Military Service Members’ Satisfaction With Outness: Implications for Mental Health

Abstract

This study is among the first examining lesbian, gay, and bisexual (LGB) service members in the United States following the “don’t ask, don’t tell” policy repeal. Higher levels of outness predict better mental health among general LGB populations. The military environment, like other traditional/conservative settings, may alter this relation; however, no data are available on outness among LGB service members in the United States. We examined 236 service members’ level of outness and satisfaction with outness in relation to depression and anxiety symptoms. Results revealed greater level of outness was related to higher satisfaction with outness, with each variable related to better mental health. Importantly, satisfaction fully mediated the relation between level of outness and mental health, indicating satisfaction to be a more salient predictor than level alone. Findings relevant to military policy makers and health-care providers are discussed along with recommendations for advancement of research into outness among LGB people.

Keywords

minority issues military culture LGB outness psychology

Over the past few decades, research on mental health among lesbian, gay, and bisexual (LGB) populations (i.e., sexual minorities) has indicated elevated rates of psychological distress. A large meta-analysis revealed risk of depression and anxiety was more than 1½ times greater among LGB individuals when compared with heterosexual individuals (King et al., 2008). Recently, Barnes, Hatzenbuehler, Hamilton, and Keyes (2014) reported that LGB individuals experience greater current and lifetime presence of any mood disorder, anxiety, and psychological comorbidities than heterosexual counterparts. However, while sexual minorities have high risk of distress, the majority does not meet diagnostic criteria (King et al., 2008).

Literature also provides evidence that mental health disorders including depression and anxiety disproportionately impact military personnel compared to civilians (Ramchand, Karney, Osilla, Burns, & Caldarone, 2008). In fact, a recent study revealed that over one fourth of a sample of deployed and nondeployed U.S. soldiers met criteria for a mental health disorder (Kessler et al., 2014). Combat exposure is the strongest predictor of mental health problems among deployed military personnel (Ramchand, Rudavsky, Grant, Tanielian, & Jaycox, 2015); however, many factors beyond combat contribute to increased prevalence, including preexisting health problems and adjustment difficulties (MacCoun & Hix, 2010).

Limited research has been completed to date examining mental health of LGB service members in the United States largely due to limited access to this population under the “don’t ask, don’t tell” (“DADT”) policy. LGB veterans have been found to be more likely than a general sample of veterans to screen positive for depression and post-traumatic stress disorder (PTSD; Cochran, Balsam, Flentje, Malte, & Simpson, 2013). Lesbian and bisexual women veterans report higher rates of mental distress and poorer physical health compared to sexual minority, nonveteran women (Blosnich, Foynes, & Shipherd, 2013). Additionally, greater anxiety about concealment of sexual identity predicted higher rates of PTSD and depression (Cochran et al., 2013). In summary, in line with literature on LGB, military, and LGB veteran mental health, it is likely that LGB service members in the United States experience elevated rates of psychological distress–related minority stressors as well as military-related stressors that negatively impact mental health.

Outness and Mental Health

Outness, the degree to which an LGB individual has disclosed their sexual identity to others, exists on a continuum ranging from active concealment to direct disclosure (Mohr & Fassinger, 2000). The current evidence elucidates a distress ameliorative impact of disclosure, particularly as it relates to increased social support (Balsam & Mohr, 2007; Morris, Waldo, & Rothblum 2001), reduced internalized stigma, and reduced distress related to concealment (Rosario, Hunter, Maguen, Gwadz, & Smith, 2001). Negative health consequences of concealing one’s sexual identity are also well-documented in LGB research (Hatzenbuehler, 2010; Hatzenbuehler, McLaughlin, Keyes, & Hasin, 2010). Costs of concealment include restriction of interpersonal relationships, decreased relatedness in key institutions (e.g., jobs), increased risky behaviors, decreased self-esteem, and increased distress (Corrigan & Matthews, 2003).

Recent studies with LGB veterans of the U.S. Armed Forces provide some initial insight into implications of outness in the military. Retrospective research with convenience samples of LGB veterans revealed that concealment increased psychological distress and mental health disorder prevalence, elevated minority stress, and disrupted interpersonal relationships (Cochran et al., 2013; Estrada, Dirosa, & Decostanza, 2013; Moradi, 2009). On a military unit level, sexual identity concealment was negatively related to unit cohesion, while disclosure may have a positive role in unit cohesion (Moradi, 2009).

Despite the evidence for overall positive mental health implications of disclosure in the general LGB population, these associations are generally weak (e.g., r = .19; Balsam & Mohr, 2007), indicating these effects may be impacted by factors beyond just the level of outness. To this end, research into the positive implications of disclosure describes connection to social support, reduction in internalized stigma, and decrease in isolation, as they relate to positive mental health outcomes (Corrigan & Matthews, 2003; Meyer, 2003). Correspondingly, where documented, negative consequences of disclosure are more frequent in environments where LGB people are stigmatized by discriminatory societal norms, policies, or beliefs (Hatzenbuehler, 2010). For example, disclosure in regions dominated by political conservatism and/or religious fundamentalism may beget negative health outcomes (Swank, Frost, & Fahs, 2012). Due to the long-standing policy of DADT, it may be that LGB service members in the United States experience similar minority stressors subsequent to disclosure comparable to LGB individuals in these more conservative/fundamentalist regions.

Satisfaction With Outness

Satisfaction with outness may represent a construct capable of capturing some of the variance in the relationship between level of outness and mental health by accounting for individuals’ appraisal or judgment of their level of outness based on contextual factors. Currently, no empirical literature exists on satisfaction with outness, making this a novel construct without a clear operational definition. Theoretically, McCarn and Fassinger (1996) suggest the final stage of sexual identity development in LGB individuals consists of a synthesis of minority sexual identity within an overall self-identity. In this stage, individuals may choose where and how to disclose their sexual identity for important contextual reasons and, as long as the choice is purposefully addressed, a concealed individual may be no different with regard to identity development (and mental health correlates) than a fully disclosed person.

It becomes important then to efficiently measure latent factors of identity and contextual influence to more accurately understand the role of outness in LGB mental health. Satisfaction with outness may be a construct capable of doing this, as it represents an individual’s subjective appraisal of their level of outness. Although level of outness and satisfaction are likely positively correlated, one may be highly satisfied with their level of outness whether their level is high or low. In this way, satisfaction with outness may, indeed, partially explain the relation between outness and mental health.

Current Study

The current study is one of the first published on currently serving LGB service members in the United States. The primary goal was to examine level of outness and satisfaction with outness, as they relate to mental health symptoms. To accomplish this, the unique relationships between level of outness and satisfaction with outness and mental health (depression and anxiety symptoms) were examined. Subsequently, the mediating role of satisfaction with outness on the relation between outness and mental health symptoms was ascertained.
Hypothesis 1: Outness will be negatively associated with symptoms of (a) depression and (b) anxiety.

Hypothesis 2: Satisfaction with outness will be negatively associated with symptoms of (a) depression and (b) anxiety.

Hypothesis 3: Satisfaction with outness mediate the relationship between outness and symptoms of (a) depression and (b) anxiety.

Method

Participants included 236 Active Duty, Reserve, and National Guard service members 18 years of age or older who identified as LGB. Five hundred twenty-two individuals initially engaged with this anonymous, online survey between June 2014 and May 2015 by clicking on a link to the survey and advancing beyond the informed consent document. The first three questions represented the inclusion questions and assessed age, military status, and sexual identity. Individuals who were younger than 18 years of age did not identity as lesbian, gay, or bisexual or identified any military status other than Active Duty, Reserve, or National Guard were excluded and were routed to the end of the survey. Other respondents who were excluded discontinued the survey before providing a minimum of essential demographic information. Recruitment utilized paid and unpaid advertisements, postings at military installations, the online publication of the Military Times, social networking sites, listservs, and peer-to-peer recruiting.

Participants accessed a secure, web-based survey where they were provided detailed information about the purpose of the study and investigators and were prompted to provide consent whether they wished to participate. At the end of the survey, a debriefing page provided crisis resources and means to refer others. The secure survey did not collect identifying information, and each participant was assigned a unique respondent identification code. Data were analyzed using IBM SPSS Version 24. Participant data were entered according to unique identification code only.

Measures

Demographics

Items assessed race, ethnicity, age, sex, sexual identity, education, military status, branch of service, and pay grade.

Generalized Anxiety Disorder 7 (GAD-7)

Anxiety symptoms were measured using the GAD-7, a widely used screener for anxiety disorders (Kroenke, Spitzer, Williams, Monahan, & Lowe, 2007). Instructions ask how often participants have been bothered by problems such as feeling nervous, anxious, or on edge and not being able to stop or control worrying over the past 2 weeks. Responses range from 0 (not at all) to 4 (nearly every day). Total scores range from 0 to 21, with scores of 5, 10, and 15 representing cutoff points for mild, moderate, and severe anxiety, respectively. α for the GAD-7 in this sample was .92.

Patient Health Questionnaire (PHQ-8)

Depressive symptoms were measured using the PHQ-8 (Kroenke, Spitzer, & Williams, 2001). Instructions ask how often participants have been bothered by problems such as little interest or pleasure in doing things and feelings down, depressed, or hopeless over the past 2 weeks. Responses range from 0 (not at all) to 4 (nearly every day). Total scores range from 0 to 24, with scores of 5, 10, 15, and 20 indicating mild, moderate, moderately severe, and severe depression, respectively. An α for the PHQ-8 in this sample was .91.

Outness Inventory (OI)

A modified version of the OI was used to assess level of outness (Mohr & Fassinger, 2000). The original OI is an 11-item self-report scale, assessing the extent to which individuals have disclosed their sexual identity to family, religious communities, and the world. Three additional items assessed outness to medical providers, mental health providers, and military members. Each item is rated on a 7-point scale from 1 (person definitely does not know) to 7 (person definitely knows and it is openly talked about). The mean score for the overall OI (all 14 items) as well as the item score for the question assessing outness to military members is reported here. An α for the 14-item OI in this sample was .91.

Satisfaction with outness

Satisfaction with outness was measured by a single item inquiring, “In general, how satisfied are you with your level of outness?” Participant responses ranged from 1 (very dissatisfied) to 5 (very satisfied). This item was developed uniquely for this study, given the novelty of research into this construct, and was constructed as a global assessment, measuring evaluation of satisfaction with outness overall.

Results

Demographic characteristics of service members in the current study are presented in Table 1. With regard to dependent variables, depression was assessed as a continuous variable represented by total PHQ-8 score. Participants’ responses ranged from 0 to 24 with a mean score of 5.99 (standard deviation [SD] = 5.77), representing a mild degree of depression. Anxiety was assessed as a continuous variable represented by total GAD-7 score. Participants’ responses ranged from 0 to 21 with a mean of 5.91 (SD = 5.54), representing a mild degree of anxiety. No significant differences were observed between men and women with regard to depression or anxiety. Correlations among study variables and salient demographic variables are reported in Table 2.

Table 1.
Demographic Characteristics of Participants.

Characteristic % Characteristic %

Age (M) 30.12 Uniform branch of service

Gender Air Force 27.0

Female 26.1 Army 24.0

Male 71.8 Coast Guard 3.0

Nonbinary 2.1 Marines 7.7

Sexual identity Navy 37.3

Lesbian 21.9 Current military pay grade

Gay 67.8 Enlisted 54.0

Bisexual 10.3 Warrant officer 0.8

Race Officer 44.3

American Indian or Alaskan Native 1.3 Highest level of education

White or Caucasian 88.8 High school/GED 8.6

Asian 3.0 Some college/trade school 25.3

Black or African American 6.0 Associate’s degree 9.9

Native Hawaiian or Pacific Islander 2.1 Bachelor’s degree 32.6

Other 2.6 Master’s or doctorate 23.5

Ethnicity

Hispanic or Latino 11.6

Not Hispanic or Latino 85.8

Note. n = 236

Table 2.
Descriptive Summary Correlations Among Study Variables and Key Demographics.

Variables 1 2 3 4 5 6 7

1. Depression —

2. Anxiety .81 —

3. Outness −.18 −.12 —

4. Military outness −.06 −.04 .78 —

5. Satisfaction −.32 −.27 .56 .44** —

6. Age −.09 −.13 −.05 −.15* −.12 —

7. Education −.29 −.25 .01 −.13* −.01 .54 —

8. Pay grade −.35 −.36** −.01 −.16* −.001 .49 .80

Mean 5.99 5.91 4.63 4.39 3.87 — —

SD 5.77 5.54 1.46 2.12 1.29 — —

Range 0–24 0–21 1–7 1–7 1–5 — —

Note. SD = standard deviation.

*p < .05. **p < .01

Level of outness was assessed as a continuous variable represented by a mean of the 14 OI items. Previous research (Mohr & Fassinger, 2000) has allowed for one to two missing responses in the OI. We then analyzed the single item assessing outness specifically in the military context to simultaneously capture an aggregate of the respondent’s outness to military members while limiting the scope in specificity to military members only (i.e., not to include colleagues or supervisors in other employment contexts). In the current sample, participants reported higher average scores on overall level of outness (m = 4.63, SD = 1.46) in comparison to scores on level of outness to other military members (m = 4.39, SD = 2.12; t = −2.71, p < .01). Mean satisfaction with outness was 3.87 (SD = 1.29).

Primary Analyses

Following bootstrapping procedures outlined by Preacher and Hayes (2004), analyses were conducted to examine the relations between level of outness, satisfaction with outness, and mental health symptoms, as well as to assess whether satisfaction statistically mediated the relation between level of outness and mental health. The mediated effect is significant if the 95% confidence interval (CI) does not contain zero (Preacher & Hayes, 2004). Results are based on 5,000 bootstrapped samples, and limitations based on sampling methodology will be discussed. Separate analyses were conducted for each symptom measure.

With regard to the direct effects of outness on mental health symptoms, greater outness significantly predicted higher symptoms of depression (b = −0.71, standard error [SE] = .25; t = −2.77, p < .01) and approached significance in its prediction of anxiety symptoms (b = −0.47, SE = .25; t = −1.90, p = .058). A linear relation emerged between outness and satisfaction with outness revealing greater outness also significantly predicted greater satisfaction (b = 0.50; SE = .05; t = 10.20, p < .001). Last, greater satisfaction significantly predicted lower symptoms of depression (b = −1.42; SE = .33; t = −4.30, p < .001) and anxiety (b = −1.25; SE = .32; t = −3.87, p < .001).

In the full mediation models (Figures 1 and 2), the predictors (outness and satisfaction) accounted for 10% of the variance in depression symptoms, F(2, 233) = 13.37, p < .001, R ² = .10, and 7% of the variance in anxiety symptoms, F(2, 233) = 9.39, p < .001, R ² = .07. Notably, outness was no longer a significant predictor of symptoms of depression (b = −0.002; SE = .30, t = −0.008, p > .05) after controlling for the mediator, satisfaction with outness, with a 95% CI [.08, .23]. With regard to anxiety symptoms, the indirect effect of outness through satisfaction was significant with a 95% CI [.07, .21].

Figure 1.
Mediation model for outness, satisfaction with outness, and depression.

Figure 2.
Mediation model for outness, satisfaction with outness, and anxiety.

Discussion

This study represents the first effort to examine the experiences of sexual minority service members since the 2011 repeal of DADT, which permitted LGB military members to serve openly. Findings revealed most participants had disclosed their sexual identity in most, if not all, contexts including to other military members. Average outness was moderate in this sample and over 95% of the sample reported at least some degree of outness. Level of outness to other service members was significantly lower than overall level of outness; however, mean level of outness to military members was in the moderate range, and over 72% reported at least some outness to military members.

We posited that, despite a traditionally adverse environment in the military for LGB individuals (Johnson, Rosenstein, Buhrke, & Haldeman, 2015), the positive implications of disclosure (i.e., high outness) would yield a net positive influence on mental health. This hypothesis was mostly supported, as higher outness was significantly associated with lower depression symptoms and approached significance in relation to lower anxiety symptoms. Overall, findings are consistent with studies of LGB veterans, revealing concealment (i.e., low outness) is associated with greater psychological distress (Cochran et al., 2013; Estrada et al., 2013).

Of note, level of outness to military members was not significantly correlated with mental health symptoms. This may reflect ongoing negative consequences of outness in a more traditionally conservative/fundamentalist environment like the military (e.g., prejudice, victimization) or the salience of sexual identity among many LGB service members. Further research is warranted to examine such mechanisms that cause outness in the military to function differently than overall outness.

As a first step to this end, findings of the current study revealed satisfaction with outness (across life contexts) was negatively associated with depression and anxiety symptoms—a stronger relationship was then observed between level of outness and mental health. Participants in this sample were generally satisfied with their level of outness. However, a significant minority reported dissatisfaction with current levels of outness. Of note, level of outness and satisfaction with outness were only modestly correlated. Satisfaction does then appear to be a unique construct and one that is, in fact, a better predictor of mental health than level of outness alone.

Most importantly, satisfaction with outness fully accounted for the relation between outness and depression and a significant indirect effect of outness on anxiety through satisfaction was observed. Although satisfaction with outness was not assessed in relation to level of outness to military members specifically, this construct is of particular interest to LGB service members due to the contextual factors described above. This novel finding necessitates an essential shift in our understanding of the broader relationship between outness and mental health.

Limitations

Several limitations need to be considered in the interpretation of these results. First, this was a nonrandom convenience sample recruited primarily online. While this study had participation/representation from service members in all branches of the Department of Defense (2014), proportions did not match the current composition of the U.S. Armed Forces. Additionally, the current sample included a majority of individuals identifying as White, older, and/or higher ranking—all of which may potentially related to higher outness, satisfaction, and mental health. Results should, therefore, be interpreted with caution when generalizing to younger, junior ranking, or racial/ethnic minority individuals. In previous LGB research, individuals who are more out have traditionally been more responsive to this type of research (see Institute of Medicine, 2011). As such, service members who are not out or not satisfied with their outness may be underrepresented, skewing data with the majority of participants reporting greater level of outness and satisfaction with outness as well as better overall mental health. To this end, differential response rates could, in fact, be an indicator of different levels of outness and satisfaction. It is, therefore, possible the relations revealed herein are more robust in the diverse population of LGB service members.

With estimates between 66,000 (Rostker, Hosek, & Vaiana, 2011) and 71,000 people (Gates, 2010) in the current Armed Forces identifying as sexual minorities, it may have been expected that more individuals would have participated in the survey, given the broad efforts at advertisement and recruitment. Although it is commonly difficult to get service member participation in research due to frequent internal data collection, it may be that our modest participation rate reflects a continued suppressive environment for LGB individuals in the military, salience of sexual identity among LGB service members, or a combination of such personal and environmental factors. Again considering sample demographics, it is possible that, to the degree a suppressive environment remains for LGB service members, this may disproportionately affect younger, junior ranking, and racial/ethnic minority individuals. With regard to identity salience, identity development in younger participants may be in earlier phases with minority sexual identity less integrated. Moreover, in a scenario in which an individual’s identity as a service member (or another identity) notably outweighs the strength or salience of their sexual identity, disclosure may be less important or less reinforced.

Importantly, this study examined outness and satisfaction with outness as global constructs, representing participants’ experiences across life contexts. While outness to military members was reported, satisfaction with outness to military members was not assessed. Expanding inquiry into satisfaction will be required to understand whether satisfaction with outness to military members functions similarly to satisfaction with overall outness described here. The overall outness score was utilized in primary analyses to most closely align with extant literature on LGB populations; however, as research into LGB service members progresses, a more refined focus on military-specific experiences will be essential.

Future Directions

With regard to clinical implications, this study supports the clinical standard of care with sexual minorities (American Psychological Association, 2012), which describes the importance of addressing disclosure when working with LGB individuals. In the shifting military social climate, providers should inquire about sexual identity and assess negative expectations about disclosure. These recommendations are consistent with those of Goldbach and Castro (2016), who advocate for care that creates an open health-care environment, encouraging LGB service members to continue to interact with and the military health-care system. For military and nonmilitary health-care providers, it is important to assess satisfaction beyond level of outness alone and seek to resolve conflicts between level and satisfaction. It is also essential to assess distress related to outness so as not to over interpret concealment as problematic if satisfaction is high.

Future research should make an effort to recruit larger and more diverse samples of sexual minority service members, seeking more representation from people of color, bisexual individuals, younger, and more junior enlisted service members, and service members with lower outness. The construct of satisfaction with outness represents an important area for future research for sexual minority health more broadly. Future research on minority stress among LGB people should incorporate questions about satisfaction with outness along with frequently utilized measures of (degree of) outness. It would most notably extend these findings to add retrospective and longitudinal data comparing levels of outness and satisfaction with outness pre- and post-DADT repeal.

Conclusion

The information provided by the 236 participants in this study grants unique insight into the experiences and perspectives of these individuals, giving voice to these long-silenced service members. Notwithstanding the aforementioned limitations, this study provides preliminary support for satisfaction with outness contributing to mental health symptoms (depression and anxiety) among LGB military service members. If replicated in larger, longitudinal studies, these findings would suggest satisfaction represents a more salient predictor of positive mental health than level of outness alone. As identity development theorists have long posited that outness may intentionally vary across contexts (McCarn & Fassinger, 1996), empirical research with LGB populations—particularly those in conservative, heterocentric environments—would benefit from shifting focus from level of outness to satisfaction with outness. To this end, refining assessment of satisfaction in each context will also be helpful. Looking ahead, it is hoped these developments provide meaningful information to the leaders, researchers, and clinicians serving the now growing population of LGB military service members.

Characteristic	%	Characteristic	%
Age (M)	30.12	Uniform branch of service
Gender	Air Force	27.0
Female	26.1	Army	24.0
Male	71.8	Coast Guard	3.0
Nonbinary	2.1	Marines	7.7
Sexual identity	Navy	37.3
Lesbian	21.9	Current military pay grade
Gay	67.8	Enlisted	54.0
Bisexual	10.3	Warrant officer	0.8
Race	Officer	44.3
American Indian or Alaskan Native	1.3	Highest level of education
White or Caucasian	88.8	High school/GED	8.6
Asian	3.0	Some college/trade school	25.3
Black or African American	6.0	Associate’s degree	9.9
Native Hawaiian or Pacific Islander	2.1	Bachelor’s degree	32.6
Other	2.6	Master’s or doctorate	23.5
Ethnicity
Hispanic or Latino	11.6
Not Hispanic or Latino	85.8

Variables	1	2	3	4	5	6	7
1. Depression	—
2. Anxiety	.81**	—
3. Outness	−.18**	−.12	—
4. Military outness	−.06	−.04	.78**	—
5. Satisfaction	−.32**	−.27**	.56**	.44**	—
6. Age	−.09	−.13	−.05	−.15*	−.12	—
7. Education	−.29**	−.25**	.01	−.13*	−.01	.54**	—
8. Pay grade	−.35**	−.36**	−.01	−.16*	−.001	.49**	.80**
Mean	5.99	5.91	4.63	4.39	3.87	—	—
SD	5.77	5.54	1.46	2.12	1.29	—	—
Range	0–24	0–21	1–7	1–7	1–5	—	—

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Wyatt R. Evans

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