After Sexual Identity Disclosure: An Ecological Perceptive of LGB Young Adults

Abstract

Objectives:

A plethora of research exists concerning determinants prior or during the sexual identity disclosure process; yet, information is limited concerning internal and external experiences after one discloses his or her sexual identity to their social support system. Through the lenses of the Social Ecological Model, the purpose of this study was to further understand the current lived experiences of persons in post-sexual identity disclosure.

Methods:

Semi-structured interviews were conducted among 15 lesbian, gay, and bisexual young adults. Sample size was determined by thematic saturation. A semiotic phenomenological procedure was used for analyzing the data.

Results:

Based on the reported experiences after sexual identity disclosure among participants, 7 themes were identified. Themes entailed stereotypical perceptions of sexual identity, improvement in mental health, relationship estrangement, development of new relationships, social support, non-acceptance of sexual orientation, and minority stress.

Conclusions:

Through various theories and models, this study provide recommendations for stakeholders invested in the health of lesbian, gay, and bisexual individuals.

Persons that self-identify as lesbian, gay, and bisexual (LGB) are oftentimes faced with challenges in adapting to a stigmatized sexual orientation minority status, because same-sex attraction is marginalized in various cultures.^1–3 LGB youth are more likely to engage in sexual risk-taking and other risk behaviors that affect their physical health.^2,4,5 The US Centers for Disease Control and Prevention (CDC) report that 96.6% of adults in the United States self- identify as heterosexual, 1.6% as lesbian or gay, 0.7% as bisexual, and 1.1% as other.⁶ It is estimated that the percentage of bisexuals is higher than reported. The latest estimates from a Gallup poll report that 10 million American adults identify as LGB or transgender, which is 4.1% of Americans.⁷ Persons that self-identify as LGB have different needs than heterosexual individuals, especially because there might be internal and external factors specific to sexual identity that sexual minorities may have to overcome.

Sexual identity disclosure is the process of internally and externally communicating and expressing one’s same sex attraction, oftentimes called “coming out” or “coming out of the closet.”⁸ The process of coming out, is not necessarily a one-time action; for many, it is a continuous or lifelong element.⁹ Eliason and Schope reviewed various stage models of sexual identity development and noted that these linear stage models vary mostly in subtle details; the researchers argue that there are several key themes that span them all. These themes were feeling different; identity formation as a developmental process; the need for disclosure; the need for pride and cultural immersion; and identity integration.¹⁰ Most of these models have internal and external components that are important for healthy sexual identity development.

An Ecological Perceptive

The Social Ecological Model is a theoretical model used to explain interactions among internal, social, and structural factors. The framework emphasizes the influence of multiple levels that are the intrapersonal (individual components such as knowledge, attitude, self-efficacy), interpersonal (social network and social support), community (connections with organizations and institutions), and societal (policy and regulations).¹¹ The Social Ecological Model is helpful for understanding the relationship between behavior and the social environment.¹² Within the last decade, the Social Ecological Model has been used to examine social influence on health and disease;^13,14 assessing risk factors;^15,16 bully prevention;^17,18 community health programs;^19,20 and examining resilience and connectedness to gay communities.²¹

Intrapersonal Level

Coming out is a developmental milestone that begins with disclosure to oneself. Non-heterosexual individuals are 3 times more likely to experience mental health problems.²² Oftentimes, the fear of non-acceptance of sexual identity is associated with post-traumatic stress disorder, depression, suicide, and substance abuse.^23–25 Internalized homonegativity, which refers to a negative evaluation of one’s sexual identity is a common issue that some LGB persons face.^24,26–28 Internalized homonegativity can be experienced within the process of sexual identity development, and overcoming this internal factor is essential to the development of a healthy self-concept.^26,29,30 Levels of internalized homonegativity are positively influenced by participation and satisfaction within the LGB community.^31–33 Perceived stigma refers to the awareness of negative evaluations of others about one’s sexual orientation or sexual identity.^1,34 Stigma can affect physical and mental health, whether one seeks health services, and the quality of the services one receives.^35,36 Beyond the stigma-related stress and the association of adverse mental health outcomes, many sexual minorities struggle with identity development. Healthy identity formation is important for reducing intrapersonal risk factors associated with coming out.³⁷

Interpersonal Level

Mental health issues, as discussed previously, can be impacted by interpersonal relationships such as with family, friends, coworkers, and others within one’s social system. Familial rejection is related to negative health outcomes such as suicide attempts, mental health problems, substance use, and high-risk sexual behavior.^38,39 On the contrary, family support regarding sexual orientation can reduce the likelihood of mental health disturbances.³⁹ After disclosure, it is possible for friends, family, and other acquaintances to distance themselves from the non-heterosexual individual.^40,41 Negative reactions to sexual orientation disclosure has been associated with religious affiliation or homophobic ideologies.^42–44 Experiencing negative treatment after disclosure can cause discomfort for sexual minoriites.⁴⁴ Interpersonal discrimination as conceptualized by Barron and Hebl were described as indirect (nonverbal) and direct (verbal) behaviors that occur during interactions with others.⁴⁵ Apart from potential neglect from family and friends, non-heterosexual persons can face indirect and direct interpersonal discrimination by acquaintances such as co-workers and schoolmates.⁴⁶

Community Level

Community is another important aspect. People are part of various groups which in aggregate make up their community; the workplace, school affiliation, and religious groups are some examples of institutions within a community.⁴⁷ The number of people who are publicly out within communities has increased drastically.⁴⁸ Those that are out in their public life are physiologically and physically healthier.⁴⁹ On the other hand, being visible can increase chances of victimization, discrimination, and prejudice.^50,51 Russell, Toomey, Ryan, and Diaz found that being out at school was associated with victimization, but could increase positive psychosocial adjustment.⁵² In the workplace, LGB individuals are vulnerable to harassment and discrimination.⁵³ For instance, gay and bisexual men are estimated to earn less than their heterosexual counterparts.^54,55 A study conducted among lesbian, gay, bisexual, and transgender (LGBT) healthcare providers found that physicians’ experience perceived discrimination from their heterosexual co-workers, were harassed, and witnessed discriminatory homophobic comments.⁵⁶ Among LGBT patients, there was a lower utilization of primary care, delayed healthcare, or issues with finding a healthcare provider.^36,57 In addition, religious affiliations had the strongest negative attitude towards sexual minorities.⁵⁸ Non-affirming religious institutions had a negative impact on mental health, and increased internalized homophobia.⁵⁹ However, connection to the gay community increased feelings of inclusivity and belongingness.^60,61 Friendships and romantic relationships can stem from LGBT community centers, events, and organizations.⁶² Although developing positive relationships within the community is beneficial, not all institutions are welcoming and inclusive.⁶³

Societal Level

At the societal level, regulatory components such as laws are set to protect people from harm, discrimination, amend cultural discourse and stigma. The gay and lesbian movement in the 1960s decriminalized many sodomy laws.⁶⁴ The declassification of homosexuality in the Diagnostic and Statistical Manual of Mental Disorders (DSM) III as a mental disorder in 1973 was an enormous societal milestone in the US.⁶⁵ Perhaps, the removal of homosexuality as a mental health illness increased comfort in coming out; however, the AIDS epidemic during the 1980s increased hesitance in disclosing sexual identity due to stigma. For instance, gay men were banned from donating blood beginning in 1985, a ban that persisted until the Food and Drug Administration lifted it, with the stipulation that gay or bisexual men could only give blood if they have not engaged in same-sex behaviors within 12 months. Critics still find this ban discriminatory, especially, because modern HIV testing is reliable.⁶⁶ In 2003, same-sex sexual activity was federally recognized as legal; prior to this law, the legality of sexual behavior by consenting same-sex adults varied by jurisdiction. Twelve years later, same sex marriage was recognized federally.^67,68 The following year, child adoption by LGB couples became legal nationwide.⁶⁷ Other than federal executive orders that are limited, a nationwide federal law outlawing discrimination does not exist. Hate crimes are punishable by federal law but may be difficult to prove. Employment discrimination among LGB individuals is not included in federal law or in most equal opportunity laws.⁶⁹ Laws that do not support LGB individuals can have a negative impact, and signal sexual identity non-acceptance. Stigma, prejudice, fear of discrimination on a societal level increases concealment of identity and limit opportunities.⁷⁰

Purpose of the Study

A plethora of studies has either examined determinants prior or during the coming out or sexual identity disclosure process. However, research is limited on the perceived disposition of individuals after they have disclosed their sexual identity. The purpose of this study was to enhance understanding of the perceptions of those that are “out” to their social support system, through the lens of the Social Ecological Model. The presented information can highlight multilevel pathways that intersect understanding for components that are needed internally and externally for improving the quality of life for LGB individuals’ post-sexual identity disclosure.

METHODS

Participants

Fifteen self-identified LGB young adults between the ages of 18 and 27 were recruited for this study. Almost three-fourths (73%) of the sample were white and 27% were non-white. One participant reported a Hispanic ethnicity but did not report a race. Participants included 8 men and 7 women. Nine participants self-identified as either gay or lesbian and 6 participants self-identified as bisexual. Seven participants were undergraduate students, 6 were graduate students, and 2 participants were recent graduates. The inclusion criteria for this study were that prospective participants had to self-identify as LGB, be within the ages range of 18-29, and have disclosed their sexual identity to their social support system. Social support system was defined as immediate family members such as parents, guardians, siblings, including close friend-sand peers. Almost all participants (86%) disclosed their sexual identity to their social support system in high school, and the remainder came out during their first year of college. Other than the inclusion criteria components, no attempts were made to select participants with varying demographics. A total of 22 individuals expressed interest in the study; some were excluded for not disclosing their sexual identity to their entire social support system. It is important to note that other than an LGB identity, none of the participants in this study self-identified as pansexual, queer, or any other terms used to describe sexual identity. The participants in this study represented a qualitative subsample of a larger study that focused on resources necessary for younger LGBT individuals that were within the sexual identity disclosure process.

Procedure and Instrument

Participants were recruited through the utilization of flyers, LGBT serving organization listservs, and other electronic advertisement outlets. Once eligible, interested potential participants emailed the researcher and scheduled an interview time and provided a preferred location to conduct the interview. Participants were advised that the interview would take approximately 2 hours and that they would be compensated with a $10 gift card. Informed consent was obtained before the interview began. Depending on the participant’s preference, interviews were conducted in private locations such an office or private reserved room at a library. To safeguard identity disclosure, participants were given a participant number, and their names were not connected to the interview recording or notes. Semi-structured interviews were chosen to provide flexibility in responses and probing when needed. Interviews were transcribed after each session and were conducted until saturation was reached.⁷¹ Saturation was determined after redundancy in the information (roughly 70%) presented by participants was apparent. Saturation was researched after the 12 interview was transcribed and reviewed. However, the remaining scheduled interviews were conducted before data collection was concluded.

The interview guide was created through the collaborative effort of qualitative and sexual health researchers. As stated previously, the components of this study were part of a larger study that examined other components of the sexual identity disclosure process of LGBT individuals. As such, the interview guide targeted 4 topics: (1) sexual identity disclosure in connection to social support and institutional systems; (2) professional relationships; (3) romantic relationships; and (4) sexual behavior. Demographic questions were asked in the beginning of the interview. Data for this study primarily came from topics 1 through 3, as highlighted above. Sections that dealt with experiences post-sexual identity disclosure utilized the components of the social ecological framework for consideration of the dynamic interaction of lived experiences of participants on multiple levels. The codebook focused on perceptions of self, interpersonal relationships, community-based experiences, and societal elements after sexual identity disclosure.

Data Analysis

A semiotic phenomenological procedure was used to understand content and analyze the data, which is inclusive of description, reduction, and interpretation.⁷² As the interviews took place, both perceptions and expressions were considered. Interviews were recorded to capture the perception of participants’ experience, and the interviewer took notes to capture expressions of participants.’ Phenomenological description occurred through referent content provided by the perception of participants (vocalization of their experiences and perceptions). After each interview, the audio-recording was carefully transcribed verbatim. Phenomenological reduction was conducted by analyzing both transcripts (perceptions) and marginal notes (expressions) numerous times to ensure familiarity and to identify preliminary themes. The researcher attempted to set aside personal assumptions and suspended judgment to ensure authenticity in data analysis, a process called bracketing.^71,73 Phenomenological interpretation was conducted by analyzing the data independently by 2 thematic analysts. After identification of preliminary themes, the data were further analyzed collaboratively with the utilization of NVivo, a qualitative software for thematic organization and identification. NVivo allowed for hierarchical coding and analysis of text across multiple themes based on participant responses.^74,75 Two debriefers reviewed the data to increase internal validity by triangulation to ensure conceptualization of the data from various perspectives.⁷⁵ Ensuring trustworthiness included sustained engagement, observation, and reflexivity, all of which were applied in this study through peer debriefing and theoretical triangulation.⁷⁶ To ensure reliability and dependability, description of the procedure, instrument (interview guide), and data analysis were detailed.⁷⁵

RESULTS

Seven themes emerged from participants’ responses. With the first theme, participants described perceptions of sexual identity. Theme 2 included improvements in mental health after sexual identity disclosure. Theme 3 involved interpersonal experiences such as estrangement from family and close friends. Theme 4 entailed the development of new relationships post-sexual identity disclosure. Theme 5 included social support from LGBT groups. Theme 6 described non-acceptance of sexual orientation from others not within the LGBT community. Theme 7 described various minority identities that contributed to stress. Table 1 provides an expansive list of quotes.

Table 1.

Expansion of Selected Quotes

Level	Theme		Quote
Intrapersonal	1	Perception of Sexual Identity	Bisexual, Male, 25: I try not to let the stereotypes define me, but it’s hard. Like you get this stereotype of this is who that group is, and um so there’s this stigma if you’re gay you have to be super flamboyant; and basically there’s tons of YouTube videos about it. But it’s like you’re basically a girl, which is totally not true because there’s such a spectrum of queer and it’s like matching someone’s personality with their sexual orientation and so you kinda get this stigma of ‘oh, you’re bi but you really act gay, flamboyant, or whatever.’
			Bisexual, Female, 27: I’ve internalized what does it mean to be like, to be bi. What does that mean? When I was talking to my friend, the first girl I was with. Um, she was like you don’t look like you like girls. I’ve gone through a lot of physical changes since then. I used to have really long hair, um it was like really curly, and it made me look really Latina. And like recently, I’ve shaved it all off. Now, like I’m sexually a bit more ambiguous, and so I feel like women are inclined to talk to me.
	2	Mental Health Improvement	Gay, Male, 25: It’s been a long time since I’ve came out, I’m sure it’s really improved my mental health because I no longer have to worry about the stress of someone finding out I’m gay, or just like having this looming coming out in my future, and dreading the moment, and once it’s over it’s like, this is great.
			Gay, Male, 18: I’m just like okay it’s pretty much like everyone knows, and so it’s like easier and I don’t have to hide stuff. I don’t have to try to be someone I’m not and I feel like I can be myself, and so it’s like um better for my mental health. I feel like now I can go to a clinic you know and just not, I don’t have to hide things from my doctor, and you know.
Interpersonal	3	Estrangement	Gay, Male, 24: After coming out…I went back to [undergraduate university] and I was pretty much estranged from them [his family]. Didn’t talk to them, didn’t have really anything to do with them. I came home that summer, but that was because I was desperate. But it got so bad, so I stayed in [near by city] that summer … with my ex-lover.
			Bisexual, Female, 25: I came out in high school, well because I was outted, but never felt accepted. It was a religious town, so I stayed to myself. And every time I go home for file holidays or something, people still talk, it’s like they never forgot. So, I still stay to myself when I’m home.
	4	Relationships	Gay, Male, 18: I came out for myself just to be totally myself, but then at the same time I came out so that I could openly be in a relationship with this person. But, for friendships it’s like a stigma but not really because on a college campus, I feel like you hangout with the people who are going to accept you.
			Lesbian, Female, 25: I have more queer friends now because I am out and open about it. I feel like it’s good to have other people that have gone through similar situations too in your friend circle. I guess I have more friends than I did before.
Community	5	Support	Gay, Male, 25: As far as social networks go it’s important, being gay knowing what it’s like. If it wasn’t for being gay, I sense…I see it in other networks to, especially for other minorities. In the same way. Older black scholars are really willing to help young black scholars because the road is so hard. In the same way older gay male scholars look out for younger ones.
			Bisexual, Female, 25: After I left home, well it was either that or being asked to leave. I stayed with friends for a while in the dorms. When I overstayed my welcome, I got housing assistance through the center. They were so nice; it definitely pushes me to help other queer people after I get my life together [chuckle], I guess if we don’t stick up for each other, who will?
	6	Sexual Orientation Non-acceptance	Bisexual, Female, 22: Well I get it from both ends. Um, straight people, okay generally, people want to know are you gay or are you straight, and I am none of the above, and then they want you to pick a side, and that’s not going to happen really, and you have the gay hatters [laugh], and like the pick a side comes from the heterosexuals and homosexuals. There’s a lot of groups that say they’re inclusive but are pretty much just homosexual only kinda groups, and not accepting of like bisexuals or like pansexuals, but it really depends on the groups.
			Gay, Male, 26: I think plenty of people still don’t accept, there’s still a lot of discrimination against sexual minorities, and even within that, you know the different kind of sexual minorities. Some people are more likely to be accepted, and it can be just, discrimination plays out in different ways. I was reading an article about biphobia and like bi people don’t exist, there’s no need for this. Gays aren’t treated any better.
Societal	7	Minority Stress	Lesbian, Female, 24: The government is still discriminatory towards queer people. And, even in places where things have been legalized it doesn’t necessarily mean that it’s respected. It’s a systematic depression as there is with any kind of social system.
			Gay, Male, 24: I feel like, yeah, a dual stigma because it seems that being gay in the White community is more acceptable and becoming like more of the norm. But I feel like Blacks and Whites, we have different issues within our own communities. I feel like in the White community they accept it a lot more than in the black community. Because in the black community, I feel like you’re raised to not be gay, if you are it’s something that is very negative. Then you have to, you know keep this portrayal among black females. That whole masculine thing and no I’m not a faggot, and live in this secondary lifestyle that you really don’t have to live.
			Bisexual. Female, 20: Being a minority especially at [college] is kind of difficult on its own, adding another element to it is difficult. Being taken seriously, I would say. People think that being bisexual is a White thing. It’s like you can’t be Latina and like girls. It’s bad enough you have to prove in a college setting that you’re smart enough and worth it. Adding another element is just hard.

Theme I: Perception of Sexual Identity

Participants in this study discussed internalized elements of personal perceptions of what it seems like to be a sexual minority. Some mentioned that LGB individuals were discussed more in mass media, which provided a point of reference and understanding for people who were not members of the LGB community. After coming out, many participants still struggled with identity regarding terminology and identity categories. As demonstrated in the quote, many discussed the connection between mannerisms and sexual orientation stereotypes. Some discussed that certain physical characteristics and mannerisms were expected of them to fit into the LGB community. Some reported stereotypes based on their mannerisms as being a sexual minority. For instance, a gay male, age 19 stated: “Most people would read me as gay based on my physical appearance anyway.” Another participant, a gay male, age 24 stated: “A lot of people…assumed [that he is gay] because of my mannerisms and things like that.” Some discussed the excitement in embracing their sexual identity after coming out. Participants noted that they enjoyed talking about their sexual orientation, used sexual orientation-based discussions as an opportunity to educate others and form new relationships. Participants mentioned that they felt that being a sexual minority was already constructed for them, making it difficult to develop their own identity of what it means to be LGB. Many discussed stereotypes that were difficult to overcome. These stereotypes were primarily about being perceived as hypersexual and possibly having a sexually transmitted infection.

Lesbian female, 25: It’s [being a sexual minority] talked about it on TV. More gay characters on TV. It’s not great, but there is way more than when I was younger. I use the term lesbian, professionally, as an identifier. I much prefer to term gay to lesbian. I don’t know why I have a negative reaction to the term lesbian. It doesn’t offend me when people identify me that way. But I don’t use it for myself, in a personal sphere, and I don’t know why because it’s not as if my struggles are different. I think it’s the stigma and what people expect me to be and look like. You know, the ‘butch lesbian,’ mullet and cargo pants.

Gay male, 26: I feel like if you are a gay man people automatically assume you’re after every straight man you see, or have HIV, or are very promiscuous, or are feminine, and things like that. It’s hard for me to look past that as I try to understand myself.

Theme II: Mental Health Improvement

After coming out, all participants reported having an improvement in mental health, even though some disclosed being “outed” by others such as siblings. Participants mentioned a decrease in depression, anxiety, and suicidal thoughts. In addition, openness about one’s sexual identity assisted with stress reduction, shame, loneliness, and confidence. A bisexual female, age 20 said: “It’s been a real improvement. I was extremely depressed…I’ve been suicidal at times.” Many discussed noticing an enhancement in their psychological and mental health quickly, and made references that outsiders noticed mental health improvements as well. That same participant also noted: “I’ve been told by many people that they can see a change in me after I came out.”

Bisexual female, 22: I had a pretty severe eating disorder thoughout high school, and for me it was all tied up in not expressing my identity, and that fear, and that severe loneliness that I thought no one in the world understood this deep secret. So that was my mental health. Coming out I have a lot more confidence…self-assured and like extroverted where it used to be really low confidence, low self-esteem.

Theme III: Estrangement

Many interviewees came out during high school, and a little over half discussed that after coming out their established relationships changed immensely. The coming out process distorted built relationships within their social support system, and many discussed that years after sexual identity disclosure these relationships were never recovered. Many felt estranged from family and friends in their hometown. Among those that felt estranged, almost all reported coming out in a conservative town, and having friends and family members with strong religious beliefs.

Lesbian female, 25: I have a few friends in the past that took it [coming out] negatively. I had friends who were very mean to me about it, and it was a lot of Christianity shoved in my face like you’re going to hell and people wanted to pray for me and stuff like that. It hurt because they were close friends. I’ve never been religious, so I never felt bad about myself because I was confident enough with myself at that point. I didn’t care that much so we stopped being friends. It was more awkward then anything. People typically made comment in front of other people.

Theme IV: Relationships

Participants that had the option claimed that they came out for themselves due to the annoyance of secrecy; however, many came out to be open within their romantic relationships. After coming out, many discussed an improvement in their dating life and navigating same-sex relationships without the fear of hiding. For many participants college was the first time they felt comfortable dating and building friendships. Due to discrimination and fear of stigma, participants reported being more comfortable accruing friends that shared the same or similar sexual identity. For instance, one participant, a gay male, age 25 stated: “Um, my male circle of friends is all gay as well. That’s all I hang with.” Exclusivity to sexual minority friends was the norm among the sample in this study.

Lesbian female, 22: Yeah, definitely, being out allows me to date and find friends that will be friends with me. College was a first time that I ever had gay friends. For a lot of my friends, college was the first time they had gay friends too. So, it kind of worked out. Organic network in a way that you don’t have to worry about what anyone is thinking. The same goes for pursuing someone romantically, if you’re in that crowd it’s easier.

Theme V: Support

Through relationships within sexual minority peer groups, various participants stated that they were able to seek and receive support. These sexual minority groups provided advice, shelter, financial assistance, and educational or career advancement. Many discussed receiving support from local LGB organizations and venues. These organizations were started or owned by older LGB individuals, and provided an opportunity for participants to make friends, receive useful information and resources, and validation about sexual orientation identity. Some participants stated that through these means they were also able to help other individuals who might need support.

Lesbian female, 24: I ended-up at [university name] which I thought would be more conservative, but it was the first time that I knew gay people and queer people and people with different backgrounds started to have more, a closer, a stronger network of support. And, people were overwhelmingly accepting. I was able to join networks and groups that were filled with people who were like me that I could talk to. When my friend was asked to leave his home, one of the groups found housing for him and startup money.

Theme VI: Sexual Orientation Non-acceptance

After coming out, many participants gave accounts of not feeling accepted by strangers, family members, or friends. Non-acceptance was expressed indirectly by non-verbal communication such as strange looks or not acknowledging one’s sexual identity. Participants also mentioned direct non-acceptance of sexual orientation by negative comments, jokes, and in extreme cases, property damage. As some participants discussed, bisexuality is a phenomenon that is under a lot of scrutiny by both heterosexual and LGB communities. Participants reported the hardship in being part of a sexual minority community that was non-accepting, discriminatory, and at times even discourteous. As many participants implied, the LGB community is subjected to various elements of prejudice and discrimination related to sexual orientation non-conformity from the heteronormative sector; however, gay men and lesbian women inflict prejudice among bisexual individuals by ridicule, exclusion, and refusal to date or befriend. One participant, a bisexual male, age 25 said: “There are some people who don’t believe in bisexuality even in our community.”

Lesbian female, 24: Yeah, there are situations; you can be at a bar in [city name] downtown, which is a certain kind of area and not getting served in that way. People sometimes can stare or give weird looks, and you can tell people are disapproving. I know there’s some jobs that I can’t do just because I’m who I am. And that’s frustrating, but at the same time I know I don’t want to do them. Yeah, I think it does limit some opportunities, but those opportunities are definitely not worth it.

Theme VII: Minority Stress

Participants discussed elements of minority stress as LGB. All racial and ethnic minorities felt that their white counterparts have it much easier, and being a racial minority added another layer to hardship. Some mentioned that being a sexual minority was more accepted in the white community, and there is more support provided for Caucasians. Racial and ethnic minorities stated that they felt misunderstood within their racial and ethnic communities because being a sexual minority was perceived to be a white issue. Interestingly, some white participants discussed elements of “white privilege.” Caucasian participants, primarily gay men, discussed being able to empathize with other minority groups, especially racial minority groups, due to their own experience as gay men. Some stated that within the LGB community there are more resources available for white gay men. Five of 17 participants self-reported their religious minority status as atheist. Some participants mentioned having to come out twice.

Gay male, 26: You know I was in 2 closets really looking back. I had to keep a lot to myself. Opinions about anything, basically because they might portray that I didn’t believe in God and that I was gay, you know. You know if they can kill me twice they might. Again, in many ways, atheism and being gay are so similar.

Five participants mentioned the difficulties in navigating a dual or triple minority status. Some stated that being an atheist was deemed worse than a sexual minority. A bisexual female, age 27 stated: “Religion is a biggest reason being queer is deemed wrong, so being an atheist is worse because then it’s perceived that you lack a moral backbone.”

DISCUSSION

Seven themes were identified to understand the disposition of individuals who have disclosed their sexual identity status to their social support system. These themes could be organized through the concepts of the Social Ecological Model¹¹ as demonstrated in Figure 1. At the intrapersonal level, 2 themes were identified: (1) perception of a sexual identity that was oftentimes stereotypical: and (2) mental health improvement after coming out. The interpersonal level included 2 themes: (3) estrangement from hometown family and friends; (4) however, the development of new positive relationships after coming out. Two themes were identified at the community level such as (5) support from members of the LGBT community; but (6) perceived sexual orientation non-acceptance from others. One theme was reported at the societal level, (7) which involved minority stress due to multiple minority identities.

Figure 1.

Themes Organized within the Context of the Social Ecological Model

Within public health, there are various theories and models that are overutilized such as the Health Belief Model, Theory of Planned Behavior, Social Cognitive Theory, and Diffussion of Innovation.^77–79 Numerous theories exist that are left out of the conversation, and these theories/models can provide a theoretical understanding or highlight strategies to address a phenomenon among specific populations. The Social Ecological Model can provide a framework for integrating multiple theories. As the identified themes of this study are discussed, theories and models are highlighted to promote theoretical concepts for improving internal and external perceptions among individuals that are “out” in their daily lives. These models include 3 sexual identity developmental models, the Vivienne Cass Homosexual Identity Model,^80,81 the Model of Homosexuality Development,^82,83 and the Developmental Stages for Coming Out;⁸⁴ a model that considers relationships and social context called Lifespan Model of Identity Development;⁸ Communication Privacy Management Theory;⁸⁵ and Minority Stress Model.^86,87

Intrapersonal Level: (1) Perception of Sexual Identity and (2) Mental Health Improvement

A reduction of intrapersonal risk factors is a goal of sexual identity development models. The Vivienne Cass Homosexual Identity Model is a stage model that provides useful information for understanding identity development,^80,81 which could assist providers rendering services to LGB individuals in navigating intrapersonal problems post sexual identity disclosure. This model has been used to understand sexual identity development among various sexual minority groups.^88–90 The Cass Model has a total of 6 stages. Stage 1 is identity awareness (consciousness of sexuality differences); stage 2, identity comparison (one compares queer and heterosexual identities); stage 3, identity tolerance (identity is viewed as non-heterosexual); stage 4, identity acceptance (new identity begins as one becomes active in the LGB community); stage 5 is identity pride (immersion in LGB culture); and stage 6, identity synthesis (identity is fully accepted).^80,81

In this study, participants discussed internalized elements and perceptions of what sexual minorities stereotypically should look and act like such as mannerisms and physical characteristics for fitting into the LGB community. Many stated that after coming out their mental health improved but reported struggling with identity. In stage 2 of the Cass Model, identity comparison takes place. Self-identity is an ongoing life process, and it is essential to discuss challenges within identity formation. The coming out process can be difficult, especially when one’s social support system are not accepting of their sexual identity. Perhaps, community programs and/or support groups at local LGBT centers could focus on self-stigma, internalized homonegativity, identity verification, and other identity risk factors after the disclosure process. Some participants were “outed” by others or their sexual orientation were disclosed to others prematurely. Perceived identity contentment is needed before one can be propelled to identity acceptance. With the assistance of mental health providers such as counselors, this model could be used to highlight areas of focus for increasing self-worth, self-esteem, and other internalized components. Although participants in this study were post-disclosure, there are certain milestones that may require further assistance that the Cass Model could highlight for mental health providers.

Most participants reported mental health improvement after the disclosure process. Troiden’s Model of Homosexuality Development (MHD)^82,83 could be a useful model for further improving mental health. The MHD has 4 stages. Stage one is sensitization (feelings marginalized from heterosexual peers); stage 2, identity confusion (social isolation and guilt); stage 3, identity assumption (self-acceptance); and stage 4 is commitment (sexual minority status is embraced).^82,83 Perhaps many participants in this study were within stage 4, because they described mental health improvement but did not report a complete abolishment of issues. This finding coupled with MHD can guide or provide health professionals and LGB service providers with ideas on how to assist LGB individuals to reach commitment. In addition, commitment occurs when the individual considers their identity valid and satisfying. Commitment could be a goal among mental health providers for synthesizing topics and discussion points during counseling or group sessions.

Interpersonal Level: (3) Estrangement and (4) Relationships

At the interpersonal level, participants reported estrangement from some members of their social support system such as family and friends. Rosario et al found that healthy identity formation is associated with support from friends and family.⁹¹ However, many stated that coming out helped them seek new relationships such as romantic partners and new friendships. The Developmental Stages for Coming Out⁸⁴ and Lifespan Model of Identity Development⁸ are 2 models that could be beneficial for addressing relationships after the coming out process.

The Lifespan Model of Identity Development takes interactions and social circumstances into consideration. Within this framework, the development of personal relationships, connections with peer groups and community are emphasized. The 6 components of this model are exiting the heterosexual identity, developing a personal LGB identity status, developing an LGB social identity, claiming an identity as an LGB offspring, developing an LGB intimacy status, and entering the LGB community.⁸ Family rejection is associated with poor health outcomes such as suicide, depressive episodes, high-risk sexual behavior, and substance abuse.^39,92 The Lifespan Model could provide ideas for workshop development that focuses on educating allies and sexual minorities on how to cope or reconnect with estranged family or friends due to sexual orientation non-acceptance. Family rejection may interact with unresolved identity risk, reduce affirmation of identity, and reduce access to the protective benefits of community connectedness.³⁹ It could be beneficial to connect those with similar relationship challenges as a mechanism for social support and coping. Perhaps, the components of this model can assist with creating programs for bridging and healing relationships.

The Developmental Stages for Coming Out⁸⁴ is a model that can be used to assist LGB individuals with seeking meaningful relationships and promote the ongoing process of establishment in one’s community. The model illustrates stages of development that outline the plausible general process of disclosure. The stages are pre-coming out, coming out, exploration, first relationship, and identity integration.⁸⁴ Stage 4, first relationship, describes an individual’s need for intimacy and a committed relationship. Stage 5, integration, explains the ongoing process of establishing oneself as LGB to others. The use of both theoretical models can be useful for creating themes in group counseling settings to encourage individuals to connect with others within the LGBT community due to estrangement from their prior social support system. In addition, these 2 models could encourage friendship development or romantic relationship formation outside group counseling. Previous research found that supportive social support is associated with higher self-esteem and a reduction in mental health issues.⁹³ PFLAG, formerly known as Parents, Families and Friends of Lesbians and Gays (LBGT advocacy group located in various cities throughout the nation); the Family Acceptance Project (offers evidence-based education); and Family Equality Council (advocates social justice for LGBT families) are some examples of resources that exist within the community that could benefit parents and family members.^39,94

Community Level: (5) Support and (6) Sexual Orientation Non-acceptance

Relationships and support are interrelated, and many individuals in this study stated that they received support through LGBT-serving groups and community centers. To the contrary, participants also gave perceived accounts of sexual orientation non-acceptance by strangers and other members of LGBT and non-LGB communities. One has to feel comfortable seeking support and reducing phobias related to non-acceptance; therefore, it is essential to increase support to LGB individuals who may be seeking resources within their community.

The components of Communication Privacy Management (CPM)⁸⁵ and the Lifespan Model of Identity Devlopment⁸ could be useful in promoting safer space and acclimation to social environments after sexual identity disclosure. In previous studies, CPM has been used to describe how to disclose and increase ownership of one’s sexual identity.^95,96 Context disclosure could be unsafe. Perhaps, CPM could be a guide on how to disclose in different social environments, or how to navigate potential negative conversations and situations. According to CPM, one useful method used to disclose private information is by selection, in which LGB individuals discretionally disclose their status. Disclosure is a lifelong process and it is left to the discretion of the person on whether they chose to disclose their sexual identity. Another CPM method is called reciprocity in which one may disclose information if or when another LGB individual discloses their sexual minority status. When dealing with sexual orientation non-acceptance and hostile or unsafe settings, practicing ambiguity may be beneficial for safety matters (eg, military, religious settings, occupation, etc.). As suggested with CPM, ambiguity can be applied when an LGB is intentionally unclear about their sexual identity. Deflection is another method of CMP, in which one intentionally deflects when asked or put in a situation to disclose their sexual identity. Similarly, the last method of CPM is avoidance of disclosure, especially in settings that may be unsafe. Sometimes, concealment may be utilized to avoid dangerous or uncomfortable situations, but concealment can come with a cost such as self-esteem or reduction in social and community-based support.^86,87 In addition, concealment could interfere with the developmental process of forming connections. Privacy is important in various domains; however, community leaders can take steps to address and prevent marginalization, discrimination, and stigma among LGB individuals. At an organizational level, safe zones stickers, signs in front of businesses with LGBT flags, or accepting images can increase visibility of allies. Workplaces, as well as academic and medical institutions can be more inclusive by mandating sexual identity awareness training or endorsing zero-tolerance policies against discrimination and harassment.

The Lifespan Model of Identity Development was suggested previously for interpersonal counseling strategies.⁸ This model could provide ideas for integration into the LGBT community and other groups where healthy relationships can be promoted. Entering the LGB community is a component which involves being active, going to community and social events, and being involved in organizations that are LGBT friendly. Developing a connection to the LGB community and a perceived sense of self-worth based on the affiliation within these communities could protect one from stigma-based and discriminatory situations.⁶¹ At the community level, it is paramount for sexual minorities to surround themselves with individuals with similar lived experiences. Encouragement to seek support through allied organizations is an important topic of discussion for those navigating society post disclosure. LGBs can seek out supportive resources such as the LGBT centers and social groups that are available virtually or in various cities and neighborhoods.

Societal Level: (7) Minority Stress

Minority stress was a theme reported by those who were members of more than one minority group. The Minority Stress Model might be useful for creating strategies to combat minority status distress. Components of this model include: (1) identifying proper coping techniques and social support; (2) recognizing distal minority stress processes like prejudice events; (3) understanding one’s own proximal minority stress processes like expectations of rejection; and (4) concealment and internalized oppression.^86,87 The Minority Stress Model has been used to highlight levels of psychological stress among LGB populations.^97–99 The model argues that to minimize minority stress and societal homophobia experienced by sexual minorities, it is important and ideal to incorporate public policymakers as prime stakeholders for creating interventions and enforcing strategies to decrease minority stress at a societal level.⁹⁸ Public policymakers, LGB institutions, and community organizations can advocate for safer spaces, LGB-inclusive policies, and visibility of current resources. Needed strategies include community organizing, coalition building, harassment prevention, and partnerships with LGBT allies. Perhaps, the legalization of same-sex marriage and other pro-LGBT laws can propel societal acceptance. To promote dialogue and discourse surrounding diversity initiatives and reducing oppression, allies are needed at the forefront. In addition, it is paramount to elucidate the gap between literature and practice. Further research is needed on the extent to which these theoretical models are successful in counteracting experiences reported in this study at the intrapersonal, interpersonal, community, and societal levels. In addition, further research should examine new perspectives on the experience of multiple identities such as race, ethnicity, religiosity, gender, and sexuality.

Conclusions

Coming out is inclusive of identity development, as well as internal and external disclosure. Generally, after the coming out process, one is committed to the sexual minority identity. The goal is for an individual to have a healthy integration of identity, relationships, and community and societal acceptance. In this study, identity developmental models were used to discuss and highlight strategies for reducing intrapersonal risk factors. However, relationship, community, and social processes are not examined within developmental frameworks; therefore, non-developmental models were noted to emphasize needed social resources. The minority stress framework highlighted the political and community organizing needs to combat multiple minority stressors.

Limitations

This study provides essential information for theories/models and strategies for those who are post-sexual identity disclosure, as they navigate their lives as LGB. However, there were several limitations. Direct associations between the coming out process and the contents reported by participants cannot be made from these qualitative findings. The results were from a small sample of sexual minority young adults recruited using convenience sample strategies and may not be generalizable to the larger LGB population. The principal investigator was the primary interviewer and participated in data analysis. However, the presence of additional coders/analysts and peer debriefers decrease potential bias. Data were not collected that specifically inquired about one’s social support system. Perhaps, this information would have added more in-depth understanding to the results. Nonetheless, these results, models and strategies suggested are imperative to consider for those with an LGB identity.