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. Author manuscript; available in PMC: 2022 Mar 1.
Published in final edited form as: Soc Sci Med. 2021 Jan 30;272:113731. doi: 10.1016/j.socscimed.2021.113731

Mortality Risk Among a Sample of Sexual Minority Women: A Focus on The Role of Sexual Identity Disclosure

Bethany G Everett 1,*, Melanie Wall 2, Eileen Shea 2, Tonda L Hughes 3
PMCID: PMC8022871  NIHMSID: NIHMS1672396  PMID: 33578310

Abstract

Almost no research has examined factors that contribute to mortality risk among sexual minority women (SMW). This study capitalizes on a 21-year community-based longitudinal study of SMW to examine the association between sexual identity disclosure and mortality risk. Forty-nine SMW who were recruited in 2000–01 or 2010–12 (6.3% of the sample), were confirmed dead by 2019. The mean age at death was 56.5 years. We used Cox proportional hazard models to show that SMW who had disclosed their sexual identity to 100% of their immediate family members had a 70% reduction in the risk of mortality compared to SMW who disclosed to less than 33% of their immediate family, after adjusting for several sociodemographic and health variables. Our results suggest that facilitating acceptance of SMW and their ability to disclose their identity may be an important way to improve health and life expectancy among SMW.

Keywords: Sexual Minority, Women’s Health, Mortality, Minority Stress

Introduction

A large body of research has documented sexual orientation disparities in women across multiple health outcomes including mental health (Hughes et al., 2010; Hughes et al., 2014; Marshal et al., 2011), health risk behaviors (Bowen et al., 2008; Hughes, 2011; McCabe et al., 2019), and physical health conditions (Caceres et al., 2019; Cochran et al., 2017; Veldhuis et al., 2019). Sexual orientation disparities in health are usually explained using minority stress theory, which argues that additional stressors specific to sexual minority populations are at the root of population-level health disparities (Meyer, 1995, 2003; Meyer & Frost, 2013). These additional stressors can include experiences of discrimination, at both the interpersonal and structural level, and may also include sexual-minority-specific individual-level mechanisms, such as identity disclosure, or the process of sharing a stigmatized identity with others.

To our knowledge, only three studies have examined sexual orientation disparities in mortality and just one has examined the link between identity disclosure and mortality risk. Cochran and colleagues (2016) used National Health and Nutrition Examination Survey (NHANES) data and found that sexual minorities had greater all-cause mortality. Higher mortality was explained by health risk behaviors and health conditions; but the researchers did not examine sexual-minority-specific sources of stress. The second (Hatzenbuehler et al., 2020) used the General Social Survey and National Death Index to illustrate a dose-response relationship between structural stigma exposure and all-cause mortality for men and women who reported same-sex behavior in the past year. A final study examined mortality risk among HIV-infected men and found time to AIDS infection and mortality was more rapid among men who had not disclosed their gay identity (Cole et al. 1996) No research to date, however, has examined the relationship between sexual identity disclosure and mortality risk among sexual minority women (SMW).

Theories of sexual orientation development argue that identity disclosure is a key feature of developing a positive sense of self (Cass, 1979; Corrigan & Matthews, 2003; D’augelli et al., 1998; Mohr & Fassinger, 2003). Individuals who decide to disclose their minority identity to family members may do so for several reasons including the desire to reduce potential cognitive dissonance or stress related to concealing their identity, the desire to increase intimacy and trust with the person to whom they wish to disclose, and the desire for social support (Chaudoir and Fisher 2010). Identity disclosure has been linked to higher levels of self-esteem, sexual identity acceptance and integration (Bry et al., 2017; Floyd & Stein, 2002). Disclosure to family members may be particularly important for overall health, especially from a life course perspective. Studies have shown that facilitating healthy parent-child relationships and parent acceptance of their LGBTQ child is a powerful protective factor for LGBTQ youth; it is associated with greater self-esteem and social support, lower rates of substance abuse, and improved mental health (Ryan et al., 2010). Importantly, Disclosure Mediating Process theory posits that the disclosure process is a feedback loop through which a disclosure event can shape the likelihood of future disclosure to other individuals (Chaudoir and Fisher 2010). If the disclosure process yields social or psychological benefits, disclosure to other individuals is more likely. Alternatively, a negative reaction may hinder future disclosures and blunt the potential benefits of a disclosure event.

Indeed, the decision to disclose a stigmatized identity does not guarantee health benefits and, in fact, may increase exposure to stigma or discrimination and result in lower levels of social support (Huebner and Davis 2005; Ryan et al. 2009; Waldo 1999). Individuals who face challenges to identity disclosure and LGBTQ identity integration report more sexual risk taking and poorer psychological health (Rosario et al., 2006), as well as greater substance abuse, depression, and suicide attempts (Ryan et al. 2009). Studies of the workplace have shown that disclosure is positively associated with harassment (Waldo 1999). Gay and bisexual men who are “out” in their workplaces have elevated levels of cortisol (Huebner and Davis 2005), which may indicate increased cardiovascular risks. In countries with high levels of structural stigma, concealing one’s sexual minority identity is protective against lower levels of life satisfaction (Pachankis and Bränström 2018), insofar as it might serve to buffer discrimination. Thus, the decision to disclose a concealable stigmatized identity may in part be driven by external factors, such as whether a person feels that their social networks would be accepting and supportive of their sexual identity (Monk and Ogolsky 2019).

Increasingly, researchers have documented factors related to healthy aging among sexual minorities (Fredriksen-Goldsen et al. 2015; Fredriksen-Goldsen et al. 2019; Van Wagenen, Driskell, and Bradford 2013). No research to date, however, has examined the relationship between identity disclosure and mortality risk among SMW. This study uses data from the Chicago Health and Life Experiences of Women Study to explore the relationship between sexual identity disclosure and all-cause mortality in a longitudinal, community-based sample of SMW.

Methods

Data.

The Chicago Health and Life Experiences of Women (CHLEW) Study is a 21-year longitudinal study of 812 SMW (i.e., lesbian, bisexual, queer) who were recruited from the Chicagoland area in 2000–01 (original sample) or 2010–2012 (supplemental sample). Between 2018 and 2019, participants were re-contacted for either a second (supplemental sample) or a fourth (original sample) wave of data collection, at which point 50 participants were identified as having died. Forty-one deaths were confirmed using the national death registry and death certificates were obtained to confirm the respondent had died and their age at death. An additional nine deaths were confirmed by family members or spouses, including the date of death. Supplementary analyses show that results are robust to the exclusion of the self-reported deaths. The sample for this study excluded participants who identified as “mostly heterosexual” (n=31) as our primary independent variable was bisexual or gay/lesbian identity disclosure. An additional six participants were excluded who were missing data on key covariates, and therefore the analytic sample included 775 participants, 49 of whom died between recruitment and the follow-up in 2018–2019.

Measures.

Deaths were confirmed using the national death registry and death certificates, or spouse or other family when this information was unavailable. Age at the time of death or age in 2018–2019 for those still living was used as the time-to-event or censoring time, respectively, in survival models. Baseline race/ethnicity and sexual identity were used, but all other measures were taken from the last observed wave of data collection.

Identity disclosure was assessed using a composite score of the number of immediate family members that participants reported (i.e., mother, father, number of siblings), and the number to whom the participant has disclosed her sexual identity. The distribution of this score was skewed (see Supplemental Figure 1) with piling at percentages corresponding to fractions of family members (e.g. 33% [1/3], 50% [e.g. 2/4]). To facilitate interpretation, the variable was recoded as a categorical measure that captured whether participants had disclosed to <33% of their immediate family members (referent), between 33% and 99%, or 100% of their immediate family members. The score was also cut at alternative values and treated continuously to ensure robustness of the results.

We additionally adjusted for several other sociodemographic characteristics and health behaviors that have been associated with mortality in previous research including self-reported race/ethnicity (non-Hispanic White [referent], non-Hispanic Black, Hispanic, Other); education (high school or less [referent], some college, college graduate); and income (<$20,000 [referent], ≥$20,000 & <$40,000, ≥$40,000 & <$75,000; ≥$75,000). We also included a measure of whether the participants were in a committed relationship (1=yes, 0=no) at their most recent interview. Because a supplemental sample was added in 2010–2012, and because these participants were more likely to be racial/ethnic minorities, bisexual-identified, and of lower-ES, we additionally included a binary variable that captured whether respondents were members of the new cohort (1=yes, 0=no).

Tobacco use was measured as a dichotomous variable that captured whether a participant said they currently smoked cigarettes (1=yes, 0=no) at their most recent interview. Hazardous drinking was derived from a composite index that captured four indicators of hazardous drinking: heavy episodic drinking; intoxication; adverse drinking consequences; and symptoms of potential alcohol dependence (Hughes et al., 2014; Riley et al., 2017). Hazardous drinking scores ranged from 0 to 4, with a score of four indicating affirmative responses to one or more questions related to each of the four hazardous drinking indicators.

Depressive symptoms were assessed using questions from the diagnostic criteria of the National Institute of Mental Health Diagnostic Interview Schedule (Robins et al., 1981). Questions asked respondents whether in the past year (Wave 1) or since last interview (follow-up surveys) there had been two or more weeks in which they had: felt sad or blue; lost their appetite; lost weight without trying; gained weight; had trouble sleeping; felt tired all the time; were moving all the time/couldn’t hold still; moved more slowly than usual; lost interest in sex; felt worthless; felt it was harder to think than usual. Responses were yes (1) or no (0). The scale ranged from 0 to 11 and had a Chronbach’s alpha of .83.

Statistical Approach.

We conducted bivariate tests to examine differences in sample characteristics by mortality status. Next, we used Cox proportional hazard models and multivariate model building to assess the relationship between identity disclosure and mortality. The dependent variable was a binary indicator of death prior to 2019 (1=death, 0=survival). Following Kom, Graubard, and Midthune (1997), we used age as the time-to-event rather than time-in-study in the hazard models (Allison, 2014), while specifying that participants contribute to the model beginning at the age at which they were first interviewed. Because there were no deaths in the “other” racial/ethnic group, models that included this variable utilized a Firth correction (Heinze and Schemper 2001). All p-values are derived from two-tailed tests. Lastly, we used life table information from the Centers for Disease Control and Prevention (CDC; 2017) to calculate the proportion of deaths expected in a general U.S. population of women with the same age distribution and length of follow-up as those in the CHLEW sample.

Results

Table 1 presents descriptive statistics for the total sample and by mortality status. Bivariate comparisons between participants who died and those still alive show that only 37% of deceased participants had disclosed their sexual identity to all (100%) of their immediate family members—compared to 54% of those still living. Bivariate comparisons also reveal differences in sexual identity by mortality status: among participants who had died, 82% identified as exclusively gay/lesbian, compared to 61% of those alive at follow-up. Not surprisingly, given that participants recruited as part of the supplemental sample were younger than the original cohort participants, they comprised just 18% of the sample that had died at follow-up compared to 45% of the sample that was still alive.

Table 1.

Descriptive Statistics

Total Alive Deceased
N=775 N=726 N=49
%/M %/M %/M
Disclosure to Family (%)
 <33% 8.77 7.99 20.41 **
 ≥33% & <100% 38.58 38.29 42.86
 100% 52.65 53.72 36.73
Age/Age at Death (M) 49.42 48.94 56.46 **
Race/Ethnicity (%)
 White 35.74 35.12 44.9
 Black 36 35.95 36.73
 Latina 24.65 25.07 18.37
 Other 3.61 3.86 0
Education (%)
 High School or Less 22.06 22.04 22.45
 Some College 34.19 34.57 28.57
 College Graduate 43.74 43.39 48.98
Sexual Identity (%)
 Exclusively Lesbian/Gay 62.19 60.88 81.63 *
 Mostly Lesbian/Gay 21.29 22.04 10.2
 Bisexual 16.52 17.08 8.16
Income (%)
 <$20,000 28.3 27.86 34.78
 ≥$20,000 & <$40,000 20.19 19.65 28.26
 ≥$40,000 & <$75,000 26.24 26.69 19.57
 ≥$75,000 25.27 25.81 17.39
New Cohort (%) 43.1 44.77 18.37 ***
In a relationship (%) 61.94 62.67 51.02
Depressive symptoms (M) 5.13 5.06 6.18 *
Hazardous drinking (M) 1.6 1.64 1.11 *
Current Smoker (%) 30.49 29.79 40.82
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Source: Chicago Health and Life Experiences of Women Study Notes:

***

p<0.001

**

p<0.01

*

p<0.05

Table 2 presents results of the survival analyses. The proportional hazards assumption was checked for the full model, and the assumption held for all variables. Model 1 shows that compared to participants who had disclosed to less than 33% of their immediate family members, those who had disclosed to 100% of their family members had a lower risk of death at follow-up (HR = 0.33, p<.05). This relationship between identity disclosure and mortality remained statistically significant after adding sociodemographic characteristics in Model 2, and remained significant following the further addition of variables in Models 3–5. In the final model, including all covariates, SMW who had disclosed their sexual identity to all immediate family members had a 70% lower risk of death at follow-up than those who had disclosed to less than 33% of their immediate family members (p<.05). There also was a non-significant but notable difference across all models between those who had disclosed to ≥33% and <100% and those who had disclosed to <33% (all p<.10). Figure 1 presents the Kaplan-Meier survival curves stratified by disclosure categories.

Table 2.

Results from Hazard Models Predicting Mortality (n=775)

Model 1 Model 2a Model 3a Model 4a Model 5a
HR 95% CI HR 95% CI HR 95% CI HR 95% CI HR 95% CI
Disclosure to Family (<33%)
 ≥33% & <100% 0.47 (0.21, 1.03) + 0.48 (0.21, 1.08) + 0.43 (0.19, 1.01) + 0.46 (0.20, 1.08) + 0.44 (0.19, 1.06) +
 100% 0.33 (0.14, 0.75) * 0.33 (0.14, 0.80) * 0.31 (0.13, 0.75) * 0.31 (0.13, 0.75) * 0.30 (0.12, 0.76) *
Race/Ethnicity (White)
 Black 1.31 (0.57, 3.01)  1.40 (0.63, 3.15)  1.18 (0.51, 2.76)  1.35 (0.59, 3.06)
 Latina 1.23 (0.45, 3.32)  1.16 (0.44, 3.07)  1.30 (0.48, 3.50)  1.25 (0.47, 3.30)
 Other 0.38 (0.02, 7.19)  0.33 (0.02, 6.32)  0.36 (0.02, 6.88)  0.34 (0.02, 6.48)
Education (High School or Less)
 Some College 0.83 (0.35, 1.99)  0.91 (0.38, 2.18)  1.08 (0.44, 2.67)  1.18 (0.47, 2.93)
 College Graduate 0.86 (0.35, 2.09)  1.06 (0.43, 2.57)  1.18 (0.46, 3.07)  1.43 (0.55, 3.72)
Sexual Identity (Exclusively Lesbian/Gay)
 Mostly Lesbian/Gay 0.34 (0.12, 0.95) * 0.33 (0.12, 0.92) * 0.37 (0.13, 1.01) + 0.35 (0.13, 0.98) *
 Bisexual 0.69 (0.17, 2.70) 0.64 (0.16, 2.56) 0.92 (0.23, 3.70) 0.79 (0.19, 3.27)
Income (<$20,000)
 $20,000 – $39,999 0.94 (0.43, 2.05) 0.95 (0.44, 2.07) 1.12 (0.51, 2.47) 1.18 (0.53, 2.61)
 $40,000 – $74,999 0.43 (0.18, 1.06) + 0.43 (0.17, 1.07) + 0.46 (0.18, 1.16) + 0.48 (0.19, 1.22)
 $75,000 and up 0.39 (0.14, 1.07) + 0.46 (0.16, 1.29) 0.45 (0.16, 1.24) 0.60 (0.20, 1.75)
New Cohort 0.74 (0.27, 2.05) 0.75 (0.27, 2.06) 0.62 (0.21, 1.85) 0.64 (0.22, 1.91)
In a relationship 0.99 (0.51, 1.89) 0.83 (0.43, 1.61)
Depressive symptoms 1.14 (1.03, 1.26) * 1.13 (1.02, 1.25) *
Hazardous drinking 0.99 (0.78, 1.26) 0.99 (0.78, 1.25)
Current Smoker 2.39 (1.20, 4.76) * 2.29 (1.14, 4.57) *
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Source: Chicago Health and Life Experiences of Women Study

Notes: HR=Hazard Ratio; CI= Confidence Interval;

*

p<0.05

+

p<0.10

a

Models that include Race/Ethnicity use a Firth correction

Figure 1.

Figure 1.

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Survival Curves Stratiied by Disclosure Categories

Table 3 presents the percentage of actual (i.e., observed) deaths compared to the percentage of expected deaths in a U.S. female referent population, calculated using the most recently available life table information. In the CHLEW analytic sample 6.32% of participants died during the study period, but in a general U.S. population of women with the same age distribution and length of follow-up only 5.27% would be expected to die. Table 3 further stratifies the sample by original and supplemental/new cohort (i.e., recruited in 2000–01 or 2010–12), since the original sample was on average older and had a longer follow-up period than the supplemental sample, and original participants were therefore more likely to experience death during follow-up. Among all participants and among both enrollment cohorts, actual death proportions exceeded expected death proportions, although no differences were statistically significant.

Table 3.

Summary of Actual versus Expected Deaths

Sample Size Actual Deaths Expected Deaths Test of Difference
n % % p-value
All Subjects 775 49 6.32 5.27 0.22
Original Cohort 441 40 9.07 8.04 0.48
New Cohort 333 9 2.69 1.62 0.18
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Sources: Chicago Health and Life Experiences of Women Study;

“Life Table for females: United States, 2017”(CDC)

Supplementary analyses (results available upon request) were conducted using disclosure as a continuous variable, as well as with other categorical cutoffs. The results are robust to different specifications. For example, the hazard ratio when disclosure was treated continuously as the proportion of family to which an individual disclosed was 0.31 (95% CI: 0.12, 0.80), indicating an association between greater proportion of immediate family members disclosed to and decreased mortality risk. In models where the reference category was zero family members, women who disclosed to 100% had a hazard ratio of 0.34 (95% CI 0.12, 0.98), providing further support for the robustness of our findings.

Discussion

This study used a novel, longitudinal data set to provide the first evidence of a relationship between sexual identity disclosure and mortality among SMW. This finding is in line with studies that have documented the benefits to sexual minority health of identity disclosure (Corrigan & Matthews, 2003; Rothman et al., 2012; Watson et al., 2019) and similar to findings of Cole and colleagues who found that identity disclosure among HIV positive men was protective (Cole et al., 1996). Our results show that even after controlling for mental health and health behaviors, among a population of SMW, disclosure to all immediate family members was associated with a 70% reduction in risk of mortality compared to disclosure to less than a third of family members.

Why would an individual disclose to one family member versus all others? It is important to remember that disclosure is a process that individuals engage in throughout the lifecourse; it is not a one-time event. Disclosure Mediating Process theory, which highlights that disclosure processes are a feedback loop through which past experiences inform future decisions (Chaudoir and Fisher 2010), can help understand the decision to disclose a stigmatized identity at different points to different family members. A negative disclosure event may mean that an individual does not go forward with disclosing to additional family members. Indeed, disclosing a stigmatized identity can be risky (Kosciw et al., 2015). However, many sexual minority individuals who disclose their identity to their families are met with acceptance (D’augelli et al., 1998; Rothman et al., 2012) and those in supportive environments are, in turn, more willing to disclose their identities to the people around them (Legate et al., 2012). Not disclosing one’s minority sexual identity, however, also carries risks (Pachankis 2007). Concealing a stigmatized identity may tax psychological resources via preoccupation with concealing the identity, as well as increase worry about discovery,and potential consequences of being “outed” (Pachankis 2007). The results presented here suggest that at least in terms of mortality, the benefits of disclosure may outweigh the risks.

Individuals who have positive experiences disclosing their identity to family members may accrue health benefits of disclosure through family acceptance, increased trust, and social support (Chaudoir and Fisher 2010). Social support is critical for healthy aging (Seeman et al. 2001) and lesbian, gay and bisexual (LGB) adults face unique challenges in the aging process (Van Wagenen et al. 2013). Other research has found that larger social network size and social support reduce the risk of poor health among older LGB adults (Fredriksen-Goldsen et al. 2013, 2015) and that identity disclosure is associated with larger social networks in older age (Erosheva et al. 2016) and better mental health among SMW (Pachankis et al., 2015). Close relationships with family members are associated with improvements in mental health, as well as lower likelihood of health-risk behaviors such as tobacco and alcohol use and unsafe sex (Armstrong et al., 2016; Kuper et al., 2018; McConnell et al., 2016; Watson et al., 2016). Moreover, sexual identity disclosure is associated with lower levels of internalized homophobia (Bry et al., 2017) and greater comfort with minority sexual orientation (Floyd & Stein, 2002), which may have long-term health benefits that translate into lower mortality risk. For example, older SMW are more likely than heterosexual women to report chronic conditions such as arthritis, asthma, heart attack, stroke, chronic pain (Fredriksen-Goldsen et al. 2017), as well as cognitive impairments (Hsieh, Liu, and Lai 2020). Identity disclosure may be important to healthy aging because as individuals get older the support of family members becomes even more important given that family members often facilitate medical care and health care decisions. Although older LGB adults often form kinship networks outside of their biological family, the results presented here suggest that disclosure to family members remains important and may be associated with long-term health benefits.

The relationship between sexual identity disclosure and mortality risk reduction may be especially meaningful if sexual minority populations experience greater all-cause mortality as reported by Cochran and colleagues (2016). Although we did not find statistically significant differences between actual and expected death proportions in the current study, more research is needed to examine whether all-cause mortality is higher among SMW relative to the general population, and if so whether sexual identity disclosure is protective. Findings by Hatzenbuehler and colleagues (2020) suggest that sexual minorities (operationalized as having a same-sex sexual partner in the past year) living in communities with high levels of anti-gay prejudice (i.e., high levels of structural stigma) have higher risk of mortality than those living in communities with low levels of prejudice. This highlights the importance of considering sociopolitical risk factors when addressing mortality risk. This concern holds true outside the realm of sexual minority research; for example, African American mortality rates have been shown to be significantly correlated with a state-level measure of political culture (Kunitz et al., 2010).

Sociopolitical factors that affect mortality in SMW are likely to be both geographically-varying (e.g., by community, by state) as we see in the examples above, and time-varying. Prior to federal marriage equality, research findings indicated that same-sex couples living in states with legal recognition of same-sex relationships reported higher levels of self-rated health relative to those in states with anti-gay constitutional amendments (Kail et al., 2015). Federal marriage equality largely buoyed the LGBTQ community; however, the subsequent 2016 election raised concerns about progress reversal that manifested through psychological and emotional distress (Veldhuis et al., 2018). In particular, many African American and Latina/x SMW perceived increased support (or at least not active opposition) of their relationships and sexual identity within their communities after marriage equality, while the political environment during and after the election was perceived as actively hostile (Riggle et al., 2020).

Limitations

This study has several limitations. First, data are from a non-probability sample, originally recruited from the Chicago Metropolitan area; thus, findings may not be generalizable to all SMW. Second, the relatively small number of deaths made it impossible to include cause of death in the analyses. Understanding cause of death would provide greater insights into the benefits of family disclosure. Third, for eight deaths in our analytic sample, we were unable to confirm the age at death through death certificates and instead relied on reports from family and/or spouses. Sensitivity analyses excluding these additional deaths, however, yielded similar results; in the equivalent of Model 5, the hazard ratio for those who disclosed to all family members was 0.43 (p=0.10). It is also possible that some of the respondents that study staff have been unable to locate may have died. Fourth, there may be several unmeasured confounding variables that influence mortality risk. Understanding the underlying causes of variation in mortality is useful for health policy and intervention design; however, risk factors can be difficult to measure directly, as observed measures are often products of traits or circumstances that are unobserved, partially observed, or complex and multidimensional. This sample was also restricted to participants who identified as cisgender women at recruitment. Understanding how mortality risk varies by gender identity is also important. Finally, we were unable to examine health care utilization. Mortality amenable to health care is a specifically defined composite measure of deaths before age 75 from complications of conditions that might be avoided by timely effective care and prevention (Nolte & McKee, 2004). Assessing this could be useful in future research as multiple studies have shown that SMW use preventive health care services at lower rates than heterosexual women (Cochran et al., 2001; Everett & Mollborn, 2014). Thus, a measure of health care utilization and —perhaps as importantly—a measure of disclosure in health care settings should be included in future studies that examine causes of mortality among SMW.

Implications

Despite growing calls for research on aging among SMW, few studies have focused on the relationship between minority stress and mortality risk, particularly among women. These data are the first to demonstrate an association between an important minority-stress specific measure—identity disclosure—and mortality risk among SMW. A new wave of research has begun to document the aging process and the unique challenges, as well as sources of resilience, that impact aging in LGBT populations (Fredriksen-Goldsen et al., 2015; Ki et al. 2019). The results presented here tap into an understudied mechanism and outcome and suggest that among individuals who disclose their identity to their entire family, such disclosure may be protective against mortality risk. However, given the unique barriers SMW face, health care professionals should receive additional education on how social support during the aging process may differ among SMW, including the importance of incorporating “chosen family” members into caregiving plans (Erosheva et al. 2016; Fredriksen-Goldsen et al. 2018; Molinari and McSweeney-Feld 2017). Developing close and loving relationships with family members is critical for the healthy development of all people, including sexual minorities (Ryan et al., 2010; Snapp et al., 2015). Understanding in which contexts individuals are more likely to disclose their identity to all family members versus some or none, and the pathways through which disclosure improves as opposed to harms health, is an important next step in this work.

Supplementary Material

1

Supplemental Figure 1.

HIGHLIGHTS.

  • Greater identity disclosure to immediate family was associated with lower mortality risk.

  • LGBT acceptance in families may improve the health of sexual minority women.

  • Benefits of disclosure were highest among women who disclosed to all family members.

Acknowledgements:

The authors would like to acknowledge the support of the National Institute on Alcohol Abuse and Alcoholism (R01 AA013328-13, PI Hughes). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

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