The role of self-acceptance among young people and its influence in SIB, highlights the need for society to normalize sexual and gender minorities through education and appropriate role models. An interesting finding from the study is the distress caused by the lack of LGBTQþ terminology which affect their sense of identity and their own identity formation. Lack of self-acceptance could lead to internalized hatred and internalized trans-and homophobia. Among TGNC participants this internalized hatred was frequently interwoven with gender dysphoria. Furthermore, participants' internalized phobia was validated by external phobia and feelings of rejection or discrimination from peers, friends, and family members which increases the self-hate and SIB. Witnessing discrimination toward LGBTQþ individuals caused some participants to delay their self-acceptance and worsened struggles with SIB. Therefore, it is important to consider LGBTQþ young people who engage with SIB holistically, underlying processes can be influential to each other and relate to earlier experiences within the young person's development.
The final theme "Life stressors" is somewhat complicated. While these experiences were not explicitly connected to participants' LGBTQþ identity here, they may be interlinked with other aspects of participants' self-views which as discussed are highly influential to SIB. Abuse and maltreatment (Cederbaum, Negriff, & Molina, 2020;Çelik & Odaci, 2012), the perception of ill health (Goodwin & Olfson, 2002), and perfectionism (Smith et al., 2018) have all been linked to negatively impacting self-perception and self-esteem. Given that LGBTQþ youth often struggle with their self-esteem (Gnan et al., 2019;Arcelus et al., 2016), these life stressors may enhance already tumultuous self-perceptions, and relate to the behaviors of prioritizing others first. This, in turn, led to our participants struggling more with self-harm. Therefore, these findings highlight the importance of understanding how self-perceptions relate to self-harmful thoughts and behaviors.
Based on these findings, supporting young people who are LGBTQþ through their self-exploration is key to reducing self-harm. Part of our participants' experiences was that a lack of terminology to describe their developing understanding of their sexual or gender identity, and limited awareness of LGBTQþ identities during early adolescence (Thorne, Yip, Bouman, Marshall, & Arcelus, 2019). This might reflect a failing to include LGBTQþ education or information within education systems; and therefore highlights the importance of inclusive education regarding LGBTQþ experiences, history and terminology consistently throughout year groups. Such approaches enhances young people's ability to engage with LGBTQþ history and culture to promote acceptance among students broadly (Wagaman, Shelton, & Carter, 2018). Additionally endorsing accepting behaviors in students from younger ages and reduce the level of discrimination or bullying directed toward LGBTQþ peers (Gower, Rider, McMorris, & Eisenberg, 2018).
Findings also suggest that the responses from others are highly influential to personal acceptance and self-harm. Supporting young people to better understand their own identity and enhance their self-perception can be enhanced by positive approaches and acceptance from family members, friends, peers and society on a wider scale, this furthers young LGBTQþ people's confidence and self-esteem (Romijnders, Wilkerson, Crutzen, Kok, Bauldry, & Lawler, 2017). Family acceptance is crucial (McDermott, Gabb, Eastham, & Hanbury, 2021), acting as the strongest influence to positive self-esteem and feeling comfort as LGBTQþ in young people (Snapp, Watson, Russell, Diaz, & Ryan, 2015). These findings emphasize the need for families to approach LGBTQþ disclosure in an accepting and reassuring manner to ensure good mental health (McDermott et al., 2021), this would therefore help mitigate and perhaps even reduce self-harm.
Professionals working closely with LGBTQþ youth, (educators, social workers, CAMHS workers, counselors), require a broad understanding of the young person's family environment and context around the individual (Roe, 2017;Wagaman et al., 2018). For social workers or counselors engaging with the family, having an awareness that such internal dynamics around the young person's LGBTQþ identity is important, as well as considering how the family have or might respond. It has been widely acknowledged that family support is important for health and well-being in LGBTQþ youth (Westwater, Riley, & Peterson, 2019;McConnell, Birkett, & Mustanski, 2016) however, having alternative adult support may also act protectively for self-harm and suicide (Roe, 2017). Professionals should be expected to understand that a young person may require further support and potentially work with the family to explore underlying concerns around being LGBTQþ (Roe, 2017;Wagaman et al., 2018). Furthermore, professionals also need to explore how the young person perceives themselves and how this influences their mental wellbeing.

LIMITATIONS
Several interview methods were offered; in-person, by phone or through Skype, which removed geographical and financial barriers for participants. However, there are limitations such as difficulties with rapport building (Opdenakker, 2006) and complexities surrounding nonverbal cues being observed (Cohen, Manion, & Morrison, 2007;Novick, 2008) in non-visual interviews. However, the majority of participants selected methods which enhanced their privacy and anonymity (selecting not to use Skype, preferring phone calls) which may have actually increased information that was shared (Ybarra, Alexander, & Mitchell, 2005).
Two interviews were with participants in the U.K. during the COVID-19 lockdown period (March-April 2020). No changes were made to their interview process. However, both mentioned COVID-19 during the rapport building section of the interview.
Within the study, we aimed to include a range of gender and sexual identities, however there was a majority of cisgender female participants (with a variety of sexual orientations) which could bias the sample. This overrepresentation may be related to females being more likely to present with SIB (Marchant et al., 2020). It is possible that these results hold more utility of cisgender LGBTQþ women than other identities. Data on ethnicity of participants was not captured. Therefore, there is inadequate information present to determine whether any of these experiences were related to multi-minority status.
Given that ethnic minority members of the LGBTQþ umbrella are underrepresented (Kneale et al., 2019), future research should ensure inclusion and diversity of populations.

CONCLUSION
Minority stress experiences appear to interact and influence those processes underlying self-harm among LGBTQþ young people. Often these experiences are related to thoughts and feelings relating to being LGBTQþ but experiences of abuse and discrimination enhance this negative self-perception. Alongside this, LGBTQþ young people also face stressors relating to how they perceive themselves, which could compound already complicated emotions surrounding their identity. Consideration needs to be given to LGBTQþ acceptance within families, by peers, and society more widely as this could help protect LGBTQþ young people against self-harm. This could be achieved through LGBTQþ education within schools and colleges. Professionals working with LGBTQþ youth should be aware of how these young people may perceive themselves and what family environment they may be dealing with.