‘Coming out’/self-disclosure in LGBTQ+ adolescents and youth: International and Indian scenario - A narrative review of published studies in the last decade (2012-2022)

Abstract

Background:

People who identify themselves as Lesbian, Gay, Bisexual, Transgender, Queer, and others (LGBTQ+) go through a process of self-exploration and self-identification during adolescence, and the process resolves when one decides to self-disclosure. The experience of ‘Coming Out’ (CO) can be positive, leading to acceptance and a feeling of liberation, or it can be harmful, leading to stigma, humiliation, and discrimination, subsequently leading to significant psychological distress.

Aim:

This study was to do a narrative review on the studies published in the area/topic of CO in youth in the last decade (2012-2022) and to look for factors that act as barriers and facilitators of CO. Additionally, we have tried to look for differences in CO in LGBTQ+ adolescents and youth in the Western world vis-a-vis Indian/Eastern societies.

Materials and Methods:

An extensive literature search in electronic databases, PUBMED, Web of Science, EMBASE, Medline, Scopus, and search engine ‘Google Scholar’ using specific search terms and assessment of all published articles until 20^th May 2023 was done.

Results:

Twenty-three studies were found eligible for data extraction, which discussed the problems faced during the CO process. Most of the studies are from developed countries, and only one is from India. Eleven were qualitative studies, 11 were cross-sectional studies, and one was a case study. The qualitative studies focused on generating themes of CO along with various issues/problems faced by the participants. The cross-sectional studies mainly explored parental reactions, stigma, parental support, psychological distress, and perceived stress in the participants. Major themes emerging from the qualitative studies were the experience of prejudice from various strata of society, such as parental, societal, racial, cultural, and religious factors that lead to problems of hiding, internalized homophobia, and anticipatory rejections that put this population under extreme conditions. Limited research is available from Eastern societies. More recently, the new generation of adolescents has taken the help of social media platforms for self-disclosure.

Conclusions:

CO is an elaborate multi-step process that considers the presence of parental/family and societal support, cultural/traditional values, and several psychosocial factors that determine the degree of positive outcomes. Emerging data indicated an improved trend of adolescents deciding to come out to families or in online platforms, both of which are associated with challenges, more in eastern collectivistic societies and developing countries.

INTRODUCTION

People who identify themselves as Lesbian, Gay, Bisexual, Transgender, Queer, and others (LGBTQ+) belong to one of the most diverse yet minority populations that tend to experience significant minority stresses. The identity-related hardships are often endured right from the early teens as the journey of self-identification begins, and one gets the feeling that he/she does not actually belong to the assigned sexuality. The process of adolescence is marked by the psychosocial crisis of Identity versus role confusion, as per Erik Erikson's model.[1] During this phase of life, the desire to find a group to feel associated with leads to an immense sense of security and after belonging to one becomes vital for the further development of personality. Furthermore, during adolescence, sexual exploration and discovery of one's sexual Identity and orientation also evolve, which, in the case of LGBTQ+, leads to a significant amount of identity crisis as they start to identify themselves with a minority group.[2,3] This, in turn, challenges the existing norms that the adolescent has been attuned to.[4]

This process of identification is followed by the process of ‘Coming Out,’ which can be considered as one of the most important journeys for an individual goes through who desires to express their LGBTQ+ identity to family and friends.[5,6,7] The term ‘Coming Out’ (CO) has been used as a metaphor used to describe LGBTQ+ people's self-disclosure of their sexual orientation or gender identity.[5] During adolescence, many adolescents go through CO, which coincides with major changes in self and interpersonal relationships, and apart from the immense psychological relief CO brings, it also paves the way to the onset of minority stress.[5,8] In recent times, adolescents who intend to “come out” have been seen to be going for social media platforms or online forums, and this has been a major influence in improving their connectivity within the community.[4,9,10]

The early researchers have given several linear staging models to explain the process of coming out, with the most no being the Identity model of Vivienne Cass in 1979 which describes successful coming out in a staging model, namely, identity confusion, identity comparison, identity tolerance, identity acceptance, identity pride, and finally identity synthesis.[11] As more data began to arise, the role of sociocultural contexts associated with the coming out and importance was given to understanding ‘coming out’ not as a single event but as a recurring life event that occurs at various social milestones across the life-span and as a dynamic involving multiple trajectories. To explain this, a more inclusive and non-linear ‘Life-span Identity’ model was given by Anthony D’Augelli in 1994, where there is a progression from exiting one's heterosexual identity (heteronormative script), developing a personal LGBTQ+ identity status, then moving on to developing an LGBTQ+ social identity and claiming an identity as an LGBTQ+ offspring, and finally developing an LGBTQ+ intimacy status and then entering an LGBTQ+ community.[12,13] More recently, a new model known as the “Disclosure Processes Model” (DPM)[14] posits that disclosure must be conceptualized as a complex, multifaceted process involving decision-making and outcome processes. It highlights the impact of antecedent goals, the disclosure event itself, mediating processes and outcomes, and a feedback loop. Disclosure can either cause more stigma for an avoidant person, or it can also enable individuals to raise awareness about their identities and, in turn, potentially reduce the stigma associated with it.[15,16]

Studies that have looked into the effect of CO on siblings suggest that disclosure to siblings/cousins (horizontal relationships) is usually marked by reciprocity and egalitarianism, whereas disclosure to parents (vertical relationships) involves guidance, boundaries, and hierarchy.[17,18] Similarly, studies have shown that the relationship between grandchild and their grandparents was not altered by disclosure of their sexual orientation,[19] and grandparents may be a unique source of support for LGBTQ+ adolescents whom they can rely upon.[20] Thus, in view of identifying various factors influencing the decision to CO in adolescents and youth, we did a narrative review of published studies in order to summarize the issues (psychological and social) associated with the process of CO. Additionally, we also attempted to compare the findings between western and eastern literature.

MATERIALS AND METHODS

Search strategy

We conducted a literature search using the keywords “Coming Out,” “Disclosure,” “Adolescence,” “Adolescent,” “Youth,” “LGBTQ,” “Gay,” “Lesbian,” “Transgender,” “Queer” with Boolean operator ‘AND’ in the electronic databases PUBMED, Web of Science, EMBASE, Medline, Scopus and search engine ‘Google Scholar’ to look for articles in the last decade (2012–2022) that have addressed the process of “Coming Out” and its issues in adolescents and youth [details are mentioned in Supplementary Table 1]. The systematic search was performed on 20^th May 2023. Mendeley Desktop V1.19.5 software was used to filtrate and manage selected studies and further coordinate the review/selection process.

Supplementary Table 1.

The adjusted search terms as per searched electronic databases [as of 20.05.2023]

Database	No	Search Query	Results
EMBASE, Medline
	#1	‘(‘coming out’ OR disclosure) AND (adolescence OR adolescent OR youth) AND ‘lgbtqia + people’	23
PubMed
	#1	(coming out) OR (Disclosure)	272369
	#2	((Adolescence) OR (Adolescents)) OR (Youth)	2379256
	#3	((((((LGBTQ) OR (LGBTQ+)) OR (Gay)) OR (Lesbian)) OR (Transgender)) OR (Queer)) AND ((“2012” [Date - Entry] : “2023”[Date-Entry]))	35181
	#4	#1 AND #2 AND #3 AND (English[Filter])	722
Scopus
	#1	(TITLE-ABS-KEY (coming AND out) OR TITLE-ABS-KEY (disclosure)) AND PUBYEAR >2011	73539
	#2	(TITLE-ABS-KEY (adolescence) OR TITLE-ABS-KEY (adolescents) OR TITLE-ABS-KEY (youth))	2705132
	#3	(TITLE-ABS-KEY (lgbtq) OR TITLE-ABS-KEY (lgbtq+) OR TITLE-ABS-KEY (gay) OR TITLE-ABS-KEY (lesbian) OR TITLE-ABS-KEY (transgender) OR TITLE-ABS-KEY (queer))	75746
	#4	#1 AND #2 AND #3	461
Web of Science
	#1	(ALL=(coming out)) OR ALL=(Disclosure)	74843
	#2	((ALL=(Adolescence)) OR ALL=(Adolescent)) OR ALL=(Youth)	707224
	#3	(((((ALL=(LGBT)) OR ALL=(LGBTQ)) OR ALL=(Gay)) OR ALL=(Lesbian)) OR ALL=(Transgender)) OR ALL=(Queer)	40147
		#1 AND #2 AND #3	143
Google Scholar			38

SELECTION CRITERIA

The study population was adolescents of any gender between the ages of 10-19 years. We have extended the age group to 26 years to include youth. We included those studies which reported the CO process, the problems faced by the adolescents during the CO process, and how they dealt with family/parents/peers and society. We included cross-sectional, qualitative, and case studies on CO and its issues, restricted to adolescents/youth/young adults. Essays, life histories/summaries of LGBTQ+ personnel or recommendations/position statements of society/organizations, viewpoints, and editorials were excluded. The studies providing in-depth information explaining the CO process and its themes were included.

Both the authors (SS and VP) independently went through the title and abstract and, on the basis of inclusion and exclusion criteria, further selected or omitted the article. If there was a difference of opinion, it was resolved by SS (Senior Faculty). Following this, a full-text review was undertaken. Studies with no full text, lack of standardized tools/measurement scales, not employing clear definitions of LGBTQ+ or CO and/or disclosure were excluded. Studies with unclear methodology or results were excluded from the analysis. Discrepancies were resolved by mutual discussion between the authors. All the decisions were recorded in the Microsoft Excel spreadsheet.

Data extraction

Data extraction was done independently from the qualified studies: beginning with the author, then the publication year, followed by study sample, type of study, the number of adolescents/youth with LGBTQ+ orientation, study findings, and inferences derived.

RESULTS

Eligible studies

The systematic search of the databases yielded a total of 1387 unique records, based on which title-abstract screening was undertaken, and 39 studies were found eligible during the period 2012–2022 for full-text review. Following the full-text review, 23 studies were found eligible for data extraction which had discussed the problems faced during the CO process. Most of the studies are from developed countries (USA, Italy, Spain, and Canada), and only one study from India[21] (was published online in 2021). These have been summarized in Tables 1 and 2.

Table 1.

Summary of qualitative studies of LGBTQ+ on themes of ‘Coming Out’ in youth selected for the narrative review

Author, year	Country	Methods and tools utilized	Study population and study sample	Main themes discussed/emerged or results	Implications/inferences derived
Craig and McInroy., 2014[22]	Canada	Theoretical sampling with the use of constructive grounded theory for inducting themes using thick descriptions and trustworthiness measures. ATLAS.ti 6 software was used for analyses.	19 LGBTQ+ youth of ages between 18 – 22 years.	5 Themes emerged that New media use facilitated, namely, Accessing resources, Exploration of Identity, Finding likeness, Coming Out Digitally, and Potential to expand Identity.	Non-stigmatizing connections with online role models and reduced social stigma due to anonymity were seen. Youth were able to explore and rehearse LGBTQ+identities, and a tentative process of CO was tested digitally.
Guitar., 2014[23]	USA	Symbolic Interactionism is guided by constructivist grounded theory.	13 LGBT participants (18 to 22 years), of which 12 were women	CO as an affinity rather than an identity aided as a personal and political strategy. It also served as an apologetic endeavor.	CO as an affinity helped minimize disapproval, not get labeled, and to keep the door open for future relationship possibilities. It also helped one to CO as a ‘Bicurious’ or for anyone as a ‘Queer apologetic.’
Klein et al., 2015[24]	Canada	Qualitative photovoice study using NVivo 8 software.	15 LGBTQ+ youths aged 16 – 25 years.	CO is a dynamic and non-linear process and is often seen as a moral imperative but several contextual factors of social and institutional support systems matter.	CO is not always ideal and not a goal as social factors of family, friend support, religious laws, and Intersectionality faced due to financial status, bisexual discrimination within the queer community, and religious identity all play a role.
Fiddian-Green et al., 2017[25]	Puerto-Rico	Case studies demonstrating digital storytelling –narrative approach. Here an ethnographic culture-centered approach utilizing constructivist grounded theory was used. An intertextual transcription method with content analyses using MAXQDA software was done.	2 case studies of LGBTQ-identified Puerto Rican Latina youth across the life-span	Themes covered perceived rejection of CO due to the active silencing of alternative sexual identities in the community and bullying/targeting of sexual minorities at school. One story also described lesser CO due to close ties with family and fear of losing social connections.	Sexual health programs need to come out of a heteronormative approach, and more targeted outreach for LGBTQ+health is needed. Intersectionality of race and sexuality also is significant in this country.
Roe, 2017[26]	USA	Qualitative study using a phenomenological inquiry approach.	6 male and 1 female LGB adolescents	The main themes regarding gaps in parental support while CO was deduced. Here CO was necessary for one's own mental health and well-being; initial parental reactions were largely not positive, religion was a barrier to getting parental support, and LGB youth desired explicit support from family.	Narrative therapy techniques become relevant while addressing disclosure stress towards parents, and these themes could be used to interact with parents of LGB youth to improve mental health and well-being.
Grafsky E.L., 2018[27]	USA	Mixed method study. Convenience sampling with the use of interviews and questionnaires (Parent-Child Closeness Inventory) was done by applying constructivist grounded theory. NVivo 9.0 software was used.	22 LGBQ youth – 14 to 21 years	The decision to disclose was based on four themes, namely, Sexual Identity and integration trajectories (CO to self); Family dynamics; Messages perceived from family and society in general regarding their prejudice toward sexual minorities since childhood; Expected cost of disclosure in terms of rejection of relationship and financial support.	Clear sexual Identity, Open family environment, absence of prior prejudice via messages, and readiness to deal with the consequences of disclosure would be facilitators of disclosure.
Grafsky et al., 2018[18]	USA	Qualitative study using a constant comparative method based on constructivist grounded theory.	22 LGBQ youth – 14 to 21 years	Siblings and friends were seen as horizontal relationships having high egalitarianism and reciprocity. Parents and Grandparents were seen as vertical relationships having a hierarchy, boundaries, and guiding authority. Aunts, Uncles, and even step-parents were seen as diagonal relationships with a balance of authority and equality with closer reciprocity.	Diagonal relationships, mainly with aunts, were seen best persons to disclose sexual Identity before parents offering the best source of support. Siblings and friends in horizontal support often ease emotional difficulties in decision-making to disclose to authority figures.
Libby et al., 2019[28]	USA	Qualitative study – in-depth interview and analysis using grounded theory. NVivo software was used.	Five parent-adolescent dyads (4 transgender males and one transgender female)	Three major themes emerged from the participant's discussion (1) collaboration- referring to parents and youth working as a team towards the goal of affirming the youth's gender identity (2) The Nature of the family environment characterized by tolerance and openness facilitated the coming out process (3) Being accepted at home enhances self-efficacy and promotes advocacy and leadership at school and community.	Youth reported working as a team with their parent to be their greatest support.
Cover et al. 2020[29]	Australia	A qualitative study (based on interviews and focused group discussions)	50 participants from the 1970s and 71 participants from the 1990s as a part of the “Queer Generations Project,” a study to examine sources of support among young LGBTQ participants in Australia	The study revealed that coming out is not necessarily chrono-normative and not always applicable to all. There is no perceived distinction between rural and urban settings to facilitate coming out, and there is no need to migrate to a city to mitigate one's coming out among contemporary accounts.	The study debunked one of the cultural myths of the Australian society that LGBTQ youth growing up in rural settings do not always migrate to urban settings in order to overcome the coming out process or growing up.
Stevens et al. 2021[30]	USA	Content analysis by Natural language processing methods. Computerized coding tools were used for linguistic inquiry and word count, and a latent Dirichlet allocation (LDA) by a machine learning algorithm was used to examine topics provoking shifts in anxiety.	LGBT teens subreddit posts, n=39,389 between 1st January 2020 and 1st February 2021.	Apart from COVID-related anxiety during the lockdown, the study revealed a list of 10 anxiety-provoking topics discussed during the pandemic among LGBT teens. These are an attraction to a friend, coming out, coming out to family, discrimination, education, exploring sexuality, gender pronouns, love and relationship advice, starting a new relationship, and struggling with mental health.	LGBTQ+ teens found anonymous social platforms/forums as safe spaces for discussing anxiety-provoking topics, which included coming out as one of the top 10 topics. Computer-mediated communication is now vital for exploring identities and finding support for LGBT teens.
Andrzejewski et al., 2021[31]	USA	Qualitative study – in-depth interviews of transgender youth. Thematic analyses were conducted using the MAXQDA 12 – Verbi software.	33 transgender youth	4 Themes of support were described, namely Emotional support offering love, empathy for mental illness, and communication about emotions;	Gender-affirming programs and support programs can benefit the parents using the above themes found in this study in promoting the acceptance of transgender youth.
				Instrumental support in the form of financial, healthcare, and legal transition-related support; Appraisal of one's gender affirmation, using chosen names and pronouns and lastly, information support by advice.
Achar and Gopal., 2023[21]	India	A qualitative study of narratives of disclosure of sexual orientation by Thematic narrative analysis using NVivo-10 software.	Five males and five females of same-sex sexuality between 18 – 25 years, India	The study revealed five major themes about self-disclosure in the Indian context - 3 restraint factors and two propulsion factors. The restraint factors of coming out were an incessant pressure to conceal, perceived lack of stability and support, and anticipated disintegration of long-standing familial tradition. The propulsion factors identified were the approachability of the target of disclosure and parental validation.	Freedom from parents, the positive first experience of disclosure, unhindered positive regard from family, and fusion of dual identities of culture and sexual Identity allowed more disclosure. The study also highlighted the tremendous change Indian cultural values have undergone in the metropolitan cities, and there is less stigma as compared to the 1990s regarding same-sex sexuality.

Table 2.

Summary of quantitative studies of LGBTQ+ on themes of ‘Coming Out’ in youth selected for the narrative review

Author, year	Country	Methodology and scales utilized	Study population and study sample	Results	Implications/inferences derived
Baiocco et al., 2012[32]	Italy	Cross-sectional study. Scales used – Kinsey scale for Orientation; Measure for Internalised Sexual Stigma for Lesbian and Gays (MISS-LG); The Friendship qualities Scale.	202 Lesbian and 201 Gay adolescents between ages 14 – 22 years	For Gay Youth – The predictors of Self-disclosure to a best friend were the presence of social internalized sexual stigma and self-disclosure by a friend. For Lesbian Youth – The predictors were Age, Individual Internalised sexual stigma, and self-disclosure by friends.	Internalized Sexual Stigma interferes with Coming Out. The presence of a Cross-orientation best friend, acceptance by a best friend, and self-disclosure of sexual Identity by a best friend were important facilitators of CO.
Baiocco et al., 2015[33]	Italy	Cross-sectional study. The scales used were the Kinsey scale for orientation, the Perceived Parental Reactions scale, Family adaptability, and the cohesion evaluation scale (FACES IV).	164 Italian Gay and Lesbian youth aged 18 – 26 years.	Homosexual youth were likely to disclose more to mothers directly, and fathers tended to find more indirectly. Negative family function and younger age of disclosure were associated with more negative reactions to CO.	High religiosity, especially Catholicism, Right-wing political inclinations, Negative family environment, and Younger age were likely to invoke negative reactions to CO.
Pistella et al., 2016[34]	Italy	Cross-sectional study. The Internalised sexual stigma scale for lesbians, gay men, and bisexuals was used.	291 Italian adolescents (LGBT)	Lesbians/Gays were more likely to CO to family members compared to Bisexuals. Higher internalized sexual stigma, conservatism, and Catholicism were associated with lesser CO to family. More LGB friends and stable relationships are associated with more CO.	CO is possible only after overcoming self-devaluation due to internalized sexual stigma. Bisexuals face a stigma from within the LG community, causing intersectionality within the community of LGB. Less conservatism and less catholic religiosity were associated with more CO.
Baiocco et al., 2016[35]	Italy	Cross-sectional study. The scales used were the Kinsey scale for orientation, FACES IV, Perceived parental reactions scale.	150 Italian homosexual adolescents between 16 – 19 years.	Poor family function and conservatism were predictive of higher negative reactions from the family for CO.	Negative family reactions to CO mediate the relationship between rigid family functioning and the development of Internalised sexual stigma in homosexual adolescents.
Pollitt et al., 2017[36]	USA	Cross-sectional study. The scales used were the child and adolescent social support scale, LGBTQ Coming out stress scale, and Beck's Depression Inventory.	383 cisgender bisexual youth aged 15 – 21 years.	Stress-related to disclosure to friends predicted depressive symptoms in cisgender bisexual youth.	Parental support did not moderate the relationship between depressive symptoms and disclosure stress to friends. The rejection from unsupportive close friends was more stressful compared to the parental negative reaction. Female gender bisexuals specifically faced significant barriers to disclosure due to stigma.
Wei and Liu., 2019[37]	China	An online cross-sectional survey exploring school experience of LGBTQ students	732 LGBTQ students in Mainland China	Most Chinese schools were not inclusive for LGBTQ students. Despite the lack of LGBTQ-specific school policies, most of the LGBTQ students felt safe living and learning at school. 42% had less freedom to express sexual Identity, and more than 50% had been uncomfortable discussing LGBTQ+issues with teachers in school. About 85% of the LGBTQ students reported feeling depressed, and 40% had suicidal thoughts	Having a more LGBTQ-friendly school atmosphere and specific LGBTQ school policy can improve the overall well-being of LGBTQ adolescents.
Rosati et al., 2020[9]	Italy	Mixed methods using Cross-sectional study and also Thematic analyses to obtain deductive categories. The scales used were the Daily Heterosexist experience questionnaire, Measure of Internalised sexual scale for Lesbian and Gay men (Short version),	266 LGBTQ subjects from 3 generations, young aged 20-40, middle age aged 41 – 60 and older aged 61-80.	The study revealed that older adults became self-aware and disclosed their sexual Identity at a significantly older age as compared to young and middle adults. Older adults preferred coming out to their catholic community, which reacted to their coming out in three ways – unconditional acceptance, invitation to change, or open rejection.	Minority stress of sexual identities is similar across the generations, and the younger generations tend to CO much earlier in life compared to the older generations. The order of preference among social support for coming out was first to best friend, sibling, mother, and lastly, father. Higher Catholicism was associated with increased internalized sexual stigma.
Grossman et al., 2021[38]	USA	Cross-sectional study. The scales used were Parental Knowledge and Reaction to youth gender identity; Child and adolescent psychological abuse measure; Child and adolescent social support scale; Beck's depression inventory; LGBTQ Coming out stress scale; Gay related stress scale.	129 Transgender and gender nonconforming youth (15 to 21 years)	The study reported that greater parent support was associated with less parental abuse, depressive symptoms, and LGBTQ-identity disclosure stress. Mothers and more likely to be disclosed to before fathers.	Parental support has been found to correlate with LGBT-identity disclosure stress. Improved parental support is associated with reduced psychological distress and improved adjustment.
Kiperman et al., 2022[39]	USA	Concurrent mixed methods design to explore how peer victimization predicted LGBTQ youth's Identity development. Inductive-deductive thematic analyses with code development were done in qualitative analyses. The quantitative assessment used scales, namely the Lesbian, Gay and Bisexual Identity scale, the Multidimensional peer victimization scale, Child and Adolescent scale of social support – revised (CASS-R).	349 LGBTQ youth (14 – 17 years old) for the Quantitative sample. 39 LGBTQ Youth for Qualitative sample	The study findings revealed that LGBTQ youth who reported being out to their straight friends observed their friends as distancing themselves (relational bullying). Peer victimization predicted increased stigma sensitivity and increasingly difficult processes (difficulty accepting one's LGBTQ+identity). Themes found included victimization, identity development barriers, and the effect of social support and outness.	Stigma sensitivity, Concealment motivation, and the difficult process of self-identity all appear to cause barriers for CO. Social support and outness moderate the relationship between sexual identity development and peer victimization.
Semborski et al., 2022[40]	USA	Cross-sectional study design with anonymous telephonic survey of LGBTQ youth who contacted suicide crisis prevention service. The Interpersonal needs questionnaire (INQ-10), which is based on the ‘Interpersonal Theory of Suicide,’ was used to assess thwarted belongingness and perceived burdensomeness.	462 LGBTQ youth (12 to 24 years)	Regardless of homelessness state, not coming out to parents increased scores in INQ-10. More the number of family members, the lesser the scores on thwarted belongingness and perceived burdensomeness. Homelessness can be protective if the family is hostile.	Not Coming out to parents independently increases the risk of suicidality in LGBTQ+youth. The presence of social support in numbers, the presence of a romantic partner, and targeted institutional support to the LGBTQ+community help in CO and thus reduce suicidality.
Dueñas et al., 2023.[41]	Spain	Cross–sectional study. The scales used were Subjective Happiness Scale; Perceived stress scale; Centre for epidemiological studies – depression scale; Non-specific psychological distress scale; Psychological maturity assessment scale; Overall Personality assessment scale.	228 Spanish gay or lesbian youth aged 16 – 23 years	People in the closet show greater psychological distress (anxiety and depressive symptomatology) and perceived stress. Perceived stress and psychological distress were higher in the closeted group than in the coming out group	The study highlighted greater stress and psychological distress in those who are in the closet.

Eleven studies were qualitative studies, eleven were cross-sectional studies, and one was a case study. The qualitative studies focused on generating themes of CO along with various issues/problems faced by the participants, and the cross-sectional studies mainly explored parental reactions, stigma, parental support, psychological distress, and perceived stress in the participants.

Themes discussed in qualitative studies

One of the recurring themes of discussion in the lives of LGBTQ+ is the experience of prejudice from various strata of society, such as parental, societal, racial, cultural, and religious factors that lead to problems of hiding, internalized homophobia, and anticipatory rejections that put this population under extreme conditions[21,23,24,25,26,27,28,29]. All these can be very well explainable by the ‘Minority Stress Model’.[42]

Major themes which have emerged are as follows: (1) coming out was necessary; (2) initial reactions of parents are most often not positive, and it depends on the tradition, religion, and family environment; (3) LGBTQ+ adolescents viewed religion as a barrier to support from parents; (4) LGBTQ youth want explicit support from parents and family members; (5) parental validation helped the LGBTQ+ adolescents in the process of CO; (6) being accepted at home enhances self-efficacy and promotes advocacy and leadership at school and community; and (7) parents and adolescents should work as a team towards the goal of affirming the youth's gender identity.

Issues reported from the cross-sectional studies

Although most of the studies have reported stigma and several psychosocial factors (such as traditional beliefs/religious affiliations, culture and society) which hindered the process of CO,[24,33,34,35] few studies have also highlighted the importance of parental/family support and support of best friends/classmates which helped the majority of the adolescents during self-disclosure. Being in the closet was associated with significant psychological distress (which is well understood).[39,43]

Summary of factors acting as a barrier and facilitators in the process of CO in adolescents and youth

Personal factors

Peers influence the CO significantly as they can either encourage CO by being supportive and also if they themselves CO as LGBTQ+. Any rejection from best friends or peers is more likely to discourage further CO than rejection by parents.[32] The presence of a romantic partner of preferred orientation further tends to encourage disclosure.[40] Peer influences are thus vital, and any depressive symptoms tend to be more associated with the disclosure of stress towards friends, irrespective of parental support.[36] With family and community, adolescents feel disclosure to their mothers is easier and acts as a facilitator if they share a close bond with mothers compared to fathers who often find the CO status indirectly. But on the flip side, any negative reaction from the mother more than the father would also act as a barrier to further CO. Furthermore, a negative family environment[81] instead of a more open and adaptable family also tends to discourage any form of disclosure to family members.[33,35] Furthermore, extended family members also play a role in facilitating CO, especially diagonal relationships, such as uncle/aunt or step-parents who are considered a guarding authority but closer and reciprocal compared to parents/grandparents (vertical relationships) who are more a distant authority.[18] Rejection from family is also more if the age of adolescent is younger, but despite the findings, current data show that the younger generation prefers CO much earlier in age compared to the previous generation of the baby boomers.[9,23] Within the Indian context, CO is facilitated by a supportive parent who can validate with unhindered positive regard, but any fear of family disruption or need to preserve the status quo tends to delay the CO in adolescence.[21] In recent times, the availability of new social media has enhanced the ease of CO anonymously or testing one's tentative identities, while also following or connecting to any other members of the community to share one's narratives.[22]

Psychological factors

Several psychological challenges are present during the formation of sexual Identity, with the need to overcome internalized sexual stigma and have strong self-acceptance being the single most important factor in the CO process. This, along with a lack of any concrete sexual identity, further delays the process of finding the strength to CO.[21,27,32,34,40] An interesting psychological tendency is to openly express a sexual affinity as either a queer apologetic or even a political affiliation that is expressed towards LGBTQ+, which is also largely utilized to CO just as an affinity instead of identity, thus enabling the chance of future relationships and also reducing any disclosure stress.[23] Many times even a culture that lacks the right language to express one's sexual Identity clearly also causes problems in establishing a clear self-identity and eventually to CO to family clearly.[48] Once the decision to CO is made after an established identity, the next barriers are one's mental resilience to face the consequences of disclosure, fight discrimination, integrate multiple identities within one's intersection, and continue the dynamic process of CO in various contexts.[21,26,40]

Social factors

Right-wing political affiliations and also being part of a catholic religious group have been shown to cause further barriers to CO to family members, and in several countries, the major religions either make LGBTQ+ identities illegal or the political climate has a tendency to label the CO effort as a form of political activism.[9,34,35,48,81] An interesting observation from the data is that even within the LGBTQ+ communities, there are intersections that tend to restrict the participation of cis-gender bisexual females[82] Challenges of finding professional help, the presence of financial stability, and an overall heteronormative approach to sexual health training further cause systemic barriers to CO in many societies.[21,46,47]

Details are mentioned in Table 3.

Table 3.

Summary of factors acting as barriers and facilitators of CO in adolescents and youth

Factors	Barriers of CO	Facilitators of CO
Personal	Rejection of CO by best friend Younger age Maternal Negative reaction Negative family environment Bisexual cis-gender females Less parental education Rigid family systems Close ties to family Anticipated disintegration of long-standing family traditions Peer victimization Experience of discrimination and violence	Acceptance of CO by best friend Self-disclosure of LGBTQ+ status by best friend Older age Closeness to mothers/unhindered positive regard from family Cohesive and adaptable family High parental education Extended family members of LGBTQ+Presence of diagonal relationships Positive first experience of disclosure Parents aiding gender affirmation Presence of a romantic partner
Sociocultural	Right wing/High political conservatism Catholicism/High religiosity Rigid Queer communities Education/career/financial instability The intersection of race, religion, and sexual Identity The heteronormative approach in sexual health programs High treatment costs for psychological support Lack of parental support to reach out to professional support	Internet/New Media access with anonymity Presence of real-life role models (online/offline) Left Wing/Less political conservatism Less religious Presence of an open Queer community Career/education/financial stability School policies welcoming CO Sexual Health programs inclusive of LGBTQ+
Psychological	Internalised Sexual Stigma Less affirmed concrete sexual Identity Lack of right language/verbal capacity in one's mother tongue to communicate the full meaning of one's sexual Identity Unclear sexual identity and integration trajectory Anticipated discrimination	Coming out initially with affinity Higher mental resilience Self-acceptance Clear sexual Identity Readiness to deal with the consequences of CO Fusion of dual lives of sexual Identity and culture

Studies on utilization of social media/internet[22,30]

More recently, the new generation of adolescents has taken the help of social media platforms for self-disclosure or to come out of the closet. Youth feel the new media aids in the testing of new sexual Identity anonymously and also to CO tentatively without having to go through disclosure stress. Watching several online/offline LGBTQ+ role models also enables the discussion of CO narratives. The Internet also aids in finding one's identity-affirming web spaces and also getting access to web-based counseling for the LGBTQ+ community. Studies have also revealed that over the years, there have been changes in the cultural values in developing countries like India. People are becoming more open to accepting LGBTQ+ youth in their society and families.[44,45]

DISCUSSION

The current review was intended to explore the process of CO in LGBTQ+ adolescents and all issues or problems they face during the process. In this regard, we summarized the studies that have tried to explore this phenomenon worldwide in the last decade. We got a few pertinent themes which we have discussed in more detail. Additionally, we have tried to focus on the Indian scenario in these aspects too, which can be similar to any developing country.

The predominance of qualitative methods in literature states the growing trend towards subjectively understanding the CO narratives and challenges, which would eventually help the shaping of future design of therapeutic interventions. Constructivist grounded theory-based thematic analyses and Inductive-deductive thematic analyses were the most commonly used qualitative methods, and NVivo software was predominantly used in many studies.[8,21,27,28,31,39] Advanced natural processing methods were used with machine learning software in one study analyzing meaningful trends in social media posts.[46] Newer techniques of digital storytelling[47] and qualitative photovoice methods were also used.[48] The main criticism within qualitative studies is the limited sample size and use of different software in coding the data leading to several variations in the way themes are constructed, and in many studies, theoretical sampling was not exhausted. The quantitative studies all utilized only a cross-sectional methodology, and most studies included were from Italy, which in many ways is a comparatively more collectivistic culture within Europe that values religion and family values, and in many ways may be comparable to Indian society. Many scales measuring perceived stress, internalized sexual stigma, and family reactions to CO were used to assess psychosocial stressors associated with CO, and assessment of gender or orientation was done using simple Likert scales such as the Kinsey scale. The major limitation across all quantitative studies are a universal application of self-reported scales, lack of racial diversity in samples, the problem of recall bias, and lesser representation of the rural population. The quantitative study designs are yet to explore these areas in a longitudinal cohort to more detail the changing trends within the groups. One study from China also mentions that self-rating within a Confucian culture tends to encourage people to give responses that are mid-point in the Likert scale.[49]

Based on this review, we have also summarized [refer to Table 3] the various personal, social, and psychological factors that may act as barriers and facilitators of CO.

• Parental and Family Support: The ‘disclosure stress’ that occurs in the early teens is reported to be mediated by the support systems offered by friends and family.[28,36] The ‘Buffer hypothesis’ holds true from the results of most studies that emphasize higher well-being and less psychological distress in LGBTQ+ youth who get family acceptance of their new identities.[21,36] Beyond the role of buffer, one of the studies assessed if the parental support acted as a positive long-term predictor of outcome regardless of current stressors.[26] Social and parental support can serve as a buffer, and the lack of it can become a significant stressor. Often youth report that coming out to parents is the most liberating feeling and, as an enabler of a higher level of self-acceptance, has a direct impact on the prevention of mental illnesses.[50,51] Teenagers identify their sexual orientation by pre-teen years, and by the time they decide to come out, they are around 14-18 years where most of them live with their parents, and the source of support from them serves as a crucial developmental factor. Initial reactions from parents have been mostly reported to be negative, where the unconditional love received all through childhood suddenly gets withdrawn.[26,33,35] Sometimes these teens seek support from extended relatives who may be part of the LGBTQ+ community or offer to take up the role of buffering the minority stress.[26]

• Indian Scenario: In the Indian household, the tradition of upholding family values stems from our predominantly collectivistic societal norms.[52] Thus, a problem of anticipated disruption of family systems creates a unique situation of ‘disclosure stress’ and often delays the coming out process leading to concealment.[21] Studies from India have also reported fear of aging with loneliness and internalized homophobia among middle-aged and older queer men leading to depressive symptoms.[53] Often, any CO within a traditional Indian family has a higher chance of getting family and community disapproval, violence, and worse, any attempts at forced conversion/corrective therapies being sought.[54] There have also been reports of discrimination at the workplace and at school/college due to rigid societal norms/beliefs and lack of awareness vis-à-vis acceptance in the general population. Thus, non-disclosure soon becomes a protective strategy for Indian LGBTQ+ youths until they grow up or become financially stable.[55,56]

  Often in traditional families, the parents’ reaction to coming out is akin to the grief model proposed by Kubler-Ross where the initial denial response is seen commonly. Especially in Eastern societies, the CO process is often rejected as a temporary phase and seen as a fad due to undue online influences from Western pop culture, where the parents often ignore the attempts to express self-identify as a passing phase.[24,57] The persistence of LGBTQ+ identity leads to bargaining and anger where many families react violently towards their kids who CO and seek methods to convert them back to ‘heteronormative’ identity by seeking unethical therapies. The literature also shows many families using faith-healing methods to try and keep the adolescent integrated into their traditional religious community.[57] Acceptance of LGBTQ+ identity of adolescents by parents is essentially a long journey of grieving the loss of their child's assigned sexual and gender identity and coming to terms with the acceptance of being a parent of the child who has integrated the LGBTQ+ identity into a multifaceted identity that still integrates one's family, culture and religious values and continues to represent the same.[58]

• Societal Support and School Life: The data worldwide show a trend of ever-decreasing mean age in which LGBTQ youth start CO ranging from 20-22 in the 1970s to most recent data suggesting 14-16 years.[5,59] This indicates that the societal pressures on the whole are changing, but still, the risk of facing peer rejection is very high. The prevalence of prejudice towards LGBTQ+ is, in general, higher among young adults, and LGBTQ+ adolescents coming out during adolescence period run the risk of facing social exclusion from peers and a higher risk of mental illnesses.[7] Studies have reported that LGBTQ+ adolescents who had better social support had more positive outcomes in the reduction of psychiatric symptoms, such as symptoms of low mood, suicidality, substance abuse, shame/guilt, school avoidance, sexual orientation-related violence, and anxiety.[60,61] Family and adult support was said to facilitate a more effortless high school experience for LGBTQ+ adolescents, along with less school rejection.[37,39] The presence of social support appeared to act as a mediator between mental health disorders and stress. Being part of LGBTQ+ communities as a youth also improved self-esteem among these youths.[24]

  A monumental feat in the Indian constitution in 2018 which repealed Article 377 that criminalized homosexual relationships sent a wave of liberating ripple effects across the schools in metropolitan India.[62,63] After decriminalizing homosexuality in India, there has been a welcome rise in LGBTQ+ pride within several schools across India.[64] The Indian Psychiatric Society (IPS) released a position statement in 2018 supporting decriminalizing homosexuality and clarifying officially that LGBTQ+ preferences are variations of normal sexuality and not be considered as an illness and treatment offered for the same as unethical. On 10^th April, 2023, IPS also released a statement offering support towards marriage and child adoption rights of the LGBTQ+ community.[65] Often for students in more rural India, the situation is still not friendly, and having a culture of living with their parents even till their late 20s in India makes the financial dependency and fear of social exclusion or violence a deciding factor before LGBTQ+ youths decide to fully integrate into their Identity or autonomously decide any medical procedures for transitioning.[66] Several schools in Bengaluru, Kolkata, and Delhi are becoming integrated with NGOs, Global pride movements or even creating their own LGBTQ+ clubs to actively help their students become aware of LGBTQ+ issues and create a more peer-friendly environment[67,68,69].

• Cultural Barriers/Traditional Barriers: There is an intersection of culture, religion, and race within the minority stress model of LGBTQ+. Thus, specific reactions to coming out are unique to some cultures, which are quite evident from the qualitative studies.[21,24,26,28,37] Coming out process in countries like Japan, China, and Taiwan emphasize the role of collectivistic societal ideals where the process is a violation of traditional honors and would only mean getting ousted from the family[70,71,72,73]. Thus, a model of ‘Coming Home’ is highlighted where the return to the family after gaining acceptance is a more appropriate way of understanding this process.[70] This model evolves into a beautiful integration of one's sexual identity with one's cultural/familial Identity, a process more aptly called the ‘Coming With’ model.[70]

  Experiences of LGBTQ+ youths in Eastern societies have recently been explored, with the majority still not comfortable coming out to their families.[66] A sizeable online study in 2019 shows most Chinese schools were not inclusive for LGBTQ students.[37] As well, most LGBTQ+ students felt comfortable about their sexual orientation and had come out to someone/best friend; however, most remained closeted with their siblings, parents, or teachers.[32] Often in collectivistic societies, CO is not seen as the normative outcome of LGBTQ+ identity development, and several factors of social support, financial dependence, and risk of violence need to be considered.[72,73]

  In India, the phenomenon of coming out of the ‘Desi closet’ is well highlighted in a first-person narrative study that talks about restraining factors for coming out, namely, the fear of dismantling family values and the anticipated disintegration of long-standing tradition[21] Often, contemporary Indian society labels the LGBTQ+ movement as alien or Western, whereas the contrary is that age-old Indian culture always had alternate sexualities integrated into our culture with neither rejection nor extreme pride in it.[21,74,75] In a recent study comparing the challenges faced by the LGBTQ+ community between India and Australia, the author reported that currently, India is at the early stages of reforms in the LGBTQ+ community as compared to Australia, and a lot of it is attributed to the diverse perspectives of a culturally and traditionally rich India.[54] The awareness and acceptance rate of the LGBTQ+ community in Indian society is still low, and most of the challenges faced by the community are due to a lack of awareness and knowledge.[54,61,63]

• Social Media and Coming Out Online—A 21^st Century Boon: An emerging trend is using internet platforms to aid in one's online identity construction and to come out of the closet among LGBTQ+ individuals. Studies have revealed that LGBTQ+ adolescents express several themes of internet platforms serving them, from accessing resources and awareness, exploring one's identity, finding like-minded fellow members to enable coming out digitally, and finally expanding from an online to an offline integrated identity.[22,30] Online CO helps several youths facing intersectional minority stress due to race and religion to find support.

  In a study conducted in Malaysia, the online patterns of being ‘Out and Proud,’ where complete disclosure is seen among gays, and patterns of ‘Out and discreet’/’Facebook closeted,’ where anonymity is maintained using online secret identities to explore the process of coming out was discussed.[76] The study reported several risks of living an anonymous online identity as the boundaries of age and ethical norms are bypassed, putting youths are higher risk of exploitation.[76] Few studies have also highlighted the potential advantages of CO in social media platforms (Facebook and Twitter).[77,78] However, there are safety concerns, too; these platforms can be both transformative and risky (disclosure can lead to bullying and humiliation, etc.)[78,79]

Strengths and limitations

The strength of the study is that we tried to synthesize and summarize the available literature in 6 databases on the area of CO in adolescents/youth, which had not been studied before. Additionally, we had tried to compare the International with the Indian scenario. However, we are also aware of our limitations. We had not done a quality assessment of individual study to identify any risk of bias. The study designs varied from qualitative to cross-sectional, which hindered us from analyzing the possible risk of bias. More literature on this area could be found in other databases that need an extensive search. The study findings should be interpreted based on these limitations.

Implications of the study

The study findings suggest that CO during adolescence is a critical turning point in one's life, and parental/family, as well as peer support, is the strongest predictor of its outcome. The minority group should be studied thoroughly as there are high rates of mental health issues that usually crop up during adolescence. More studies should be undertaken to understand various key issues in this population.

CONCLUSIONS

It can be summarized that CO is an elaborate entity that considers the presence of parental/family and societal support along with cultural/traditional values which determine the degree of positive outcomes. Emerging data indicated an improved trend of adolescents deciding to come out to families or in online platforms, both of which are associated with challenges, more in eastern collectivistic societies and developing countries. Our summary of data suggests that CO is a dynamic process, and the context and social factors play a role in the formation of sexual identity and also facilitating CO. Thus, CO is a different process for each. CO suggests a healthier social environment and also the formation of a more clear sexual identity which indirectly suggests mental resilience to go through the inevitable minority stress. Although there have been reforms in the legal system, there is a long way to cover to create awareness and acceptance of the LGBTQ+ community in the general population, and much more work needs to be done to reduce stigma and discrimination. This becomes more evident when same-sex marriage is being discussed in the Supreme Court of India, and the debate still continues for its acceptance or refusal.[80]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.