Age differences in the associations between outness and suicidality among LGBTQ+ youth

Abstract

Objective:

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) youth are at increased risk for suicidality compared to their heterosexual and cisgender peers, and outness (the extent to which an individual is open about their LGBTQ+ identity to others) is an important correlate of suicidality. However, previous research has led to mixed findings regarding whether outness functions as a risk or protective factor for suicidality, and the available evidence suggests that age may play an important role. As such, the goal of the current study was to examine whether the associations between outness and suicidality differed between LGBTQ+ adolescents (ages 12–17) and emerging adults (ages 18–24).

Method:

The analytic sample included 475 LGBTQ+ youth who completed an online survey after contacting a national, LGBTQ+ crisis service provider.

Results:

Results indicated that age significantly moderated the association between outness and suicidal ideation, such that greater outness was significantly associated with greater suicidal ideation for adolescents, but not for emerging adults. In contrast, age did not significantly moderate the associations between outness and likelihood of a past suicide attempt or perceived likelihood of a future suicide attempt. However, the main effect of outness was significant in both models, such that greater outness was significantly associated with a greater likelihood of a past suicide attempt and a greater perceived likelihood of a future suicide attempt.

Conclusions:

These findings suggest that the associations between outness and suicidality among LGBTQ+ youth may depend on age as well as the dimension of suicidality (ideation versus attempt).

Suicide is the second leading cause of death for youth ages 10–24 in the United States (Heron, 2019), and studies have consistently demonstrated that lesbian, gay, bisexual, transgender, and queer (LGBTQ+) youth are at increased risk for suicidality (including ideation and attempt) compared to their heterosexual and cisgender peers. For example, meta-analyses have demonstrated that sexual minority youth are twice as likely as heterosexual youth to report suicidal ideation (Marshal et al., 2011) and more than three times as likely to have attempted suicide (de Giacomo et al., 2018). These disparities are even greater for transgender youth, who are more than five times as likely as cisgender youth to have attempted suicide (di Giacomo et al., 2018). In fact, data from the 2019 National Youth Risk Behavior Survey (YRBS) revealed that 47% of lesbian, gay, and bisexual high school students had seriously considered attempting suicide in the past 12 months and 23% had done so (Ivey-Stephenson et al., 2019). Furthermore, data from the 2017 YRBS revealed that 44% of transgender high school students had seriously considered attempting suicide in the past 12 months and 35% had done so (Johns et al., 2019). These disparities are greatest during adolescence (Russell & Toomey, 2012), but they persist into adulthood (Hottes et al., 2016), highlighting the critical need to identify risk and protective factors related to suicidality among LGBTQ+ youth in order to develop evidence-based suicide prevention programs tailored to their unique needs.

Outness, or the extent to which an individual is open about their LGBTQ+ identity, has been implicated in LGBTQ+ youth’s mental health. Theories of sexual orientation development (Cass, 1979; Troiden, 1989), coming out (Rosario, Hunter, Maguen, Gwadz, & Smith, 2001), and minority stress (Hatzenbuehler, 2009; Meyer, 2003) tend to emphasize the benefits of being open about one’s identity, but doing so can also lead to negative outcomes such as discrimination (Chaudoir & Fisher, 2010; Pachankis, 2007). The disclosure process model acknowledges that disclosure can have both positive and negative consequences, and that the consequences of disclosure depend on various factors (e.g., reactions to disclosure, changes in behavior following disclosure; Chaudoir & Fisher, 2010). However, concealing one’s identity can also be a source of stress (Pachankis, 2007) and contribute to internalizing mental health problems, especially for young people (Pachankis et al., 2021).

Although outness has been identified as a correlate of suicidality among LGBTQ+ youth, previous research has led to mixed findings as to whether outness functions as a risk or protective factor for suicidality, and the available evidence suggests that age may play an important role. For example, studies of LGBTQ+ youth (ages 14–21 depending on the study) have generally found that greater outness is associated with greater suicidality, including greater suicidal ideation and a greater likelihood of having attempted suicide (D’Augelli et al., 1998; D’Augelli et al., 2001; D’Augelli et al., 2005; Hershberger et al., 1997; Rotheram-Borus et al., 1994). These findings are consistent with minority stress theory (Goldbach & Gibbs, 2017; Meyer, 2003), which suggests that LGBTQ+ individuals experience unique stressors (e.g., discrimination) that explain their disproportionate rates of negative mental health outcomes, including suicidality (see Haas et al., 2010). However, studies of LGBTQ+ adults (ages 18+) have either found that greater outness is associated with lower suicidal ideation (Michaels et al., 2016; Testa et al., 2017) or they have not found significant associations between outness and suicidality (Chang et al., 2021; Irwin et al., 2014; Woodford et al., 2018). Together, these findings suggest that there may be differences in the associations between outness and suicidality as a function of age, but we are not aware of any studies that have directly tested this possibility.

The studies of LGBTQ+ youth described above included participants ages 14–21, which not only overlaps with studies of LGBTQ+ adults (ages 18+), but also cuts across two distinct developmental periods: adolescence and emerging adulthood. Arnett (2000) coined the term emerging adulthood to describe the developmental period after adolescence but before young adulthood (operationalized as ages 18–25), which is unique demographically, subjectively, and in terms of identity exploration. For example, during adolescence (ages 12–17), there is little variation in several important demographic areas (e.g., most adolescents live at home with one or more parents, are unmarried and childless, and are enrolled in school). In contrast, emerging adulthood is characterized by a high degree of demographic diversity and instability. In addition, although identity development is typically associated with adolescence, emerging adulthood offers the most opportunity for identity exploration in the areas of love, work, and worldviews, and it is when young people move toward making enduring decisions.

The distinction between adolescence and emerging adulthood may be particularly important when it comes to the study of suicidality among LGBTQ+ youth. Adolescence is the developmental period when suicidal ideation and suicide attempts are most frequent in general (Nock et al., 2008), and it is also when many LGBTQ+ youth begin to question, explore, and acknowledge their LGBTQ+ identity, which is a normative process but can be psychologically distressing in a heteronormative context (Borders et al., 2014). In fact, coming out at a younger age is associated with experiencing more sexual orientation-related violence, which in turn is associated with a greater likelihood of having attempted suicide (Plöderl et al., 2014). As the authors suggested, LGBTQ+ people who come out at younger ages may be more likely to be in hostile environments where they are exposed to discrimination, and they may also have less control over their environments, less social support, and less developed coping abilities than those who come out at older ages. In addition, exposure to anti-LGBTQ+ discrimination tends to decrease from adolescence to young adulthood (Birkett et al., 2015). As such, being open about one’s LGBTQ+ identity may be less likely to lead to discrimination and suicidality for emerging adults compared to adolescents.

Finally, the associations between outness and suicidality may be even more complex, as they may depend on the dimension of suicidality (e.g., ideation versus attempt) in addition to age. For example, two studies (one of sexual minority youth and one of sexual minority adults) found that greater outness was associated with lower current suicidal ideation, but it was associated with a greater likelihood of having attempted suicide in one’s lifetime (D’Augelli & Hershberger, 1993; Plöderl et al., 2014). Plöderl and colleagues (2014) suggested that being more open about one’s sexual orientation may initially be a risk factor for suicidality because it can lead to experiences of discrimination and victimization, but it may change to being a protective factor because it can also provide access to social support. As such, in their study, greater outness may have been associated with a greater likelihood of having attempted suicide because it can contribute to experiencing discrimination and victimization, but it may have also been associated with lower current suicidal ideation because it can provide access to social support.

In sum, despite evidence that the associations between outness and suicidality may be different for LGBTQ+ adolescents versus emerging adults, we are not aware of any studies that have directly tested this possibility. As such, the goal of the current study was to examine age differences in the associations between outness and suicidality in a sample of LGBTQ+ youth ages 12–24. The data were collected as part of a larger project designed to understand the experiences of LGBTQ+ youth who had contacted an LGBTQ+ specific national crisis service provider. By examining the associations between outness and suicidality in this population, we focused on a subset of LGBTQ+ who were at particular risk for suicide. We tested age as a moderator of the associations between outness and multiple dimensions of suicidality (suicidal ideation, past suicide attempt, and perceived likelihood of attempting suicide in the future). We hypothesized that greater outness would be associated with greater suicidality across all three dimensions for LGBTQ+ adolescents (ages 12–17). In contrast, given mixed findings across previous studies of outness and suicidality among LGBTQ+ adults (including emerging adults), we acknowledge several possibilities for LGBTQ+ emerging adults: outness may not be associated with suicidality, greater outness may be associated with lower suicidality, or greater outness may be associated with lower suicidal ideation but a greater likelihood of a past suicide attempt.

Methods

Participants and Procedures

Data were collected from a national crisis service provider for LGBTQ+ youth ages 12 to 24 over the course of 18 months (September 2015 to April 2017). After receiving services from the provider, youth who did not need immediate attention (e.g., due to imminent risk) were invited to complete a prerecorded phone screen. The phone screen provided a brief overview of the study and assessed age, gender, sexual identity, and interest in being contacted by the study team. A total of 2,008 youth were eligible for the study based on the screener and were contacted within one week. Prior to participating in the study, study personnel confirmed that youth were referred from the national crisis service provider. A total of 657 youth assented or consented, completed the survey, and were compensated with a $15 gift card. Of those who completed the survey, 65 were removed from the analytic sample because of duplicate records or incomplete data, and an additional 117 were removed because they did not have any data on the main predictor (outness). A total of 475 participants were included in the current analyses. All procedures were approved by the Institutional Review Board at the University of Southern California.

Demographics.

Demographic information included age, sex assigned at birth, gender identity, sexual orientation, race, and ethnicity. Consistent with our conceptualization of emerging adulthood as a distinct developmental period (Arnett, 2000), age was dichotomized as adolescent (ages 12–17) versus emerging adult (ages 18–24). Using the validated two-step method of assessing sex assigned at birth and gender identity (Reisner et al., 2014), responses were used to create three groups: cisgender girls (assigned female at birth and female gender identity), cisgender boys (assigned male at birth and male gender identity), and gender minority youth (selected a gender identity that was different from their sex assigned at birth). For sexual orientation, response options included gay, lesbian, bisexual, pansexual, queer, questioning, asexual, straight, and “not listed” (with a text response option). Responses were re-coded into five groups for analyses: gay/lesbian, bisexual/pansexual, queer, questioning, and other (due to small cell sizes). Responses to questions about race and ethnicity were used to create two groups (due to small cell sizes): White (only selected White for race and ethnicity) and person of color (POC; selected any other race/ethnicity or multiple races/ethnicities).

Outness.

Outness was measured by determining the number of people in the participant’s life who knew that they were LGBTQ+ (“Do the following people know that you are LGBTQ+?”). Similar to other measures of outness (Mohr & Fassinger, 2000), the question was followed by a list of nine categories of people: parents, siblings, other relatives, adults at school, peers at school, people at work, straight friends, friends who are also LGBTQ+, and people online. Response options included “No,” “Yes,” and “Not applicable/do not have this person in my life.” A percentage score was created for each participant by dividing the number of items endorsed by the number of total answered items (excluding responses of “Not applicable”), with a possible range of 0–100%. This allows for a more accurate comparison of scores across participants and takes into account any missing data. The scale demonstrated good reliability in our sample (ω = .92).

Suicidality.

Suicidal ideation and past suicide attempt were assessed using five items that were adapted for self-report from the Columbia-Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011). Specifically, suicidal ideation was measured by asking five successive questions that asked about the severity of ideation since the last time the participant contacted the national crisis service provider (i.e., when they completed the phone screen): passive ideation (1), active ideation (2), method (3), intent (4), and plan (5). Consistent with previous research (Beck et al., 1999), a “worst-point” severity approach was used. Participants were assigned the score of the last question they endorsed, ranging from 0–5, with higher scores indicating more severe suicidal ideation. Past suicide attempt was measured with a single question, “Have you ever tried to kill yourself?” with “yes” or “no” response options. A single question from the Suicide Behaviors Questionnaire-Revised (SBQ-R; Osman et al., 2001) was also used to understand the likelihood of a future suicide attempt (“How likely is it that you will attempt suicide someday?”) Response options range from “Never” (0) to “Very Likely” (6). A decline to answer option was also included for each of these questions.

Analytic Plan

First, we examined descriptives for demographics, outness, and suicidality. Before the start of the analyses, assumptions for these statistical models were met; each of the data points were independent from each other, there were no outliers in the data, and the assumption of normality based on distributions of our continuous variables were fulfilled. We next assessed the unidimensionality of the outness construct by performing an exploratory factor analysis (EFA) and examining the loadings of each item. Then, we estimated correlations among the variables of interest (age, outness, suicidal ideation, past suicide attempt, and likelihood of a future suicide attempt) using the appropriate technique (Pearson for two continuous variables, biserial for one continuous and one dichotomous variable, and tetrachoric for two dichotomous variables). Finally, we conducted moderation analyses to examine whether age moderated the associations between outness and the suicidality outcomes. Outness was mean-centered prior to creating interaction terms. We conducted these analyses with and without gender identity, sexual orientation, and race/ethnicity as covariates. These covariates were selected because prior studies have found that each is associated with suicidality among LGBTQ+ individuals (Hatchel et al., 2021; Salway et al., 2019). There were no missing data for our predictors (age and outness), our covariates (gender identity, sexual orientation, and race/ethnicity), or suicidal ideation. Given that missingness was low for perceived likelihood of a future suicide attempt (3.4%) and past suicide attempt (6.3%), were used listwise deletion. Pearson, biserial, and tetrachoric correlations were conducted using Mplus v. 8.4. Moderation analyses were conducted using PROCSS v. 3.4 (Hayes, 2012) in SPSS v. 25.

Results

The analytic sample (n = 475) was split between adolescents ages 12–17 (n = 253; 53.3%) and emerging adults ages 18–24 (n = 222; 46.7%). Participants were diverse in terms of gender, with 159 (33.5%) cisgender girls, 103 (21.7%) cisgender boys, and 213 (44.8%) gender minority youth. Participants were also diverse in terms of sexual orientation, with 183 (38.5%) who identified as gay/lesbian, 167 (35.2%) as bisexual/pansexual, 40 (8.4%) as queer, 38 (8.0%) as questioning, and 47 (9.9%) who were categorized as “other.” Two-thirds of participants (n = 315, 66.3%) identified their race and ethnicity as White only. Additional demographic information is presented in Table 1. On average, participants reported that two-thirds of the people in their lives knew that they were LGBTQ+ (M = 66.6%, SD = 28.3%). The mean level of suicidal ideation was 2.21 (SD = 2.06), where a score of 2 indicated active suicidal ideation. Overall, two-thirds of participants (65.7%, n = 312) reported any suicidal ideation and one-third of participants (33.5%, n = 199) reported a past suicide attempt.

Table 1.

Demographic characteristics of the analytic sample (N = 475).

Demographic Characteristic	N (%)
Age
Adolescent (ages 12–17)	253 (53.3%)
Emerging adult (ages 18–24)	222 (46.7%)
Gender
Cisgender girl	159 (33.5%)
Cisgender boy	103 (21.7%)
Transgender girl	23 (4.8%)
Transgender boy	78 (16.4%)
Genderqueer	41 (8.6%
Questioning	26 (5.5%)
Other	45 (9.5%)
Sexual identity
Gay/lesbian	183 (38.5%)
Bisexual/pansexual	167 (35.2%)
Queer	40 (8.4%)
Questioning	38 (8.0%)
Other	47 (9.9%)
Race/ethnicity
White	315 (66.3%)
Latino/Hispanic	48 (10.1%)
Black or African American	33 (6.9%)
Asian/Pacific Islander	19 (4.0%)
Native American/American Indian or Alaska Native	1 (0.2%)
Multiracial	57 (12.0%)
Other	2 (0.4%)

Notes: Gender minority youth (i.e., all categories other than cisgender girl/boy) were combined for analyses; youth of color (i.e., all categories other than White) were combined for analyses; for gender, “other” included 35 youth who wrote in other identities (e.g., non-binary, gender fluid), 8 youth who selected “don’t know,” and 2 youth who declined to answer (who were retained in the analyses because they identified as bisexual).

An EFA was conducted on the nine items to understand whether outness could be assessed as a single construct. Due to the dichotomous nature of the items, the principal components extraction method and the direct oblimin rotation method were specified. An a priori requirement of loadings of .50 or higher was set to confirm unidimensionality of loadings onto one factor (Hair et al., 2009); loadings ranged from .52 (“People online”) to .93 (“Friends who are also LGBTQ”). Outness was therefore modeled as a single construct. There was a significant positive association between age and outness (r = .12, p = .030), but age was not significantly associated with suicidal ideation (r = −.08, p = .156), past suicide attempt (r = −.06, p = .411), or perceived likelihood of a future suicide attempt (r = .03, p = .652). In addition, greater outness was significantly associated with a greater likelihood of a past suicide attempt (r = .18, p < .001) and a greater perceived likelihood of a future suicide attempt (r = .13, p = .003), but outness was not significantly associated with suicidal ideation (r = .07, p = .149). Finally, greater suicidal ideation was significantly associated with a greater likelihood of a past suicide attempt (r = .29, p < .001) and a greater perceived likelihood of a future suicide attempt (r = .43, p < .001), and a past suicide attempt was also significantly associated with a greater likelihood of a future suicide attempt (r = .37, p < .001).

The results of the moderation analyses are reported in Table 2. When regression coefficients are reported in-text, they are unstandardized. The pattern of results was the same in the unadjusted and adjusted models with one exception (discussed below). Therefore, we describe the results of the adjusted models in-text. Age significantly moderated the association between outness and suicidal ideation (B = −.55, p = .004). Simple slope analyses revealed that greater outness was significantly associated with greater suicidal ideation for adolescents (B = .38, p = .006), but not for emerging adults (B = −.17, p = .222). None of the covariates were significant in this model. Age did not significantly moderate the association between outness and likelihood of a past suicide attempt (aOR = .95, p = .823) or the association between outness and perceived likelihood of a future suicide attempt (B = 1.15, p = .073). However, the main effect of outness was significant in both models, such that increased levels of outness were significantly associated with a greater odds of a past suicide attempt (aOR = 1.45, p = .018) and a greater perceived likelihood of a future suicide attempt (B = .33, p = .002). In addition, cisgender girls (aOR = 2.31, p = .011) and gender minority youth (aOR = 3.11, p < .001) were more likely to report a past suicide attempt than cisgender boys were, and gender minority youth (B = .87, p < .001) also reported a greater perceived likelihood of a future suicide attempt than cisgender boys did. None of the other covariates were significant in these models.

Table 2.

Results of analyses examining age as a moderator of the associations between outness and suicidality.

	Suicide ideation		Past suicide attempt		Likelihood of a future suicide attempt
	B (SE)	p-value	OR (SE)	p-value	B (SE)	p-value
Bivariate
Outness	.41 (.13)	.002	1.52 (1.16)	.005	.43 (.10)	<.001
Age	−.29 (.19)	.121	.89 (1.22)	.550	.03 (.15)	.852
Outness*Age	−.54 (.19)	.005	.90 (1.24)	.628	−.33 (.19)	.029
Multivariate
Outness	.38 (.14)	.006	1.45 (1.17)	.018	.33 (.11)	.002
Age	−.22 (.20)	.254	.97 (1.24)	.871	.11 (.16)	.494
Outness*Age	−.55 (.19)	.004	.95 (1.25)	.823	−.27 (.15)	.073
Cisgender boy	Ref.	--	Ref.	--	Ref.	--
Cisgender girl	.25 (.27)	.353	2.31 (1.39)	.011	.31 (.21)	.151
Gender minority	.40 (.27)	.146	3.11 (1.38)	<.001	.87 (.21)	<.001
Gay/lesbian	Ref.	--	Ref.	--	Ref.	--
Bisexual/pansexual	.12 (.24)	.619	1.01 (1.30)	.968	.01 (.18)	.968
Queer	.08 (.37)	.831	1.47 (1.48)	.325	.45 (.30)	.129
Questioning	−.51 (.38)	.186	1.24 (1.54)	.611	−.01 (.29)	.978
Other	−.51 (.26)	.156	.87 (1.45)	.721	.10 (.28)	.731
Person of color	Ref.	--	Ref.	--	Ref.	--
White	−.06 (.20)	.753	.89 (1.24)	.590	.01 (.16)	.949

Of note, in the unadjusted model, age significantly moderated the association between outness and perceived likelihood of a future suicide attempt (B = −.33, p = .029). Simple slope analyses revealed that greater outness was significantly associated with greater perceived likelihood of a future suicide attempt for adolescents (B = .43, p < .001), but not for emerging adults (B = .11, p = .315). Therefore, although this interaction effect became non-significant in the adjusted model (p = .073), the pattern of the simple slopes was consistent with the pattern of the simple slopes for suicidal ideation. It is likely that this interaction effect became non-significant in the adjusted model because gender was significantly associated with perceived likelihood of a future suicide attempt (gender minority youth reported a greater perceived likelihood of a future suicide attempt compared to cisgender boys).

Discussion

Identifying risk factors for suicidal thoughts and behaviors among LGBTQ+ youth is an important public health priority. Our study offers novel information regarding for whom outness serves as a risk factor for suicidal thoughts and behaviors in a subset of LGBTQ+ youth who were at particular risk for suicide. Our participants reported that, on average, two-thirds of the people in their lives knew that they were LGBTQ+. This is similar to the results of a recent study, in which approximately two-thirds of sexual minority youth assigned male at birth reported being out to most or all people (Moskowitz et al., 2021). With specific to our primary research questions, we found that higher levels of outness were associated with greater risk for past suicide attempts and greater perceived likelihood of future suicide attempts. Additionally, we found that greater outness was associated with greater suicidal ideation for LGBTQ+ adolescents (ages 12–17) but not for LGBTQ+ emerging adults (ages 18–24). Although outness has the potential to offer important benefits (e.g., access to social support), our findings suggest that greater outness can confer risk for suicidality for LGBTQ+ youth, especially adolescents. Below we discuss our findings and their implications for future research and clinical practice with LGBTQ+ youth in greater detail.

The results of our study help to clarify for whom outness is associated with greater suicidal thoughts, as we found that greater outness was associated with greater suicidal ideation for LGBTQ+ adolescents but not emerging adults. As prior scholars have suggested, outness may initially be a risk factor for suicidal ideation as it is associated with experiencing discrimination and victimization, and then it may become protective as it provides a sense of community and access to social support (Plöderl et al., 2014). Thus, it is possible that outness is associated with greater suicidal ideation for LGBTQ+ adolescents but not emerging adults because LGBTQ+ adolescents may have not yet developed social support and other protective resources that are sometimes associated with coming out. LGBTQ+ adolescents may also be questioning and exploring their LGBTQ+ identity (Borders et al., 2014) and/or they may be exposed to more discrimination and victimization compared to LGBTQ+ emerging adults (Birkett et al., 2015), which might contribute to psychological distress and in turn suicidal ideation. Furthermore, LGBTQ+ adolescents may have less autonomy or control over their environment than emerging adults, as adolescents are often in contexts in which they are considered a minor, rely on their guardians for permission, and lack control (e.g., school systems). In contrast, LGBTQ+ emerging adults may be in environments where they have or perceive to have more control, such as higher education institutions or work. The lack of sense of control combined with a developmental age when emotional regulation skills may be especially compromised might put LGBTQ+ adolescents at greater risk for suicidal ideation when they are more open about their LGBTQ+ identities. These possibilities are consistent with evidence that disclosing one’s sexual orientation is associated with more positive well-being in contexts that are supportive of one’s autonomy, but not in controlling contexts (Legate, Ryan, & Weinstein, 2011). Future research is needed to better understand how these developmental and contextual factors may shape the associations between outness and suicidal ideation among LGBTQ+ adolescents.

In contrast to our findings for suicidal ideation, we found that greater outness was associated with greater risk for past and future suicidal behaviors (i.e., past suicide attempts and perceived likelihood of future suicide attempts) among LGBTQ+ youth regardless of age. These findings are consistent with prior studies that have also documented associations between greater outness and a greater likelihood of suicide attempts among sexual minority youth and adults (D’Augelli & Hershberger, 1993; D’Augelli et al., 2001; D’Augelli et al., 2005; Hershberger et al., 1997; Plöderl et al., 2014; Rotheram-Borus et al., 1994). We built on this work by examining whether these associations were different between LGBTQ+ adolescents (ages 12–17) and emerging adults (ages 18–24), and found that they were not. As noted, some previous studies have not found significant associations between outness and suicide attempts among LGBTQ+ adults (Chang et al., 2021; Woodford et al., 2018). However, it is possible that greater outness is associated with greater risk for suicidal behaviors among emerging adults but not older adults. We also extended previous research by demonstrating that greater outness was associated with a greater perceived likelihood of a future suicide attempt. This suggests that LGBTQ+ youth who are more open about their LGBTQ+ identities are not only more likely to have attempted suicide in the past, they also remain at risk for attempting suicide in the future. Of note, we found some evidence that greater outness was associated with greater perceived likelihood of a future suicide attempt for LGBTQ+ adolescents but not for LGBTQ+ emerging adults, but this interaction effect became non-significant after adjusting for demographic covariates.

These findings should be considered within the context of the study’s limitations. First, the study was cross-sectional and causal relationships cannot be determined. Longitudinal research is needed to examine the associations between outness and suicidality over time from adolescence into emerging adulthood and beyond. Intensive longitudinal research is also needed to assess the daily or momentary experiences through which outness confers risk (e.g., discrimination, victimization) or protection (e.g., social support) in the lives of LGBTQ+ youth. Second, all of our participants had contacted a national crisis service provider for LGBTQ+ youth. While it is likely that our participants had higher levels of suicidality than the broader population of LGBTQ+ youth, there was still variability in suicidality in our sample (as noted earlier, 65.7% of our participants reported any suicidal ideation and 33.5% reported a past suicide attempt). Furthermore, it is particularly important to understand risk factors for suicidality among those who are at greatest risk (e.g., those who contact a crisis service provider). Still, it will be important for future research to examine whether the current findings extend to a broader sample of LGBTQ+ youth. Third, for participants who endorsed suicide attempts, we did not assess the ages at which they occurred. A recent study of sexual minority adults found that 61% of suicide attempts occurred within five years of realizing one’s sexual minority identity (Meyer et al., 2021). Therefore, it will be important for future research to examine the timing of LGBTQ+ identity disclosure in relation to the timing of suicide attempts in order to better understand the temporality of these associations. Fourth, our measure of outness did not account for the extent to which participants experienced affirming versus rejecting responses to coming out and whether participants decided to come out or were outed by others. Understanding these factors may help to explain the nuances of how and why outness confers risk for suicidality among LGBTQ+ youth. Our outness measure combined outness about sexual orientation and gender identities, which limits our understanding of outness among LGBTQ+ youth, especially gender minority youth, who may be out about one identity (e.g., sexual orientation) but not the other identity (e.g., gender identity). Future work is needed to understand the unique outness experiences of gender minority youth who are also sexual minorities given that they experience multiple intersections of stigma and minority stress. Lastly, although most studies have operationalized outness as a single construct, some have operationalized it as two distinct yet related constructs—disclosure and concealment (Jackson & Mohr, 2016; Meidlinger & Hope, 2014). These studies acknowledge that not disclosing one’s sexual orientation is not the same as concealing, or actively attempting to prevent others from knowing, one’s sexual orientation. Therefore, it will be important for future research to examine both disclosure and concealment in relation to suicidality among LGBTQ+ youth in order to understand the relative importance of each component of outness with respect to suicidality.

In sum, our results support emerging literature that shows that outness is not a universally beneficial or detrimental experience for all LGBTQ+ people. Our findings suggest that outness is associated with greater risk for suicidal behaviors for LGBTQ+ youth (including adolescents and emerging adults) and greater risk for suicidal thoughts for LGBTQ+ adolescents (but not emerging adults). Although outness may be a risk factor for suicidality, it is important to note that outness could serve as a proxy for an unsafe and oppressive social environment that LGBTQ+ youth have to navigate. Being out may put LGBTQ+ youth at greater risk for minority stress, especially in hostile and stigmatizing social environments, and these minority stressors might be driving the associations between outness and suicidality. It will be important for future research to examine the potential mechanisms through which outness contributes to suicidality among LGBTQ+ adolescents versus emerging adults (e.g., exposure to minority stress, coping strategies used in response to minority stress). Prior research has found that experiencing involuntary sexual orientation disclosure (i.e., being outed by someone else) and receiving negative reactions to disclosure from family and friends are both associated with greater suicidality (Cho & Sohn, 2016; D’Augelli et al., 2001; Puckett et al., 2015; Rimes et al., 2019; Van Bergen et al., 2013). As such, additional research is needed to inform efforts to prevent people from outing LGBTQ+ youth and to help families and friends to support LGBTQ+ youth when they come out. Additionally, clinicians are encouraged to consider the nuances of coming out, particularly when working with adolescents, and to help adolescent clients to consider the potential benefits and consequences of disclosing their LGBTQ+ identities to different people. By carefully considering if, when, and how to come out to different people, LGBTQ+ youth can try to identify potential supports in their lives and they can plan for the possibility that some people may not react positive to their disclosure. Finally, as LGBTQ+-affirming policies and laws are associated with decreased suicide risk for youth (Raifman et al., 2017), future work by researchers and practitioners must also target social institutions that perpetuate and maintain stigma toward LGBTQ+ youth in order to provide them with safe and supportive environments that affirm the coming out process.

Highlights:

• Being more open about one’s LGBTQ+ identity may confer risk for suicidality.

• The influence of outness on suicidal ideation may be strongest during adolescence.

• There is a need for LGBTQ+ affirming policies and laws to reduce suicidality.