Experiences of Minority Stress and Mental Health Burdens of Newly Arrived LGBTQ* Refugees in Germany

While many refugees have settled in Germany within recent years, little is known about LGBTQ* (lesbian, gay, bisexual, trans*, queer*) refugees, a potentially vulnerable group. This qualitative study investigated LGBTQ* refugees’ experiences of distal and proximal minority stressors as well as their mental health burdens during the post-migration period. In 2018, 26 self-identified LGBTQ* refugees were recruited in community centers of different metropolitan areas of Germany and interviewed in three focus groups. Anonymized transcripts were analyzed using thematic analysis. LGBTQ* refugees experienced discrimination based on their intersecting identities. Some described daily occurrences and higher rates in comparison with premigration. Moreover, LGBTQ* refugees reported expectations of rejection and thus concealed their identities, while some also demonstrated identity acceptance. Reported mental health burdens covered internalizing symptoms as well as low levels of well-being. Findings suggest that LGBTQ* refugees are especially vulnerable to multiple forms of discrimination based on their intersecting identities. For a subgroup of participants, both discrimination experiences and mental health burdens subjectively increased during post-migration. Our evidence substantiated that LGBTQ* refugees need to be distinctively acknowledged in social policies to counter their specific patterns of experienced discrimination and improve their mental health.


Introduction
Between 2015 and 2018, approximately 1.5 million people sought asylum in Germany (Bundesamt für Migration und Flüchtlinge 2020). 1 While official statistics on asylum claims based on sexual orientation or gender identity are not available for European countries including Germany, numbers are estimated to be significantly high (FRA-European Union Agency for Fundamental Rights 2017). Thus far, little psychological research has been conducted at the intersection of LGBTQ* (lesbian, gay, bisexual, trans*, queer*) and flight, especially within European countries. Still, such research in Germany is highly relevant, as it continues to be the only European Union member country among the top ten refugee-receiving countries in the world (UNHCR 2019).
Research with the general LGBTQ* community as well as with refugees populations has shown that both groups are at an increased risk of developing mental health issues-compared with either non-refugees (Porter & Haslam 2005) or heterosexual peers (Mays & Cochran 2001;Meyer 2003;Mustanski et al. 2016), which can at least partially be linked to the discrimination they experience.
In many regions of the world, people belonging to sexual and gender minorities experience rejection, discrimination, and in part also severe violence (Carroll & Mendos, 2017;Piwowarczyk et al. 2017). Therefore, some flee their home countries to gain safety and social inclusion elsewhere Cerezo et al. 2014;Cheney et al. 2017). Becoming LGBTQ* refugees, they often report traumatic events prior to migration and during their migration journey (e.g., Alessi et al. 2016Alessi et al. , 2017Cerezo et al. 2014;Cheney et al. 2017). Recently, first evidence has additionally pointed to adverse life events of LGBTQ* refugees in European resettlement countries (Alessi et al. 2018a). Additionally, the rise of the far-right political party "Alternative for Germany" in Germany as well as reported increases in violence against migrants (European Commission 2020) may further impact the post-migration experiences of LGBTQ* refugees settling in Germany. Using a minority stress framework, the purpose of this study was to better understand the experiences of LGBTQ* refugees during the post-migration period in Germany and to understand how such experiences relate to their mental health.

Theoretical Considerations
The minority stress framework (Meyer 1995(Meyer , 2003 postulates that LGBTQ* persons have more distressing experiences in society due to their sexual and/or gender identity. Four types of minority stress can be distinguished: (1) internalized stigma, i.e., incorporating society's negative attitudes towards non-heterosexual, non-cis-gender people into one's self-concept, (2) concealment of sexual orientation/gender identity, (3) expectations of discrimination and rejection by others, and (4) actual experiences of discrimination and violence. The first three minority stressors are also called proximal minority stress, occurring as within-person processes. The latter minority stressor of discrimination is defined as distal, occurring between persons. All four components have been repeatedly shown to contribute to heightened mental health burdens of LGBTQ* populations in comparison with non-LGBTQ* populations (e.g., Feinstein et al. 2017;Puckett et al. 2016;Sattler et al. 2017a).
Equally important, intersectional theory (Crenshaw 1989(Crenshaw , 1991 can guide research studying LGBTQ* refugees' living situations after forced migration. Being LGBTQ* as well as refugees, they hold different, intersecting minority identities which likely shape their experiences in Germany. Thus, for LGBTQ* refugees, the negative effects of minority stress, especially discrimination experiences, could impact them differentially and result in unique constellations of discrimination and mental health burdens. Intersectionality was first developed as a theoretical framework, focused on the experiences of Black women and how their intersectional identities should be acknowledged in both feminist theory as well as antiracist policies (Crenshaw 1989). Since then, it has also been employed as a methodological approach in research studies. For example, intersectionality has been used to analyze how Black heterosexual men's lives are shaped by race, gender, and their socioeconomic status (Bowleg et al. 2013). In the present study, we employed a psychological framework that not only is focused on minority stress but also employs intersectionality as a sensitizing concept to better understand the post-migration experiences of LGBTQ* refugees in Germany.

Post-migration Experiences of Minority Stress
On the one hand, LGBTQ* refugees need to cope with similar post-migration challenges as the general refugee populations such as overcoming barriers to the job market, difficulties finding housing, and problems within the asylum process (Krahn et al. 2000;Li et al. 2016;Porter and Haslam 2005). On the other hand, LGBTQ* refugees are required to master additional challenges which can be explained by their experiences of minority stressors as well as their intersecting identities. In line with the construct of distal minority stress, LGBTQ* refugees and immigrants experience discrimination during post-migration (Alessi et al. 2018b;Gowin et al. 2017;Kahn 2015;Munro et al. 2013;Ogunbajo et al. 2018). For example, immigrating LGBTQ* persons reported experiences of homophobia and racism, on individual and institutional levels (e.g., within local LGBTQ* communities; accessing social services; Munro et al. 2013). Due to their gender-nonconformity, LGBTQ* refugees reported feeling excluded from co-ethnic communities as well as the general society (Kahn 2015). Corresponding research within Germany has used an intersectional lens and strongly focused on LGBTQ* refugees' experiences during the asylum process (Dustin & Held 2018;Held 2019;Hübner 2016;Tschalaer 2019). For example, Dustin and Held (2018) have found that intersectionality is often overlooked within the asylum process, i.e., asylum seekers are merely assessed on the grounds of their sexual orientation/ gender identity while other social categories are neglected. Tschalaer (2019) highlighted how LGBTQ* refugees may face discrimination in the asylum process, for example by translators and immigration officials. In sum, these studies suggested that LGBTQ* asylum seekers may be pressured to adhere to Western stereotypes of LGBTQ* populations to gain safety in Germany (Tschalaer 2019), which likely impacts their mental health.
Less is known about LGBTQ* refugees' experiences of the different types of proximal minority stress during the post-migration period. Firstly, one study has shown that identity concealment among LGBTQ* refugees may be an important theme: Participants, predominantly gay men, reported to continue hiding their sexual orientation or gender identity throughout the post-migration period to avoid experiencing violence committed by other refugees, especially in collective refugee housing (Alessi et al. 2018a). In line with minority stress theory, this can be seen as preliminary evidence of LGBTQ* refugees continuously needing to conceal their sexual orientation/gender identity even after flight. Secondly, internalized stigma has been investigated in a study on LGBTQ* immigrants in the USA, showing high prevalence rates (Rhodes et al. 2013). Another study, conducted with LGBTQ* immigrants in Canada, explored the development of sexual or gender identity throughout the acculturation process. Participants reported that their initially high levels of internalized stigma declined throughout the process, resulting in the development of a more visible and prominent queer identity (Fuks et al. 2018). While these findings are likely to apply to LGBTQ* persons who recently came to a Western host country as refugees, research on internalized stigma for this population is lacking. Thirdly, to the best of our knowledge, no study was conducted that examined the topic of rejection expectation in LGBTQ* refugees. For gay and lesbian populations, it was shown that rejection expectation-in conjunction with internalized stigma-can mediate the relationship between discrimination experiences and mental health (Feinstein et al. 2012). Exploring such themes for LGBTQ* refugees could help understand their intrapersonal experiences of minority stress.

Mental Health of LGBTQ* Refugees
In line with predictions from the minority stress framework, LGBTQ* populations have an increased risk for developing mental health problems (e.g., Cochran et al. 2003;King et al. 2008;Valentine & Shipherd 2018). Similarly, LGBTQ* refugees living in the USA have reported experiencing symptoms of depression, anxiety, post-traumatic stress, and increased substance use, sometimes linking those symptoms to victimization and discrimination in their country of origin or to resettlement challenges such as unstable environments or economic insecurity during post-migration periods (Alessi 2016;Alessi et al. 2016;Gowin et al. 2017).
Furthermore, a study on the mental health of torture survivors showed that LGBTQ* refugees who had been persecuted for their sexual orientation and/or gender identity had a higher incidence of suicidal ideation than those who were persecuted for other reasons (Hopkinson et al. 2017). Sexual minority immigrants from Central/South America or Africa living in the USA also reported high levels of mental distress such as symptoms of depression, post-traumatic stress, and substance abuse. These symptoms were associated with discrimination experiences in their countries of origin as well as in their host country, socioeconomic factors, and internalized stigma (Cerezo 2016;Ogunbajo et al. 2018;Rhodes et al. 2013).
In line with the minority stress model, proximal minority stressors such as internalized stigma and distal minority stressors such as victimization experiences are therefore reported as possible stressors contributing to mental health burdens. While research within the overall LGBTQ* population has strongly focused on both distal and proximal minority stressors and their effects on mental health (e.g., Newcomb & Mustanski 2010;Sattler et al. 2017aSattler et al. , 2017b, research with LGBTQ* refugees has mainly investigated distal minority stress (e.g., Alessi 2016; Alessi et al. 2016;Gowin et al. 2017;Hopkinson et al. 2017). Studies integrating research on proximal minority stress are even fewer and are mainly conducted with LGBTQ* immigrants (Alessi et al. 2018a;Ogunbajo et al. 2018;Rhodes et al. 2013). More studies incorporating the psychological processes of proximal minority stress among LGBTQ* refugees can help to better understand how they may be affected by discrimination during post-migration periods and how this relates to their mental health.

Research Question
Acknowledging both intersectionality and minority stress can decisively contribute to this understanding, as belonging to (at least) two minority groups uniquely shapes their individual experiences. Considering the post-migration period in Germany, this study addresses the following research question: How do LGBTQ* refugees experience minority stress during post-migration? To answer this question, we explored their experiences of distal minority stress (i.e., discrimination), proximal minority stress (i.e., internalized stigma, rejection expectation and identity concealment), and mental health burdens.

Procedure
A qualitative approach was used in this investigation. Focus groups with LGBTQ* refugees were conducted in the metropolitan Ruhr Area, Cologne, and Berlin, three different regions in Germany in July and August 2018. Each focus group consisted of 8 to 10 participants who were refugees and self-identified as LGBTQ*. The focus groups took place in safe spaces provided by local LGBTQ* organizations and lasted approximately 2:39, 2:05, and 1:27 h, respectively. The audio tape recordings of the focus groups were later transcribed verbatim. Assuring a maximum of anonymity, participants gave verbal informed consent, which was recorded on audio tape. Each group was led by two moderators, one of whom was a member of the research team, the other was a member of the staff of the local LGBTQ* organization. The moderators led the discussions based on a semi-structured discussion protocol. Both moderators were fluent in Arabic, German, and English. After the focus group discussion, participants completed a brief questionnaire. As an incentive, participants could win a tablet.
Participants' eligibility criteria 2 included being at least 18 years old, having received an official protection status in Germany, self-identifying as LGBTQ* and speaking Arabic or English. Participants were individually approached in LGBTQ* refugee organizations by cooperating community insiders and informed about the study. As the study protocol required a high degree of personal self-disclosure, potential participants were given some days to decide on their study participation.

Participants
A total of 26 LGBTQ* refugees agreed to participate in this study. Participants were between the ages of 18 and 46 years (M = 29.7, SD = 8.99). Fourteen participants were recognized refugees, 6 were under subsidiary protection, 2 were applicants for asylum, 2 were granted asylum, one was issued a deportation ban, and one did not disclose their legal status. Their nationalities included Iraqi (n = 10), Syrian (n = 7), Moroccan (n = 3), Lebanese (n = 2), Malaysian (n = 2), Guinean (n = 1), and Kenyan (n = 1). 3 Participants identified as gay men (n = 18), bisexual men (n = 3), trans* women (n = 3), and non-binary/queer (n = 2). Eleven participants had been residing in Germany for 3-5 years while 8 participants had been living in Germany for 1-2 years, and 7 participants had been living in Germany for less than 1 year. Overall, 21 participants mentioned their sexual orientation/ gender identity as a reason for coming to Germany while three mentioned other reasons (e.g., war; other unspecified violence) and three participants did not specify their reasons for seeking asylum.

Measures
A semi-structured discussion protocol ensured that the research goals were sufficiently addressed and data from all focus groups could be jointly analyzed (see Appendix). We developed the discussion protocol based on an extensive literature review (e.g., Alessi et al. 2016;Gowin et al. 2017;) and after discussions with other experts on LGBTQ* research in Germany. Questions for the focus groups were then piloted with members of the German LGBTQ* community and translated from German into Arabic and English. In a next step, the translated protocol was tested in separate cognitive interviews with two LGBTQ* refugees and one heterosexual refugee. These interviews were not included in the final analysis. All questions were asked in an open manner in order to stimulate discussions. Follow-up questions allowed further elaboration. Additionally, a brief questionnaire was administered at the end of each group to collect demographic data on nationality, age, gender identity and sexual orientation, as well as a rating of the participant's life satisfaction with one item on a Likert scale of one to seven ("All in all, how satisfied are you with your life?", 1-"very unsatisfied" to 7-"very satisfied"). The response to the latter question was also employed to triangulate data during analysis.

Analysis
The focus group discussions were transcribed verbatim in the original languages. The transcriptions were conducted by native speakers and then revised by another native speaker to ensure accuracy. All transcripts were then translated into English by native speakers and, finally, double-checked by a second translator. The full material for analysis comprised 140 standard pages. To ensure participants' anonymity, all names were removed from the transcripts.
To analyze the data, a thematic analysis according to the process outlined by Braun and Clarke (2006) was conducted using the program MAXQDA Analytics Pro 2018 (VERBI Software 2018). In line with our research question, themes for the three topics (1) distal minority stress (i.e., discrimination), (2) proximal minority stress (i.e., internalized stigma, concealment, rejection expectation), and (3) mental health burdens were developed. The overarching goal of the themes was to allow a better understanding of the extent to which minority stress is experienced by LGBTQ* refugees in Germany. The thematic analysis was conducted by the first and fourth authors, while the third author (who also conducted the focus groups) later on checked that the thematic analysis corresponded with the focus group discussions.
While the majority of our research team is German, two have a migration background (one from a Middle Eastern country) and several identify as part of the LGBTQ* community. As our research team is composed of people with different experiences and backgrounds, we continuously discussed our potential biases and our positionalities in peer debriefings throughout the research process. Prior to developing the discussion protocol and based on previous research, we assumed study participants experience continuous discrimination and mental health burdens during post-migration. We also assumed that participants may report heightened experiences of proximal minority stress, especially internalized stigma. Those authors directly involved in the thematic analysis employed in-depth discussions to ensure that the analysis was data-driven.

Discrimination Experiences
All participants reported experiences of discrimination in a multitude of ways at some point after their arrival in Germany: in various contexts (e.g., privately, institutional), based on various attributes (e.g., race, religion, gender identity), and from various offenders (e.g., white Germans, other refugees). We identified the themes intersectional discrimination, daily discrimination, and "worse than before flight."

Intersectional Discrimination
Participants reported discrimination experiences based on numerous and intersecting attributes. Specifically, participants explained that they are discriminated against based on their gender identity/sexual orientation, their ethnic background, as well as on their status as refugees.
The racism we face isn't just because we are gay or trans. We face racism for being refugees! The racism isn't just because we are LGBTQ*, it is also because we are refugees. If your name isn't German, you automatically won't have the same rights as a German.
A trans* participant described a specific situation when they were seeking treatment at a hospital and felt discriminated against for being both trans* and not able to speak German.
I was in the hospital … and they refused to talk to me because I don't speak German. The doctors did not talk to me. Maybe they get confused because my gender in my documents and my personality isn't the same. There it shows me as a man, but I am a female.

Daily Discrimination
Additionally, discrimination was described by several participants to occur daily, from several offender groups, such as other refugees, white Germans and within the LGBTQ* community. Overall, participants reported feeling as if discrimination could happen anywhere and by anyone. The last quote also shows how this participant felt as if they had no way to counter the discrimination they faced. The quote is also an example of the theme intersectional discrimination, as the participant attributed being discriminated against due to their status as a non-binary refugee.

"Worse Than Before Flight"
While all participants reported experiences of discrimination, a subgroup of participants seemed to be especially affected. For those, there was a persistent theme that their experiences of victimization and discrimination in Germany were worse than before flight. Especially regarding the frequency of experienced discrimination, they reported a strong increase.
Even here, with our normal looks we get insulted. In Syria for example we didn't get insulted like we did here. Here it's more.
I felt that in Lebanon as a human, I was living better than here.
The violence I see here is more than the violence I see back home. I faced violence here. People mocked me and insulted me here way more than back home.

Proximal Minority Stress: Internalized Stigma, Rejection Expectation, and Identity Concealment
In a next step, we investigated the psychological processes of minority stress that LGBTQ* refugees may face by analyzing their experiences of internalized stigma, rejection expectation, and identity concealment. Analyzing this topic yielded the following themes: fear of coming out, continuous concealment, and identity acceptance.

Fear of Coming Out
Several participants revealed that they avoid coming out to their friends as they fear the consequences. This behavior could be interpreted as rejection expectation. For instance, use of the word "gay" as a self-ascription in seemingly safe situations was challenging for some participants: (referring to the word "gay"): It was the hardest word for me, even though I was like … gay (…). Even talking to friends about it is scary because they could cause you problems. I don't like to say it (that he is gay), because I know they will refuse so … I avoid doing it. Still, some participants were able to overcome this initial fear of coming out: About a year or two years ago. I was afraid. I was afraid to say that I am gay. I remember the first time I wanted to tell someone, I said: "I…" and got scared, so I wrote her on the screen of her phone instead.

Continuous Concealment
Consequently, participants reported continuously needing to conceal their sexual orientation/gender identity in Germany, for example, from friends, co-workers, or family, in order to protect themselves.

I came here and faced a lot of problems as a gay person. During the last three years I had to get out of the gay scene and be straight. It was a must.
For instance, one participant explained that they stayed with relatives who wanted to change their sexual orientation. In consequence, they tried to hide their identity from their family as much as possible:

The place I stayed at with my family was small. And my family was around me all the time. And as I said, I had to stop living the gay life. I truly became straight. I seemed straight. I was only able to meet up with people if I traveled to another city.
Another participant explained that concealing their sexual orientation/gender identity is a process that intensified for some LGBTQ* refugees in Germany, showing how identity concealment may be used as a strategy to protect them from possible harassment: Many gays suffer because they're gay. They can't act the way they want to. Because if someone acted like a girl or acted the way they feel inside, they would directly receive disrespect in return. Especially by Germans. Like most of the guys and friends I know changed. They changed their looks to receive respect in return. Some started growing beards and cutting their long hair.

Identity Acceptance
On the other hand, some participants had come to openly accept their sexual orientation/gender identity. Although some feared coming out at first in the post-migration period, they have found ways to openly live as LGBTQ*. The latter quote shows that identity acceptance was a successful process for this participant during post-migration.

Mental Health Burdens
Lastly, we investigated LGBTQ* refugees' mental health burdens. Most participants reported distress, while also reporting low satisfaction with their lives. The following themes were established: internalizing problems and continuous suffering. Realizing that their mental health status has worsened in comparison with premigration seemed to be additionally distressing to some participants.

Internalizing Problems
Participants reported various mental health burdens, most often internalizing problems. These included symptoms of depression (i.e., hopelessness and negative affect), anxiety, exhaustion, and loneliness.

On some days I am too tired to go to school. And I don't because I am exhausted. My mental health is getting worse. My depression is getting worse. In the city I am in, when I am in it, I don't interact with anyone, I don't go out with anyone. My psychological state is very tired, very tired.
Some participants tried to cope with their internalizing symptoms through substance abuse and self-harm.

Continuous Suffering
Aside from concrete psychological symptoms, some participants also reported feeling continuously distressed by their situation during the post-migration period. While several participants emphasized that their well-being has not improved in comparison with premigration, others even reported that their mental health has worsened in Germany.
It is here we started to suffer.
Until now and I am suffering, until now I am suffering. It has been two years and a half, and no school and no friends. Like they say, I am not living my life my way.
Based on the brief self-report on life satisfaction, the study sample reported overall dissatisfaction with their lives, with a mean of 3.19 (SD = 1.9). More specifically, six participants stated they were "rather unsatisfied" (value of 3), one participant reported being "unsatisfied" (value of 2) and four participants reported being "very unsatisfied" (value of 1) with their lives. On the other hand, five participants reported being "neither unsatisfied nor satisfied" (value of 4). Only few participants were satisfied with their lives: three reported being "rather satisfied" (5), one "satisfied" (6), and two "very satisfied" (7). The participants' averaged responses to this questionnaire underline their experiences of lowered well-being during post-migration.

Discussion
This study aimed at closely investigating the experiences of minority stress and mental health burdens of newly arrived LGBTQ* refugees in Germany, a Western country ranked among the top ten refugee host countries worldwide (UNHCR 2019). While reaching LGBTQ* refugees can be challenging, it is vital to gather insights on their postmigration experiences, with the overarching aim of better understanding their experiences and potential needs. Based on a study perspective informed by intersectional and minority stress theory, evidence was found that this group makes unique experiences during post-migration periods that can impact their mental health. Distal minority stressors, i.e., experiences of discrimination, were found for all participating LGBTQ* refugees, emphasizing that this group is especially vulnerable for victimization. Based on our three research themes (distal minority stress, proximal minority stress, mental health), we briefly summarize and discuss the study's findings.
First, all participants reported at least one, and most of them reported several instances of discrimination. This points to the high scope of intolerance and violence LGBTQ* refugees face from different people. Although LGBTQ* refugees often flee their home countries with the aim of escaping discrimination and violence, our findings suggest that experiences of violence and discrimination may continue in Germany. This study is hence consistent with evidence from previous studies on LGBTQ* discrimination (FRA-European Union Agency for Fundamental Rights 2014), refugee discrimination (Montgomery and Foldspang 2007), and LGBTQ* refugee discrimination (Alessi et al. 2018a(Alessi et al. , 2018bGowin et al. 2017;Kahn 2015).
LGBTQ* refugees participating in our study emphasized the amount of daily discrimination, which led to feelings of being unable to avoid such discrimination for some. Moreover, intersectional discrimination, that is, being discriminated against for being for example a trans* refugee was often prevalent. Consequently, our study findings substantiate that the framework of intersectionality (Crenshaw 1989(Crenshaw , 1991 helps understand the multitude of discriminations experiences LGBTQ* refugees face for numerous reasons, such as their ethnic background, sexual orientation, gender identity, but also for example their skin color, religion and/or gender expression. Furthermore, the experiences of discrimination due to the intersecting identities within our sample suggest how the lives of LGBTQ* refugees in Germany are shaped by distal minority stress, reflecting between-person processes. Second, investigating proximal minority stressors produced the themes fear of coming out, identity concealment, and identity acceptance and yielded some contrasting results. Participants reported fear of coming out and, consequently, concealing their sexual orientation/gender identity, especially in situations in which they expected receiving negative reactions, such as from family members wishing to change their sexual orientation. This could be interpreted as a form of rejection expectation which, as a proximal minority stressor, could negatively impact their mental health (Feinstein et al. 2012). Some researchers, however, have contrarily argued that rejection expectation can be seen as a functional adaptation mechanism to one's environment if previously confronted with discrimination (Pachankis et al. 2018). Similarly, LGBTQ* refugees living in refugee accommodations in the Netherlands and Austria continued to hide their sexual orientation/gender identity-if not, they often experienced further discrimination (Alessi et al. 2018a). Thus, concealing one's sexual orientation/gender identity may be helpful to avoid further discrimination.
At the same time, we found identity acceptance to be a significant theme and internalized stigma rarely came up within the focus group discussions. In a way, identity acceptance can be understood as the opposite of internalized stigma, thus coming to terms with one's sexual orientation/gender identity may oppose internalizing negative thoughts about one's identity. Still, this should not lead to the conclusion that internalized stigma is an unimportant theme for LGBTQ* refugees. A previous study found that internalized stigma is at an increased rate in those countries in which LGBTQ* have less legal rights and experience more discrimination (Berg et al. 2017). Legal circumstances for LGBTQ* refugees have likely improved by immigrating to Germany. However, the discrimination they face seems to be continuously high. This might lead to a continuation of increased levels of internalized stigma, which may impact their mental health. Overall, studying the effects of proximal minority stress on the mental health of LGBTQ* refugees and uncovering mechanisms that could help lessen impact of these stressors warrant additional research. As some participants in our sample came to accept their identities, future research should also take a closer look at the potential variables that enable LGBTQ* refugees to positively accept their gender identity and/or sexual orientation.
Analyzing the mental health of LGBTQ* refugees postmigration revealed both symptoms of mental distress, mainly internalizing symptoms, and the scope of these issues, which some participants perceived as continued suffering. These statements are overall backed by results from the brief questionnaire on life-satisfaction. Consistently, previous studies on the general LGBTQ* population as well as refugees after resettlement also showed heightened symptom levels of depression and anxiety (Cochran et al. 2003;King et al. 2008;Valentine & Shipherd 2018). While there are several studies reporting various mental health burdens in LGBTQ* refugees and immigrants (Alessi 2016;Cerezo 2016;Gowin et al. 2017;Hopkinson et al. 2017;Ogunbajo et al. 2018;Rhodes et al. 2013;Yamanis et al. 2018), our study highlights the theme of subjective worsening of both discrimination experiences as well as mental distress.
In sum, the notion that LGBTQ* refugees' well-being does not automatically improve but may even decrease after resettlement (Alessi et al. 2018a) could be substantiated and extended in this study. Using a minority stress approach, informed by intersectional theory, this work provides possible explanations for this decrease of well-being in LGBTQ* refugees in Germany, namely by uncovering the psychological processes of rejection expectation and identity concealment.

Strengths, Limitations, and Future Research
This study has several limitations. First, the sample is selective as the recruiting process was based on LGBTQ* refugee service organizations, in urban residencies and limited to participants speaking either English and/or Arabic. Especially LGBTQ* refugees in rural areas and from other diaspora communities without access to LGBTQ* services are likely to make different experiences. Moreover, the study sample mainly consists of gay, cis-gender refugees, and some trans* women. Neither cis-gender lesbian/bisexual women nor trans* men were part of this sample. Thus, this article is based on a predominantly male experience. A previous study has elaborated how especially lesbian women are underrepresented in research with LGBTQ* refugees and may face discrimination in the asylum process (Tschalaer 2020). Besides, it is possible that women are underrepresented in public LGBTQ* support groups, which raises the question whether their access to LGBTQ* service organizations is limited. Conducting additional interviews with LGBTQ* refugee service providers could have additionally provided insights into such phenomena influencing our sample composition and could have further strengthened data triangulation. Within our data analysis, data triangulation was limited to a brief questionnaire on the participants' well-being to improve trustworthiness of our data.
Despite these limitations, this study also has several strengths, as it is the first in-depth study on LGBTQ* refugees' experiences of minority stress during postmigration in Germany. Thus, in our qualitative study, we were able to explore personal narratives of minority stressors and mental health burdens of recently arrived LGBTQ* refugees in Germany. Evidence from this study hence provides profound insights to guide future studies, as it appears especially necessary to further study experiences of rejection expectation and identity concealment for LGBTQ* refugees. Future research may moreover explore the mechanisms of proximal minority stress in quantitative designs. It would also be interesting to investigate how a proportion of LGBTQ* refugees come to accept their identities during post-migration while at the same time facing discrimination. Additional research is also needed to investigate how discrimination experiences affect the mental health of LGBTQ* refugees and what can be done to improve LGBTQ* refugees' well-being. Employing resilience frameworks focusing on promoting the well-being of LGBTQ* refugees could therefore guide future research (see Fredriksen-Goldsen et al. 2014).

Social Policy Implications and Conclusion
Minority stress and, more specifically, overt discrimination experiences and continuously needing to conceal their identity may strongly affect the everyday lives of LGBTQ* refugees after resettlement. Considering their intersecting identities, LGBTQ* refugees should be acknowledged as a group that may likely be specifically targeted and victimized, thus promoting anti-discrimination of this group. Moreover, specific support measures could help LGBTQ* refugees cope with their experiences of discrimination. Within counselling and psychotherapeutic services, the impact of minority stress on LGBTQ* refugees must be acknowledged. Service providers and therapists need to be sensitized to LGBTQ* refugees' potential continuation of discrimination events and how identity concealment may function as a means to avoid further discrimination. Also, mental health services should be accessible to LGBTQ* refugees and sensitized to the psychological processes of proximal minority stressors, especially identity concealment and expectations of rejection, which likely impact their mental health. Social support, a potential buffer for the impact of minority stress on mental health (McConnell et al. 2018) could be facilitated by offering, e.g., LGBTQ* refugee group counselling programs. Specifically focused on the asylum process of LGBTQ* refugees in Europe, social policy implications have been summarized by the Queer European Asylum Network (2020), such as proving people working within the asylum system with trainings on intersectionality and LGBTQ* topics.
Overall, findings from our study suggest that adopting a minority stress perspective, informed by intersectionality, can help better understand the high vulnerability of LGBTQ* refugees. Our study delineates the discrimination experiences, identity concealment strategies, and subjective worsening of mental health of newly arrived LGBTQ* refugees in a Western high-income country. Identity concealment, possibly exacerbated by rejection expectation, may be both a stressor for LGBTQ* refugees as well as a strategy to avoid further discrimination. Evidence from this study and its theoretical underpinnings can provide an empirical basis for future research and needoriented policy-making.
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Appendix. Discussion Guide
1 First of all, I am interested in finding out what challenges you faced when you first came to Germany (psychological, organizational, physical), but also what worked out well for you. If you could only name one thing a) what was the hardest thing for you, when you first came to Germany? b) what worked out well here in Germany (maybe even better than expected)? c) Was your sexual orientation/gender identity the main reason why you fled from your home country? d) Did you experience discrimination here in Germany? e) Who discriminated against you? f) Do you face difficulties in your daily life because of your sexual orientation/gender identity? (If yes, how often and when?) g) Do you think, you would be happier, if your sexual orientation/gender identity was different? h) Do your friends and family know about your sexual orientation/gender identity? If yes, how do they deal with it? i) What is the typical reaction of a person from your country of origin, when you openly show your sexual orientation/gender identity?