Expert consensus on involving sexual and gender diverse preteens in suicide research: a Delphi study

Abstract

Background

Suicide rates among U.S. preteens (ages 8–12) have risen steadily since 2008, signaling a growing crisis in children’s mental health. Sexual and gender diverse (SGD) preteens are at especially high risk, with recent findings showing 4–6 times higher risk of suicidal thoughts and behaviors among sexual minority preteens and up to 14-fold higher risk among transgender preteens. Despite these alarming disparities, SGD preteens are often excluded from suicide research due to ethical, legal, and methodological barriers. There is a pressing need for expert-informed best practices to safely and ethically include this population in research.

Methods

We conducted a three-step Delphi process to develop expert-informed guidelines for ethically and effectively engaging SGD preteens at elevated risk in suicide research. The process was shaped by input from youth and adult community advisory boards and included 20 expert panelists across five overlapping roles: researchers, clinicians, legal/regulatory professionals, bioethicists, and community leaders. Experts completed a first-round survey, a structured virtual consensus meeting, and a second-round survey.

Results

Consensus was reached across multiple domains including developmentally appropriate criteria for SGD identity classification in research as well as criteria for classifying heightened suicide risk in preteens. Experts agreed that SGD identity alone should not be used as a proxy for risk nor should any preteens be excluded from research based on clinical severity of symptoms. Experts highlighted feasible sampling methods including convenience and purposive sampling and recruitment and retention strategies aimed at both youth and caregivers. Experts agreed on study safeguards such as provision of mental health resource lists and parental notification if structured risk thresholds were exceeded during research. There was full agreement on the importance of IRB review by individuals with child mental health and SGD expertise, although experts did not achieve consensus on the feasibility of implementing any IRB reforms.

Conclusions

This multi-phase Delphi study produced expert-endorsed recommendations for safely, ethnically, and effectively including SGD preteens at elevated suicide risk in research. These guidelines provide a foundation for inclusive, community-engaged suicide research with vulnerable youth.

Clinical trial number

Not applicable.

Background

Suicide is a leading cause of preventable mortality and youth are especially vulnerable. In the United States (US), suicide is the second-leading cause of death among youth ages 10–14, with increasing rates of preteen suicidal thoughts and behaviors (STBs) over the past two decades [1–4]. In response, national organizations have elevated youth suicide prevention as a public health priority. In 2021, the American Academy of Pediatrics, American Foundation for Suicide Prevention, and National Institute of Mental Health issued a joint “Call to Action” to address this urgent concern [3].

Sexual and gender diverse (SGD) youth are a population who have elevated vulnerability for suicidal thoughts and behaviors. SGD youth (e.g., those who identify as lesbian, gay, bisexual, queer, or another non-heterosexual sexual orientation; report same-sex sexual or romantic attraction; and/or whose assigned birth sex differs from their current gender identity or expression) [5] are significantly more likely to report STBs than their heterosexual, cisgender peers [6, 7]. Across studies, approximately one-third of SGD youth report a lifetime suicide attempt while nearly one-half report suicidal thoughts, with gender minority youth (e.g., transgender and nonbinary youth) facing the highest risk [7–9]. Even among high-risk clinical samples, SGD youth remain disproportionately represented [10]. For example, in one study, youth who attempted or died by suicide within three months of an emergency department visit were three to six times more likely to be SGD than those who did not [11].

Most research on SGD youth suicide has focused on adolescents and young adults, yet emerging evidence points to preadolescence as a particularly sensitive period of risk for SGD youth. For all youth, the preadolescent period (spanning approximately 8–12 years old) is a period of significant developmental change, during which youth must navigate a convergence of social, emotional, cognitive, physical, and biological transitions [12]. This stage is characterized by the increasing importance of peer influence, greater social involvement, emergent abstract thinking, the onset of puberty, and the early development of identity [13]. For SGD youth, these normative but stressful changes may be accompanied by heightened vulnerability to minority stressors that can increase risk for STBs. Recent national survey data indicate that 16% of transgender and nonbinary youth and 35% of sexual minority youth aged 13–17 report “coming out” before age 13, with those reporting coming out in preadolescence also reporting higher odds of suicidal behavior [14, 15].

Early evidence has recently revealed that SGD disparities in STBs and its precursors (e.g., depression, anxiety, interpersonal stress) seem to emerge during preadolescence [16–18]. Indeed, nationally representative studies and large-scale cohorts such as the Adolescent Brain Cognitive Development (ABCD) study show that sexual minority children ages 9-10-years-old are four to six times more likely to report STBs than heterosexual peers, while gender minority preteens face up to a 14-fold elevated risk [19, 20]. Further, in a recent study of over 12,000 middle school students (ages 10–14) in New Mexico, nearly one-quarter identified as sexual minority and reported significantly worse behavioral health outcomes, including poorer mental health, greater substance use, and higher rates of suicidal behavior, than their heterosexual peers. Importantly, these disparities seem to manifest during the preadolescent developmental period and then intensify during the transition into adolescence [21]. One prospective cohort of children followed every three years from ages 3 to 15 indicated that the significant disparity in depressive symptoms between sexual minority and heterosexual youth emerged in preadolescence, around 9–12 years old, and widened into adolescence [17]. Recognizing the onset of these disparities during the preadolescent period is pivotal because it can concomitantly allow for the identification of mutable risk factors at a critical juncture in development. Early intervention during this formative period can then disrupt maladaptive processes before they solidify and exert long-lasting effects on subsequent development and psychosocial functioning [22].

Despite growing recognition of the need for early suicide prevention, research on SGD preteens remains limited, in part due to the absence of best practices for identifying and safely, ethically, and effectively involving this population in suicide research. Little is known about how to developmentally define SGD identity and behavior during preadolescence, how to appropriately involve parents in research involving SGD preteens, or how to effectively recruit and retain these youth into prospective cohort studies that can track risk and resilience factors for STBs over time. The lack of consensus on these foundational issues hinders efforts to conduct rigorous research and, ultimately, to develop targeted interventions that address suicide risk in this population. The current study thus aimed to develop best practice recommendations for the safe, ethical, and effective sampling, recruitment, and retention of SGD preteens (ages 9–12) at risk for STBs into research. To do so, we sought to conduct a structured Delphi consensus process with an expert panel comprising researchers, developmental scientists, IRB personnel, bioethicists, clinicians, legal scholars, and community leaders with expertise in SGD youth mental health. Delphi processes are a valuable way to obtain expert consensus on topics where there is little-to-no scientific knowledge [23]. By building these best practice guidelines through a structured Delphi consensus process, this study seeks to lay the groundwork for future research and early intervention development during a critical developmental window.

Materials and methods

The Delphi method

A multi-step Delphi process was used, following the same successful structure as a previous academic-National Institute of Mental Health (NIMH) partnership aimed at obtaining consensus on ethically and safely conducting digital suicide research with high-risk populations [24]. In line with best practices for conducting the Delphi method in health sciences [23, 25, 26], the current study comprised five key stages: (1) development of the Delphi survey; (2) expert panelist selection; (3) first-round survey completion; (4) structured consensus meeting to review and discuss aggregated first-round survey responses; and (5) second-round survey completion to identify areas of agreement and finalize recommendations. All study procedures were approved by the Vanderbilt University institutional review board.

Community advisory board involvement

To ensure cultural responsiveness, ethical soundness, and relevance to SGM preteens and their families, two community advisory boards were established at the outset of the project. The youth advisory board consisted of eight SGD-identifying teenagers (ages 16 through 18) recruited through a local youth organization and met monthly in person. The adult community advisory board comprised eight leaders of SGD preteen support groups affiliated with LGBTQ+ community centers nationwide and met quarterly via web-conferencing. Both boards contributed to the Delphi process by identifying key considerations for research with SGD preteens, grounded in their lived experiences and local contexts. Meetings incorporated a range of engagement strategies including open discussions, brainstorming activities, art-based exercises, and structured review of relevant literature and study materials. Advisory board input shaped survey content, response options, item clarity, and contextual relevance.

Delphi survey development

Following the academic-NIMH Delphi precedent [24], the survey prioritized the use of quantifiable response formats, such as binary (yes/no) items and 1–9 Likert-type rating scales, to facilitate the aggregation and interpretation of expert input and support efforts to establish consensus.

To inform survey content, we conducted a targeted literature review to identify key domains and guiding questions relevant to the ethical and safe conduct of suicide research with SGD preteens. Given the paucity of research specifically focused on SGD preteens, our review included: (1) literature on best practices and ethical considerations in suicide research with general youth [27] populations, including children under age 12; and (2) literature addressing suicide research with SGD populations [28, 29] across broader age ranges, including SGD teens [30–32] and young adults. This literature review identified 8 key domains: (1) Developmentally appropriate assessment; (2) Parameters of inclusion criteria based on risk indices; (3) Effective sampling approaches; (4) Effective recruitment venues; (5) Effective retention strategies; (6) Safety considerations; (7) Best practices for responsibly including parents/caregivers; and (8) IRB considerations. Initial survey questions were developed to reflect these domains, drawing both from existing literature and the research team’s prior experience.

Survey items were iteratively refined through regular meetings among the investigator team. This process included revising item wording, generating and narrowing response options, and modifying item formats to better capture expert input. For example, several early items assessing ethical strategies for recruitment, retention, and parent/caregiver involvement used “select all that apply” formats. Based on feedback from a team member with expertise in Delphi methodology [33, 34], these items were restructured to prompt participants to independently rate the importance and feasibility of each listed strategy. This allowed for a more nuanced assessment of each strategy’s perceived utility and practicality.

The final Delphi survey included 47 items encompassing a range of formats: binary response items (e.g., yes/no), agreement scales, Likert-type ratings of importance and feasibility, and ranking tasks. Each item was followed by an optional open-ended prompt, inviting participants to elaborate on their responses or provide additional insights.

Expert panelist selection

This study aimed to recruit an expert panel to participate in the three-step Delphi process. External experts were eligible for the panel if they had professional experience pertaining to SGD preteens in at least one of the following 5 subject-matter domains: (1) Researcher (e.g., researcher in academic or professional setting focused on topics related to suicide risk in youth, SGM youth mental health or SGM youth development); (2) Clinician (e.g., mental health providers focused on provision of care to children and adolescents, experienced working with SGM youth); (3) Legal/regulatory (e.g., professional in the field of law or regulatory space with expertise in oversight of applying legal and/or regulatory processes to conduct of research); (4) Community Experts (e.g., individuals with direct communities ties to SGM youth through a professional role); (5) Ethics (e.g., professional studying or applying ethical principles to address complex questions and dilemmas related to research, with explicit focus on youth and mental health).

Purposive sampling was used to recruit experts across the 5 subject-matter domains. Potential panelists were identified based on their scholarly publications, professional expertise, and/or applied experience related to suicide prevention, SGD youth, or research ethics. Each expert was contacted via email and provided with detailed information about the Delphi process, including expectations for participation, and a secure REDCap link to review study procedures and provide informed consent.

A total of 29 external experts were invited to participate as an expert panelist in the Delphi process. Of those invited, 19 (65.5%) experts provided consent to participate. Four consented individuals were subsequently lost to follow-up and did not complete any round of the Delphi process. In alignment with common Delphi practices, including the approach used in the prior academic-NIMH Delphi study on which this project was modeled [24], members of the research team with relevant expertise were also included in the panel. Specifically, 5 PhD-level investigators involved in survey development participated as expert panelists. This yielded a final panel of 20 experts who contributed to at least the first round of the Delphi process.

Delphi round 1

The 47-item anonymous survey was sent to all expert panelists by email with a REDCap link to the survey. Panelists were asked to complete the survey within a 14-day period. The survey took approximately 30-minutes to complete, and participants were able to download their completed survey to refer to during the subsequent consensus meeting.

In line with existing research [23–25], we used the following a priori criteria as cutoffs for not reaching agreement (i.e., consensus): ≤70% agreement; median rating of 4–6 on items assessing importance and feasibility on 1 (low) – 9 (high) scale; or overlapping median ratings on ranked items. Items not reaching agreement in the first-round survey were included in the structured consensus meeting and second-round survey. All 20 expert panelists (100%) completed the first-round survey within the 14-day window. The study team then took 14 days to analyze the first-round survey results and prepare for the structured consensus meeting discussion, described next.

Structured consensus meeting

Originally, the structured consensus meeting was planned as a full-day, in-person event at the first author’s institution. However, partway through the Delphi process, funding for the project was terminated by the National Institutes of Health, citing that the study did not meet “agency priorities” due to its partial focus on gender identity. As a result of this unexpected funding loss, the research team shifted to a virtual format and condensed the meeting to a half-day (approximately 3.5 h) to maintain engagement in the online setting.

The meeting was co-facilitated by the first three authors and began with facilitator introductions, a review of objectives, and ground-rules for the discussion (e.g., utilizing the Zoom “raise hand” function). Facilitators then presented aggregated survey data, with discussion following each item. Only items that had not met consensus during the first-round survey were included. Expert panelists were encouraged to share perspectives, personal and professional experiences, and strong opinions to help foster discussion and build consensus. Two trained study staff recorded detailed, anonymous notes throughout the meeting, and the AI companion function in Zoom was also utilized to summarize the discussion [23].

Delphi round 2

A total of 30 items did not reach full agreement in the first-round survey and were subsequently discussed during the consensus meeting before being included in the second-round survey. In the case of question items with multiple response options where only some options reached consensus in the first-round, these items were retained in their entirety in the second-round survey to ensure clarity and consistency. The second-round survey followed the same procedures as the first. Participants received an anonymous REDCap survey link, distributed three days after the consensus meeting, and were asked to complete it within 14 days. Of the 20 expert panelists, 19 (95.0%) completed the second-round survey. Participants who completed all study procedures, including the first-round survey, consensus meeting, and second-round survey, received a $150 gift card as compensation.

Data analysis

Descriptive analyses were conducted using Microsoft Excel to calculate means, standard deviations, frequencies, and proportions for expert panelist demographic data, as well as frequencies, proportions, and median responses for survey items. The results presented below include final survey data: first-round items that achieved consensus and all items from the second-round survey. We also report proportions of responses for a set of items on the second-round survey that asked panelists to provide feedback on the Delphi process itself including how valuable and engaging they found the process.

Results

Expert panelist demographics

Expert panelist demographics are presented in Table 1. Panelists were on average 39.5 years old, and most were assigned female sex at birth (85%), identified as women (75%), and were White (85%). Panelists reported a broad array of sexual orientations, with the most common being bisexual (35%) and queer (30%). Among panelists, 90% reported full-time employment, and 95% had Master’s, doctoral, or medical degree. Panelists spanned all professional domains, with most reporting research (75%) or clinical (50%) expertise followed by community expertise (15%), ethics (15%), and legal/regulatory (5%).

Table 1.

Expert panelist demographics (N = 20)

Variable	Response Option	Frequency (%)
Age, Mean (SD)		39.55 (6.69)
Gendera	Woman	15 (75%)
	Man	3 (15%)
	Nonbinary	2 (10%)
	Genderfluid	1 (5%)
	Genderqueer	2 (10%)
	Agender	1 (5%)
Sex	Male	3 (15%)
	Female	17 (85%)
Sexual Orientationa	Straight or heterosexual	5 (25%)
	Gay	5 (25%)
	Bisexual	7 (35%)
	Pansexual	4 (20%)
	Queer	6 (30%)
	Questioning	1 (5%)
Racea	Asian	3 (15%)
	Black/African American	2 (10%)
	White	17 (85%)
Employment	Full-time (40 h or more per week)	18 (90%)
	Part-time (less than 40 h per week)	1 (5%)
	Part-time work - full-time student	1 (5%)
Education	Bachelor’s degree	1 (5%)
	Master’s degree	4 (20%)
	Doctoral degree	13 (65%)
	Medical degree	2 (10%)
Professional Domaina	Research	15 (75%)
	Clinician	10 (50%)
	Legal/regulatory	1 (5%)
	Community Expert	3 (15%)
	Ethics	3 (15%)

Note. Table only displays response options selected by at least 1 participant

^aParticipants could choose multiple options; frequency is greater than n = 20

Consensus on developmentally appropriate identity and risk assessment

Table 2 summarizes expert panel feedback on developmentally appropriate approaches to identity and risk assessment. Experts reached consensus that preteens should be classified as SGD if they self-report a non-heterosexual orientation (100%), non-cisgender gender identity (100%), or identify as “questioning” (89%), “other” (100%), or “something else” (100%). Consensus also supported inclusion of preteens who report same-sex romantic attraction on developmentally appropriate measures (84%). Most experts agreed that parent-reported measures are not necessary for SGD classification (75%) and endorsed retaining youth in SGD cohorts even if they later change how they identify (100%).

Table 2.

Expert panelist scores on developmentally appropriate identity and risk assessment

Issue	Question	Response	% / Median	Consensus indicator (✓ = reached in pre-meeting survey; ☑ = reached in post-meeting survey; ⊗ = not reached)
Assessment of sexual and gender diversity	When assessing sexual and gender diversity during the preteen period (9-12-years old), what categories should we rely on to classify preteens as SGD versus not SGD? (Select all that apply)	Preteens who self-identify as lesbian, gay, bisexual, queer, pansexual, or any other non-heterosexual sexual orientation	100%	✓
		Preteens who self-identify as transgender, non-binary, genderqueer or any other non-cisgender gender identity	100%	✓
		Preteens who self-identify as “questioning” on measures of sexual or gender identity	89%	✓
		Preteens who self-identify as “other” on measures of sexual orientation or gender identity	100%	✓
		Preteens who self-identify as “something else” on measures of sexual orientation or gender identity	100%	✓
		Preteens who respond “I don’t know” to questions assessing sexual orientation or gender identity	11%	☑
		Preteens who respond “I don’t understand the question” to questions assessing sexual orientation or gender identity	0%	✓
		Preteens who report gender variance (e.g., through gender-typed behavior, more interest in other-gender, and/or less interest in same-gender toys, playmates, and activities)	16%	☑
		Preteens who report same-sex romantic attraction on developmentally appropriate measures (e.g., report ‘crushes’ on members of the same sex)	84%	✓
Involving parents in assessment of sexual and gender diversity	When assessing sexual and gender diversity (SGD) in preteens (ages 9–12), should parent-reported measures (e.g., gender-typed behaviors, perceptions of sexual orientation) be used to classify a child’s SGD status, in addition to the child’s own report?	Yes - It is important to include parent-reported measures to classify a child’s sexual and gender diversity (SGD) status in addition to the child’s own report.	25%	✓
		No - Parent-reported measures are not necessary for classifying a child’s sexual and gender diversity (SGD) status, and child self-report should be prioritized.	75%	✓
Exclusion based on sexual and gender diversity over time	During screening, a preteen is classified as being SGD based on their responses to measures of sexual orientation, sexual and romantic attraction, and gender identity. They are enrolled into a longitudinal study where they are assessed every 6 months for two years. Should youth who no longer report being SGD at follow-up points be excluded?	Yes - Youth who report being heterosexual and cisgender (i.e., not SGD) at any follow-up point should be excluded.	0%	✓
		No - As long as youth report being SGD during screening, they should be retained in the cohort study regardless of future SGD.	100%	✓
Involvement of SGD preteens and their parents in the development of research protocols	Rate the following list of strategies on both importance and feasibility on a scale of 1 to 9. Importance refers to how essential or valuable you believe the strategy is to ensure preteens’ and parents’ perspectives are meaningfully incorporated into the research. Feasibility refers to how practical or realistic you think the strategy is, considering potential time, resources, and other constraints.	Conduct focus groups with preteens to gather input on study design and ethical concerns.	IMPORTANCE = 9	✓
			FEASIBILITY = 7	☑
		Conduct focus groups with parents of preteens to gather input on study design and ethical concerns.	IMPORTANCE = 7	✓
			FEASIBILITY = 8	✓
		Develop a community advisory panel of preteens to review research plans and provide feedback.	IMPORTANCE = 7	✓
			FEASIBILITY = 5	⊗
		Develop a community advisory panel of parents of preteens to review research plans and provide feedback.	IMPORTANCE = 6	⊗
			FEASIBILITY = 7	✓
		Obtain feedback from adults outside of the family who work closely with SGD preteens (e.g., LGBTQ+ support group leaders, clinicians) to review research protocols.	IMPORTANCE = 8	✓
			FEASIBILITY = 8	✓
		Use “co-design approaches,” where preteens, parents, and researchers collaborate together on creating ethical and practical research designs.	IMPORTANCE = 7	✓
			FEASIBILITY = 4	⊗
		Implement exit interviews with preteens involved in research studies to understand their views and improve future research protocols.	IMPORTANCE = 9	✓
			FEASIBILITY = 8	✓
		Implement exit interviews with parents of preteens involved in research studies to understand their views and improve future research protocols.	IMPORTANCE = 7	✓
			FEASIBILITY = 9	✓
Inclusion of all SGD preteens as “at-risk”	A growing body of research shows that SGD preteens have higher rates of suicidal thoughts and behaviors than non-SGD preteens. In this context, should all SGD preteens be considered “at-risk” for suicidal thoughts and behaviors?	Yes - All SGD preteens should be considered “at-risk” for suicidal thoughts and behaviors.	21%	☑
		No - Preteens should not be considered “at-risk” for suicidal thoughts and behaviors based solely on their SGD identity.	79%	☑
Inclusion prioritizing minority stress experiences	Should inclusion criteria for research prioritize preteens who have experienced minority stress (e.g., bullying, discrimination) based on their SGD status?	Yes - Research should prioritize SGD preteens who have experienced minority stress.	20%	✓
		No - Research should include all SGD preteens regardless of minority stress experiences.	80%	✓
Involvement of SGD preteens at “elevated risk for suicide”	In future survey research with SGD preteens, we seek to involve preteens who are classified at “elevated risk for suicide.” Which of the following mental health parameters should definitely be used to classify preteens (9-12-years-old) at elevated risk? (Select all that apply)	Youth-reported active suicidal ideation (e.g., thoughts of killing oneself)	100%	✓
		Youth-reported passive suicidal ideation (e.g., ambivalence about staying alive)	95%	✓
		Youth-reported death ideation (e.g., ruminating about death)	16%	☑
		Youth-reported suicide attempt history	100%	✓
		Youth-reported non-suicidal self-injury history	84%	✓
		Youth-reported clinically elevated internalizing symptoms (e.g., depression or anxiety)	42%	⊗
		Youth-reported psychiatric hospitalization	79%	✓
		Parent-report of child’s clinically elevated internalizing symptoms (e.g., depression or anxiety)	32%	⊗
		Parent-report of child’s clinically elevated externalizing symptoms (e.g., conduct problems, acting out)	26%	✓
		Parent-report of child’s suicidal ideation history	84%	✓
		Parent-report of child’s suicide attempt history	95%	✓
		Parent-report of child’s non-suicidal self-injury history	74%	☑
		Parent-report of child’s psychiatric hospitalization history	74%	✓

Note: Importance and feasibility items rated on Likert scale from 1 (low) – 9 (high)

Regarding youth and parent involvement in protocol development, experts endorsed the importance and feasibility of most strategies (Table 2) but did not reach consensus on the importance of parent advisory panels, or the feasibility of preteen advisory panels or of co-design approaches involving preteens, parents, and researchers.

Experts agreed that SGD identity alone should not be used to designate suicide risk (79%) and that research should include all SGD preteens regardless of their reported minority stress exposure (80%). Regarding what criteria to use when assessing “elevated suicide risk,” experts reached consensus on including youth-reported histories of active and passive suicidal ideation, suicide attempts, non-suicidal self-injury, and psychiatric hospitalization. Experts also supported using corresponding parent-reported data for these measures.

Consensus on sampling, recruiting, and retaining SGD preteens into suicide research

Table 3 summarizes expert consensus on sampling, recruiting, and retaining SGD preteens in suicide research. Experts agreed that convenience and snowball sampling methods are feasible, while purposive and quota sampling approaches are important for assembling diverse samples. However, consensus was not reached on the relative effectiveness of recruitment venues. School-based programs, mental health settings, and social media platforms were all rated as relatively effective (median rank = 2/4), while LGBTQ+ organizations were rated as less effective (median rank = 3/4). During the structured consensus meeting, experts emphasized that the effectiveness of sampling methods and recruitment venues depends on the specific research question, which may account for the lack of consensus in this area.

Table 3.

Expert panelist scores on sampling, recruiting, and retaining SGD preteens into suicide research

Issue	Question	Response	% / Median	Consensus indicator (✓ = reached in pre-meeting survey; ☑ = reached in post-meeting survey; ⊗ = not reached)
Sampling approach	There are several possible sampling approaches that might be used to recruit SGD preteens at elevated risk for suicide into research. Rate the following list of sampling approaches on both importance and feasibility on a scale of 1 to 9. Importance refers to how essential or valuable you believe the approach is to sampling/recruiting SGD preteens at elevated suicide risk. Feasibility refers to how practical or realistic you think the approach is, considering potential time, resources, and other constraints, to sampling/recruiting SGD preteens at elevated suicide risk.	Convenience Sampling: This method involves selecting participants who are readily accessible and willing to participate (e.g., anyone who responds to an online study flyer).	IMPORTANCE = 5	⊗
			FEASIBILITY = 9	✓
		Snowball Sampling: This technique involves existing participants recruiting future participants from among their acquaintances.	IMPORTANCE = 6	⊗
			FEASIBILITY = 8	✓
		Purposive Sampling: Participants are selected based on specific characteristics or criteria set by the researcher (e.g., SGD preteens with a history of suicide attempts).	IMPORTANCE = 9	✓
			FEASIBILITY = 6	⊗
		Quota Sampling: Researchers ensure certain characteristics (e.g., age, gender) are represented in the sample to predefined proportions. Once quotas are reached in a specific category, no more participants are recruited.	IMPORTANCE = 9	✓
			FEASIBILITY = 5	⊗
Recruitment venue	We aim to recruit SGD preteens into research who are diverse in race/ethnicity, sexuality, gender, and socio-economic status. Rank the following list of recruitment venues from least to most effective for recruitment.	LGBTQ+ organization	RANK = 3	⊗
		School-based programs	RANK = 2	⊗
		Mental health clinics and therapists	RANK = 2	⊗
		Online social media platforms	RANK = 2	⊗
Obtaining a diverse sample	For many research ethics committees, recruitment materials seeking to involve minors in research must target the parent/caregiver who will be providing consent for their child to participate. To obtain a diverse sample of 9-12-year-old SGD preteens at elevated risk of suicide, would you suggest that recruitment materials targeting parents/caregivers prioritize targeting the child’s sexual and gender diversity, mental health, or both? Select the best approach for a recruitment advertisement	Does your child ages 9-12-years-old identify as LGBTQ+? [In this case, we would assess pre-determined suicide risk classification criteria during the screening process but not target it directly in recruitment ads]	21%	☑
		Does your child ages 9-12-years-old struggle with thoughts of suicide? [In this case, we would assess sexual and gender diversity during the screening process but not target it directly in recruitment ads]	79%	☑
		Does your LGBTQ+ child ages 9-12-years-old struggle with thoughts of suicide?	0%	☑
Retention strategies	We aim to retain SGD preteens at-risk for suicide across a longitudinal follow-up period spanning 2 years. Rate the following list of retention strategies on both importance and feasibility on a scale of 1 (low) to 9 (high).  Importance refers to how essential or valuable you believe the approach is to retaining SGD preteens across a 2-year follow-up period.  Feasibility refers to how practical or realistic you think the approach is, considering potential time, resources, and other constraints to retaining SGD preteens across a 2-year follow-up period.	Regular Check-ins: Periodic phone calls, texts, or emails to maintain contact with participants and parents.	IMPORTANCE = 9	✓
			FEASIBILITY = 8	✓
		Incentives: Gift cards, cash rewards, or other incentives for participation and continued involvement.	IMPORTANCE = 9	✓
			FEASIBLITY = 8	✓
		Flexible Scheduling: Offering appointment times that accommodate school, extracurricular activities, and family commitments.	IMPORTANCE = 9	✓
			FEASIBLITY = 8	✓
		Parental/Caregiver Engagement: Involving parents or caregivers in the research process and providing them with research updates and parent-focused resources.	IMPORTANCE = 7	✓
			FEASBILITY = 7	✓
		Regular Newsletters: Sending out newsletters with updates on the study, its progress, and any relevant findings.	IMPORTANCE = 6	⊗
			FEASBILITY = 8	✓
		School Involvement: Coordinating with schools to facilitate participation, such as allowing data collection during school hours.	IMPORTANCE = 5	⊗
			FEASIBILITY = 2	✓
		Social Media and Technology: Utilizing social media platforms, apps, or other digital tools to keep in touch and send reminders.	IMPORTANCE = 8	✓
			FEASIBILITY = 7	✓
		Educational Opportunities: Offering educational materials, workshops, or seminars on topics of interest to the participants and their parents.	IMPORTANCE = 3	☑
			FEASBILITY = 5	⊗
		Long-Term Incentives: Offering larger rewards or bonuses for completing multiple follow-up sessions or the entire study.	IMPORTANCE = 8	✓
			FEASIBILITY = 8	✓
		Consistent staffing: Maintaining consistency in the research team to build trust and rapport with participants over time.	IMPORTANCE = 8	✓
			FEASBILITY = 5	⊗
		Participant Advisory Boards: Forming advisory boards that include participants to give feedback on study processes and retention strategies.	IMPORTANCE = 7	✓
			FEASBILITY = 6	⊗
		Token of Appreciation: Sending small tokens of appreciation (e.g., birthday cards, holiday greetings) to participants to make them feel valued.	IMPORTANCE = 7	☑
			FEASBILITY = 7	✓

Note: Importance and feasibility items rated on Likert scale from 1 (low) – 9 (high)

Experts also agreed that recruitment advertisements targeting preteens with suicidal thoughts—rather than SGD identity—may be more effective for identifying SGD youth at elevated suicide risk (79%). During the structured consensus meeting, some experts raised concerns that recruitment advertisements explicitly referencing sexual orientation or gender identity may inadvertently exclude eligible youth or deter participation from parents.

Regarding retention strategies, experts endorsed the importance and feasibility of multiple approaches to maintain engagement among SGD preteens and their parents (Table 3). Strategies lacking consensus on importance included newsletters and school involvement, while those lacking consensus on feasibility included educational opportunities (e.g., workshops for parents and youth), consistent research team staffing, and the use of participant advisory boards.

Consensus on safety considerations, responsible inclusion of parents/caregivers, and ethical review considerations

Table 4 summarizes expert consensus on safety protocols, the inclusion of parents and caregivers, and ethical review processes. Experts unanimously agreed that SGD preteens should not be excluded from research based on clinical severity or elevated suicide risk (100%). For minimum mental health safeguards during study procedure, experts endorsed providing participants and parents with crisis line contact information (100%) and local mental health resources (79%). Consensus was not reached on whether a licensed mental health professional must be present during assessments or whether follow-up check-ins with participants and families are necessary. During the consensus meeting, experts clarified that while a licensed clinician should oversee study procedures and be available to support research staff if risk was indicated, their presence during all assessments is neither essential nor feasible.

Table 4.

Expert panelist scores on safety considerations, responsible inclusion of parents/caregivers, and ethical review considerations

Issue	Question	Response	% / Median	Consensus indicator (✓ = reached in pre-meeting survey; ☑ = reached in post-meeting survey; ⊗ = not reached)
Exclusion of SGD preteens at elevated risk	Should SGD preteens be removed from research or excluded based on clinical severity or elevated risk?	Yes - Preteens who are too high risk should NOT be included.	0%	✓
		No - We should collect data from all preteens, even those who are at elevated risk.	100%	✓
Minimum mental health considerations for SGD preteens	What are the minimum mental health considerations and supports needed when involving SGD preteen participants in mental health survey research? (Select all that apply)	Mandate the presence of a licensed mental health professional during survey assessments in case a mental health check-in is required (e.g., if a participant reports high suicide risk).	47%	⊗
		Only involve preteens in research who are already connected to mental health services (e.g., regularly seeing a therapist).	0%	✓
		Require follow-up check-ins with participants and families after the study to monitor their well-being.	32%	⊗
		Provide contact information for a helpline (e.g., 988, Trevor Project) for participants and/or parents to contact if they experience distress.	100%	✓
		Provide information about local mental health resources for participants and/or parents in the preteen’s local region.	79%	✓
Consent/assent of SGD preteens	Consent and assent forms will state that preteens will be asked questions related to their mental health, suicidality, identity characteristics, and diversity. In this context, should parents/caregivers always be made aware of a study’s goal of enrolling SGD preteens who meet criteria related to sexual and gender diversity even if it may deter participation?	Yes - Parents/caregivers should always be made aware of the study’s targeted recruitment group.	30%	✓
		No - As long as the consent process clearly documents the types of questions preteens will be asked during the study, parents/caregivers should not necessarily be made aware of the study’s targeted recruitment group.	70%	✓
Risk thresholds for parent notification	When conducting a study involving preteens at risk for suicide, when should parents or guardians be notified if their child crosses a defined risk threshold during study activities (e.g., during self-report surveys, clinical assessments)? (Select all that apply)	Immediately - Notify parents/guardians as soon as the child exhibits any level of risk, even if the level is moderate or low.	11%	✓
		After confirming risk through a structured suicide risk screening by a training professional - Notify parents/guardians only after a standardized risk screening tool (e.g., Columbia Suicide Severity Rating Scale) is used to confirm the child’s risk level.	53%	⊗
		After consulting with a clinical professional - Notify parents/guardians only after a clinical professional has been consulted (e.g., licensed clinical psychologist) to confirm the risk level.	53%	⊗
		Only in cases of imminent risk - Notify parents/guardians only if the child’s risk level is severe (e.g., active suicidal intent, specific plans, or immediate risk of harm).	32%	⊗
		At a predetermined risk threshold - Notify parents/guardians if the child’s score on a structured risk screening or clinical assessments meets or exceeds a specific threshold that indicates significant risk, based on predefined study criteria.	89%	✓
IRB considerations	What role should institutional review boards (IRBs) or ethics committees play in overseeing this type of research, and how can we ensure they are adequately prepared to assess studies involving preteens, including SGD preteens? Rate the following options with regard to importance and feasibility on a scale of 1 (low) to 9 (high). Importance refers to how essential or valuable you believe the approach is for IRBs or ethics committees overseeing this type of research.  Feasibility refers to how practical or realistic you think the approach is, considering potential time, resources, and other constraints, to implementing the approach within an institutional IRB or ethics committee.	Require IRBs to include members with expertise in child psychology and adolescent development, especially in mental health and suicide risk, to ensure age-appropriate protocols and ethical guidelines.	IMPORTANCE = 8	✓
			FEASBILITY = 6	⊗
		Establish subcommittees within the IRB specifically for child-focused research, ensuring that preteens’ developmental needs and vulnerabilities are fully considered.	IMPORTANCE = 3	✓
			FEASIBILITY = 2	☑
		Mandate regular training for IRB members on adolescent cognitive and emotional development, including the specific vulnerabilities of preteens when addressing sensitive topics like suicide risk.	IMPORTANCE = 6	⊗
			FEASIBLITY = 3	✓
		Ensure that IRBs have members or consultants who are knowledgeable about LGBTQ+ issues, especially regarding the unique challenges faced by SGD preteens (e.g., minority stress).	IMPORTANCE = 8	✓
			FEASBILITY = 6	⊗
		Develop LGBTQ+-specific ethical guidelines for research, ensuring that protocols are sensitive to the experiences of SGD youth, with a focus on minimizing stigma and respecting identity.	IMPORTANCE = 7	✓
			FEASIBLITY = 6	⊗
		Partner with LGBTQ+ community organizations to review research proposals involving SGD preteens, ensuring that the study design, language, and procedures are inclusive and do not unintentionally reinforce harmful stereotypes or bias.	IMPORTANCE = 7	✓
			FEASBILITY = 5	⊗
		Include community representatives (e.g., LGBTQ+ community members, parents, or advocacy groups) as part of the IRB or as consultants when reviewing research proposals involving diverse preteen populations.	IMPORTANCE = 7	✓
			FEASBILITY = 4	⊗

Note: Importance and feasibility items rated on Likert scale from 1 (low) – 9 (high)

Experts also reached consensus (70%) that parents or caregivers do not need to be informed of study inclusion criteria related to sexual or gender diversity, provided that consent and assent documents clearly outline the topics covered (e.g., mental health, identity, diversity). With respect to parental notification of suicide risk, there was consensus that parents/guardians should be alerted if a child’s score on a structured risk screen or clinical assessment exceeds a predefined threshold indicating significant risk (89%). Other risk thresholds did not meet consensus.

Regarding ethical review, experts agreed on the importance of involving institutional review board (IRB) members with expertise in child mental health and SGD issues, developing SGD-specific ethical review guidelines, and engaging LGBTQ+ community organizations and representatives (e.g., SGD adults, parents, advocates) in IRB review processes. However, consensus was not reached on the feasibility of implementing these recommendations, highlighting a gap between the perceived importance of these safeguards and the practical challenges of reforming IRB structures and policies.

Expert panelist feedback on Delphi process

Table 5 presents expert panelist feedback collected during the second-round survey. Overall, participants rated the Delphi process as both valuable and feasible. All experts agreed or strongly agreed that the time commitment was reasonable (100%) and that the questions posed throughout the rounds were relevant or very relevant (100%). Most reported that the questions were clear or very clear (90%) and that participation somewhat or significantly enhanced their understanding of involving SGD preteens in suicide research (85%). Nearly all participants found the consensus meeting with other experts to be valuable or very valuable (95%) and indicated they would probably or definitely participate in a future Delphi process based on their experience in this study (95%).

Table 5.

Expert panelist feedback on Delphi process (N = 19)

Question	Response	%
Do you agree or disagree with the following statement: The time commitment required for the Delphi process was reasonable?	Strongly agree/Agree	100%
	Neutral	0%
	Disagree/Strong disagree	0%
How would you rate the clarity of the questions asked throughout the Delphi rounds?	Very clear/Clear	90%
	Neutral	11%
	Unclear/Very unclear	0%
How would you rate the relevance of the questions asked throughout the Delphi rounds?	Very relevant/Relevant	100%
	Neutral	0%
	Irrelevant/ Very irrelevant	0%
How did participating in the Delphi process influence your own views or understanding of the topic of involving SGD preteens in suicide research?	Significantly enhanced/Somewhat enhanced	85%
	Neutral	16%
	Somewhat diminished/Significantly diminished	0%
How valuable did you find the consensus meeting discussion with other Delphi experts?	Very valuable/Valuable	95%
	Neutral	5%
	Not very valuable/Not valuable	0%
Based on your experience as a Delphi expert, would you be willing to participate in a Delphi process again in the future?	Definitely yes/Probably yes	95%
	Neutral	5%
	Probably no/Definitely no	0%

Discussion

This Delphi consensus study established best practice recommendations for the safe, ethical, and effective recruitment and retention of SGD preteens at risk for STBs into research. Across two survey rounds and a structured consensus meeting, a multidisciplinary expert panel reached agreement on numerous aspects of research design and implementation, including developmentally appropriate identity classification, sampling approaches, minimum safety protocols, and ethically responsible caregiver involvement. Although consensus was not reached in all domains, particularly around the feasibility of youth advisory boards, the role of parents in study design, and IRB-related considerations, the results from this Delphi process provide a foundational roadmap for ethically sound research with SGD preteens, an under-studied population at elevated risk for STBs. Below is a summary of 15 key recommendations from the Delphi process, followed by a discussion of the findings:

1. Classification of SGD status in preteens

   SGD classification during the preteen period should include youth who:

   • Self-identify as lesbian, gay, bisexual, queer, pansexual, or another non-heterosexual sexual orientation;
   • Self-identify as transgender, non-binary, genderqueer, or another non-cisgender gender identity;
   • Endorse “questioning,” “other,” or “something else” on measures of sexual orientation or gender identity;
   • Report same-sex romantic attraction using developmentally appropriate measures (e.g., reporting “crushes” on same-sex peers).

2. Prioritization of youth self-report in SGD classification

   Child self-report should be prioritized when classifying SGD status; parent-reported measures are not required for determining a child’s SGD identity.

3. Retention of SGD youth over time in longitudinal cohort

   Youth who report SGD status at screening should remain included in any cohort during follow-up, regardless of subsequent changes in self-identification.

4. Avoiding pathologization

   SGD identity alone should not be considered an indicator of elevated suicide risk.

5. Inclusive enrollment criteria

   Research should include all SGD preteens, irrespective of documented minority stress experiences.

6. Parental disclosure in targeted recruitment

   Provided that the consent process clearly describes study content and procedures, parents/caregivers need not be explicitly informed of targeted recruitment of SGD youth or their child’s self-report SGD-related information.

7. Risk notification protocols

   Studies should establish predefined risk thresholds. When structured screening or clinical assessment scores meet or exceed these thresholds, parents/guardians should be notified in accordance with prespecified safety protocols.

8. Community engagement in study design

   Research protocols should incorporate meaningful input from preteens and parents (e.g., focus groups, exit interviews). Although co-design models and youth advisory boards may present feasibility challenges with preteens, their inclusion remains important where possible.

9. Core indicators of elevated suicide risk

   Assessment of elevated suicide risk should at minimum include:

   • Youth-reported active suicidal ideation;
   • Youth-reported passive suicidal ideation;
   • Youth-reported suicide attempt history;
   • Youth-reported non-suicidal self-injury (NSSI) history;
   • Youth-reported psychiatric hospitalization;
   • Parent-reported history of child’s suicidal ideation, suicide attempts, NSSI, and psychiatric hospitalization.

10. Inclusion of youth at elevated clinical risk

    Data collection should include preteens at elevated clinical risk, with appropriate safety protocols in place.

11. Sampling strategies

    Purposive and quota sampling approaches are recommended to ensure representation of key sociodemographic characteristics (e.g., age, gender, race/ethnicity). However, feasibility constraints should be acknowledged.

12. Recruitment approaches

    Sexual and gender diversity should be assessed during screening procedures, but recruitment may be more feasible when not explicitly targeted in recruitment advertisements when recruiting SGD youth at risk for suicidal thoughts and behaviors.

13. Retention strategies in longitudinal research

    Effective retention strategies include regular check-ins, flexible scheduling, developmentally appropriate incentives, and use of online and social media platforms to maintain engagement with preteens and families.

14. Minimum mental health safeguards

    Research protocols should, at minimum:

    • Provide contact information for crisis resources (e.g., 988 Suicide & Crisis Lifeline, The Trevor Project);
    • Provide information about national and local mental health services relevant to participants’ geographic regions.

15. Institutional review boards (IRBs) composition and expertise

    IRBs should include consultants or members with expertise in LGBTQ+ populations, as well as child and adolescent mental health and suicide risk. While feasibility may be constrained particularly in certain sociopolitical contexts, such expertise is critical to ethical review of SGD preteen research.

Developmentally sensitive SGD identity classification

Expert consensus supported the classification of preteens as SGD based on developmentally appropriate, self-reported assessments of non-heterosexual orientation, non-cisgender identity, “questioning” sexual or gender identity, or same-sex romantic attraction. This inclusive approach aligns with current developmental science, which recognizes that identity development often begins in preadolescence or earlier and that questioning and/or non-binary identifications are normative expressions of identity exploration during this period [35, 36]. The panel’s agreement that parent-report of children’s sexual orientation or gender identity is not necessary for SGD classification further reflects an ethical stance that centers youth agency and privacy in research, which is especially critical in contexts where identity disclosure may be unsafe for some youth, especially those from non-affirming family environments [37, 38]. Further, previous research has shown notable discordance in parent-child reports of children’s sexual orientation during preadolescence [39], suggesting that requiring parent-reported measures of children’s identities could exclude otherwise eligible youth. Notably, experts endorsed retaining preteens in SGD-focused cohort studies even if their identities evolve over time, acknowledging the fluid nature of identity development, particularly during early and middle adolescence, and the need for longitudinal designs that are responsive to the complex realities of identity development.

Recruitment and sampling considerations

Experts endorsed purposive and quota-based sampling as important strategies to ensure that research includes diverse SGD preteens across a range of sociodemographic and clinical characteristics. While convenience and snowball sampling were rated as feasible, there was less agreement on the relative effectiveness of specific recruitment venues for SGD preteens, including schools, mental health settings, online contexts, and SGD-focused youth organizations. In this case, experts underscored the need for researchers to tailor recruitment strategies to the goals and target populations of each study. Importantly, panelists expressed concern that recruitment efforts focused explicitly on children’s sexual orientation or gender identities might deter participation, both from youth who may endorse SGD-related identities or experiences on surveys but do not yet self-identify as such, and from parents who may be unaware of or not accept their child’s identity. Instead, framing recruitment efforts broadly around children’s mental health was viewed as both inclusive and pragmatic, since SGD preteens are overrepresented among youth with STBs [19, 20].

Involvement of parents and preteens in study design

The panel offered cautious support for including parents and preteens in research design, endorsing many strategies as important in principle but raising feasibility concerns. While most experts agreed on the value of engaging SGD youth through advisory boards or co-design models, consensus was not reached on the practicality of these approaches, particularly with respect to involving preteens. This tension mirrors broader challenges in pediatric mental health research, where youth engagement is both ethically desirable and logistically complex [40, 41]. While youth advisory boards have become more common in adolescent mental health research, fewer studies have engaged preteens. Future studies might explore scalable models for meaningful youth participation—particularly with 9-12-year-olds—that balance developmental appropriateness, ethical rigor, and operational feasibility.

Safety protocols and clinical oversight

There was strong consensus that SGD preteens should not be excluded from research based on clinical severity or elevated suicide risk, a recommendation echoed by experts in a previous Delphi study focused on involving adults in digital suicide research [24]. Instead, panelists supported a research framework that incorporates essential safety measures, including the provision of crisis resources and local mental health referrals, without creating undue barriers to participation. Experts rejected the notion that a licensed mental health professional must be present during all study procedures, instead recommending that such individuals oversee protocols, supervise research assistants, and be available as needed to respond to potential risk. Experts agreed that this approach promotes youth safety while ensuring that research remains accessible, particularly for investigators working in community-based settings or with fewer resources where engaging on-site or on-call clinical support staff may not be feasible.

IRB review and ethical oversight

Experts identified the critical need for IRB processes that are informed by SGD-specific expertise. Consensus recommendations included involving IRB members with backgrounds in child and adolescent mental health, developing SGD-specific ethical guidelines, and engaging LGBTQ+ community representatives in the review process. However, consensus was not reached on the feasibility of implementing these recommendations, reflecting broader concerns about institutional inertia and structural barriers to IRB reform.

Notably, during the course of this study, the Secretary’s Advisory Committee on Human Research Protections (SACHRP) Recommendations for LGBTQI+ Inclusion in Human Subjects Research, federal guidelines developed in 2024 to promote the safe and ethical inclusion of SGD populations [42] in research, were removed from the U.S. government website following the change in presidential administration. This underscores that barriers to ethical oversight in research with SGD populations exist not only at the institutional level but also at the federal level. The change in context during this study period highlighted two distinct yet related concepts: the Delphi panel carefully weighed issues of clinical safety in research participation, which is related to an overall societal safety of SGD identities. As anti-SGD sentiment and policy continue to proliferate, they are likely to further restrict and politicize human subjects research involving SGD youth, exacerbating existing challenges to conducting inclusive and ethical research including with SGD preteens.

Strengths and limitations

This study has several important strengths. First, it is among the first to directly address the ethical and methodological considerations for including SGD preteens in suicide research, a population that is both high-risk and severely underrepresented in existing studies. By focusing on this early developmental window, the study fills a critical gap and lays the groundwork for more inclusive research. Second, the Delphi process engaged a diverse and multidisciplinary expert panel, with high rates of participation and retention across survey rounds (100% in Round 1 and 95% in Round 2). The integration of youth and adult community advisory boards throughout survey development further enhanced the cultural relevance and responsiveness of study materials. Third, the study followed the structure of a previous successful NIMH-academic Delphi study [24], and employed a multimodal approach to consensus-building, combining two rounds of structured survey data with a virtual consensus meeting which allowed for both quantitative and qualitative input. Additionally, the inclusion of importance and feasibility ratings provides an actionable framework for future research with SGD preteens, and helps to distinguish between ideal and realistic practices.

Nonetheless, several limitations warrant consideration. While the expert panel was diverse in terms of professional background and some sociodemographic characteristics (e.g., sexual orientation), representation from legal and regulatory domains was limited, potentially constraining perspectives on IRB reform and implementation feasibility. The smaller sample size (N = 20) aligns with best practices for Delphi panels [43], but may limit generalizability, especially related to differences across racial, ethnic, and cultural identities. Additionally, although consensus was reached on many items, a subset of strategies, particularly those related to youth and parent engagement and IRB processes, remained points of disagreement or uncertainty highlighting ongoing challenges in the field and areas for future research. Although the study focused on U.S.-based experts and contexts, future research would benefit from incorporating global perspectives, particularly given global variability in sociopolitical conditions affecting research involving SGD youth. Finally, the termination of National Institutes of Health funding partway through the project, due to its partial focus on gender identity, necessitated modification of the originally planned full-day, in-person consensus meeting to a shortened virtual format. Although the condensed virtual meeting facilitated substantive discussion and was rated as highly acceptable by participating experts, the change in format may have limited opportunities for more extensive dialogue and deeper examination of specific constructs.

Future directions

Future work should pilot the application of these best practices in real-world research contexts to evaluate their feasibility, acceptability, and impact on participant safety and retention. Studies might also investigate strategies for engaging IRBs in reform processes, including the creation of SGD-specific ethical review guidelines and training modules. For example, institutions could adopt policies requiring IRBs reviewing SGD-related protocols to include members with expertise in child and adolescent mental health and minoritized populations, including SGD communities. Such structural changes may represent a relatively low-burden and feasible approach to ensuring that human subjects determinations are informed by relevant population-specific expertise. There is a need for additional Delphi studies that engage broader international and cross-cultural perspectives, as SGD youth in different sociopolitical environments may face distinct ethical and logistical challenges. Finally, further research is needed to develop scalable youth engagement strategies, particularly those that allow for meaningful participation by preteens in shaping research that affects them.

Conclusions

This study offers the first set of consensus-based guidelines for involving SGD preteens in suicide prevention research. By outlining ethically sound, developmentally appropriate, and culturally responsive strategies, the findings provide a roadmap for advancing early intervention science during a critical developmental window. In doing so, this work supports the broader goal of ensuring that suicide prevention research is inclusive of the youth most at risk.

Author contributions

KAC led the conceptualization, funding acquisition, project administration, and supervision of the study and drafted the manuscript. JRB contributed to study conceptualization, supervision, and manuscript writing and review. MC contributed to study conceptualization, supervision, and manuscript writing and editing. AB and KM contributed to conceptualization, methodology development, and critical manuscript review. KP and EH supported data collection, project coordination, and data management. EH also contributed to data analysis. JC and DSL contributed to conceptualization and methodology design. JG contributed to study conceptualization, methodology design, and supervision prior to his passing. All authors reviewed and approved the final manuscript.

Funding

This work was supported by the National Institute of Mental Health of the National Institutes of Health under Award Number R01MH137695 (PI: Clark). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

All participants provided informed consent. Ethics approval was obtained from the Vanderbilt University Institutional Review Board.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.