Sexual Orientation Concealment and Mental Health: A Conceptual and Meta-Analytic Review

• Published in: Psychological bulletin 2020-10, Vol.146 (10), p.831-871
• Main Authors: Pachankis, John E, Mahon, Conor P, Jackson, Skyler D, Fetzner, Benjamin K, Bränström, Richard
• Format: Article
• Language: English
• Subjects: Adult; Anxiety - psychology; Anxiety Disorders; Anxiety Disorders - psychology; Bisexuality; Bisexuality - psychology; Classification; Comorbidity; Concealment; Confidentiality; Cross-Sectional Studies; Defense Mechanisms; Discrimination; Distress; Drug Abuse; Drug Usage; Drug use; Female; Folkhälsovetenskap, global hälsa och socialmedicin; Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi; Gender Identity; Health problems; Human; Humans; Hälsovetenskap; Identity; Internalization; Internalizing disorders; Klinisk medicin; Life course; Major Depression; Male; Measurement; Medicin och hälsovetenskap; Mental Disorders; Mental Disorders - epidemiology; Mental Disorders - etiology; Mental Disorders - psychology; Mental Health; Minority & ethnic groups; Moderators; Psychological distress; Psykiatri; Reliance; Risk Factors; Samhällsvetenskap; Sexual and Gender Minorities - psychology; Sexual and Gender Minorities - statistics & numerical data; Sexual Behavior - psychology; Sexual Minority Groups; Sexual Orientation; Social Stigma; Socialpsykologi; Sociologi; Stigma; Stress; Substance abuse; Substance-Related Disorders - epidemiology; Substance-Related Disorders - psychology; Systematic review
• ISSN: 0033-2909; 1939-1455; 1939-1455
• DOI: 10.1037/bul0000271

Identity concealment affects all sexual minority individuals, with potentially complex mental health implications. Concealing a sexual minority identity can simultaneously generate the stress of hiding, protect against the stress of discrimination, and keep one apart from sexual minority communities and their norms and supports. Not surprisingly, existing studies of the association between sexual orientation concealment and mental health problems show contradictory associations-from positive to negative to null. This meta-analysis attempts to resolve these contradictions. Across 193 studies (n = 92,236) we find a small positive association between sexual orientation concealment and internalizing mental health problems (i.e., depression, anxiety, distress, problematic eating; ESr = 0.126; 95% CI [0.102, 0.151]) and a small negative association between concealment and substance use problems (ESr = −0.061; 95% CI [−0.096, −0.026]). The association between concealment and internalizing mental health problems was larger for those studies that assessed concealment as lack of open behavior, those conducted recently, and those with younger samples; it was smaller in exclusively bisexual samples. Year of data collection, study location, and sample gender, education, and racial/ethnic composition did not explain between-study heterogeneity. Results extend existing theories of stigma and sexual minority mental health, suggesting potentially distinct stress processes for internalizing problems versus substance use problems, life course fluctuations in the experience of concealment, distinct experiences of concealment for bisexual individuals, and measurement recommendations for future studies. Small overall effects, heavy reliance on cross-sectional designs, relatively few effects for substance use problems, and the necessarily coarse classification of effect moderators in this meta-analysis suggest future needed methodological advances to further understand the mental health of this still-increasingly visible population. Public Significance Statement Across 193 studies, sexual orientation concealment demonstrates small positive associations with internalizing mental health problems (i.e., depression, anxiety, distress, problematic eating) and a small negative association with substance use problems, suggesting potentially distinct pathways to these outcomes among sexual minorities. The association between sexual orientation concealment and mental health likely depend