Shortcomings of transgender identity concealment research: a scoping review of associations with mental health

Figures & data

Figure 1. Paper selection process.

Table 1. Characteristics of studies.

Characteristic	Studies (n = 46)
Year of publication
2010–2015	5 (10.9%)
2016–2018	6 (13.0%)
2019–2023	27 (58.7%)
Ahead of print at time of data collection	8 (17.4%)
Location
United States/Canada	23
Europe	9
Asia	4
Australia	3
International	8
Study design(s)
Cross-sectional survey	36
Longitudinal survey	1
Interviews	9
Focus groups	3
Case study	2
Content analysis	1
Role of outness variable(s)
Main subject	20
Broader focus on minority stress	18
Demographic/control variable	4
Theme identified during analysis	4
Average participant age
Range	24.90—48.92
Mean	29.63
Sample size (quantitative papers)
Range	71–27,715

Table 2. Details of disclosure/concealment measurement strategies.

Used in…	Measure	Items	Example prompt, response format	Target groups	Coded as…
Validated scales
17 papers	Nondisclosure (GMSR)	5	“Because I don’t want people to know my gender identity/history, I change the way I walk, gesture, sit, or stand.” 5-point scale: strongly disagree to strongly agree	N/A	Summary variable
van de Grift (2023)	Openness (DSD-specific coping)	4	“I can talk openly to my friends about my condition.” 4-point scale: completely true to not true at all	N/A	Summary variable
Lindley and Budge (2022)^a	Nondisclosure (TNCM)	4	“When meeting new people I avoid disclosing my trans identity.”	N/A	Summary variable
	Strategic gender expression (TNCM)	5	“I use pronouns that are more comfortable for others so that I am not perceived as trans.” 5-point scale: I do not do this to I almost always do this		Summary variable
Osmetti and Allen (2023)^a	Disclosure (NOS)	5	“What percentage of the people in this group do you think are aware that you identify as transgender, non-binary or otherwise gender diverse?” 11-point scale: 0% to 100%	Immediate family, extended family, acquaintances, work / school, strangers	Two summary variables, overall score (outness)
	Concealment (NOS)	5	“How often do you avoid talking about topics related to or otherwise indicating your gender identity (e.g., not discussing your transition, not correcting people who use your deadname or the wrong pronouns) when interacting with members of these groups?” 11-point scale: Never to Always
Non-validated scales and items
Bränström and Pachankis (2021)	Concealment of transgender identity	4	“To how many people among the following groups are you open about yourself being transgender?” 4-point scale: none to all	Family, friends, neighbors, colleagues / schoolmates	Dichotomous summary variable
Flynn and Smith (2021)	Identity concealment	1	“When people in your life assume you are something other than non-binary/genderqueer (such as a man or a woman), how do you respond?” 3-point scale: I usually let them assume… to I always tell them I identify as…	N/A	Dichotomous variable
	Blending	1	“People can tell I’m trans even if I don’t tell them.” 5-point scale: Never to Always		Dichotomous variable
Huffman et al. (2021)	Gender identity openness (Ruggs et al., 2015)	3	“At work, I tell people that I am gender variant if it comes up.” 7-point scale: strongly disagree to strongly agree	N/A	Summary variable
Jardas et al. (2023)	“Outness (Concealment)”	3	“Who knows about your gender identity?” Checkboxes	Parents, friends, teachers	Summary variable
Kcomt et al. (2020)	Disclosure	8	“How many people in each group below currently know you are trans?” 4-point scale: None know that I am trans to All know that I am trans or I currently have no people like this in my life.	Immediate family, extended family, LGBT friends, cishet friends, boss/manager, coworkers, classmates, healthcare providers	Summary variable
	Visual conformity	1	“People can tell I am transgender even if I don’t tell them.” 5-point scale: Never to Always	N/A	Score (sorted into three categories)
McKay and Watson (2020)	“Degree of disclosure (outness)”	3	“For each of the following groups, how many people currently do you think know of your transgender or non-binary identity?” 5-point scale: None to All	Family, LGBTQ friends, healthcare providers	3 scores
Strain and Shuff (2010)	Outness Demographics Questionnaire	14	“With respect to my overall identity, being transsexual is of central importance.” 5-point scale: strongly agree to strongly disagree	N/A	Summary variable of 4 items
	Outness Attitude Scale (Bosker, 2002)	15	Not provided. 5-point scale: strongly agree to strongly disagree or very important to not at all important		Summary variable
	Openness (Franke and Leary, 1991)	1	“How open are you about your transsexualism?” 5-point scale: not provided.		Score
Taube and Mussap (2022)^a	Disclosure of gender identity	3	Not provided.	Parents, siblings, friends	3 dichotomous variables
Ünsal et al. (2023)	Identity disclosure	8	“To how many people among the following groups are you open about yourself being [RESPONDENT CATEGORY]” 4-point scale: None to All or Does not apply to me.	Family, friends, neighbors, medical staff, schoolmates, superior, colleagues, customers	Summary variable
de Vries et al. (2023)	Being “out” in community	1	Not provided. 3-point scale: No one to All.	N/A	Score
Wall et al. (2022)	Outness	2	“To what degree are you open (out) with your transgender identity in your personal/social life including with friends and family?” 7-point scale: none of the time to all of the time	Friends and family, workers or classmates	Summary variable
White Hughto et al. (2020)	Social gender affirmation	1	Not provided.	Family members or coworkers	Dichotomous variable
Yang et al. (2016)	Disclosure to family members	1	“Do your family members know that you are a transgender woman?” 3-point scale: Yes, not sure, no	Family members	Score
	Disclosure to friends	1	“How many of your friends know you are a transgender woman?” 4-point scale: none to all	Friends	Score
Zeluf et al. (2016)	Openness with being trans	1	“To what extent are you open with the fact that you are trans?” 4-point scale: Always open to Never open or Trans identity shows.	N/A	Score
Zhou et al. (2021)	Disclosure status	5	“Did you come out to your father?” Yes/no.	Father, mother, brother, sister, grandparents.	N/A^b

^a Ahead of print at time of data collection. ^bCorrelation was based on mental health before and after coming out. GMSR = Gender Minority Stress and Resilience Measure (Testa et al., 2015), TNCM = Trans and Nonbinary Coping Measure (Lindley and Budge, 2022), NOS = Nebraska Outness Scale (Meidlinger and Hope, 2014).

Table 3. Quantitative associations between disclosure or concealment and mental health in reviewed papers.

Citation	Location	Sample	Design	Focus	Outness measure	Key findings
Nondisclosure/concealment
Algarin et al.(2024)^a	Mexico	151	Cross-sectional survey	Minority stress (partial)	Nondisclosure (GMSR)	Small positive correlations with depression (CES-D-10), life stress (PSS), PTSD (PC-PTSD).
Bränström and Pachankis (2021)	Europe	6771	Cross-sectional survey	Main	Concealment of transgender identity	Mediated a moderate negative effect of structural stigma on life satisfaction and a small positive effect via reduced discrimination.
Exline et al. (2021)	Intl.	305	Cross-sectional survey	Minority stress (full)	Nondisclosure (GMSR)	Small negative correlation with self-esteem (RSES).
Flynn and Bhambhani (2021)	USA^b	402	Cross-sectional survey	Minority stress (partial)	Nondisclosure (GMSR)	Moderate negative correlation with life satisfaction (SWLS) moderated by psychological flexibility and inflexibility (MPFI).
Flynn and Smith (2021)	USA	9769	Cross-sectional survey	Main	Concealment, blending	In a nonbinary sample, “low concealers” had higher victimization and psychological distress (K6), “blenders” had lower victimization and higher distress.
Helsen et al. (2022)	The Netherlands, Flanders	143	Cross-sectional survey	Minority stress (partial)	Concealment (GMSR)	Did not predict mental health difficulties (GHQ-12) directly or indirectly through community connectedness (GMSR) or gender nonconformity.
Hidalgo et al. (2019)	USA	258	Cross-sectional survey	Minority stress (full)	Nondisclosure (GMSR)	Small positive correlations with depression and anxiety (YI).
Jäggi et al. (2018)	Switzerland	143	Cross-sectional survey	Minority stress (full)	Nondisclosure (GMSR)	Moderate positive correlation with depression (ADS-K; German-language version of CES-D).
Jones et al. (2022)^a	USA	292	Cross-sectional survey	Minority stress (full)	Nondisclosure (GMSR)	Small negative correlation with post-traumatic growth (PTGI-S), did not mediate any relationship between distal stress and posttraumatic growth.
Lindley et al. (2021)	Intl.	297	Cross-sectional survey	Minority stress (partial)	Nondisclosure (GMSR)	Small positive correlation with problematic alcohol use (AUDIT).
Lindley and Budge (2022)^a	Intl.	497	Scale development	Main	Nondisclosure (TNCM)	Small negative correlations with anxiety but not depression or stress (DASS-21).
					Strategic gender expression (TNCM)	Small positive correlations with depression, stress and anxiety (DASS-21).
Lindley and Galupo (2020)	Intl.	297	Cross-sectional survey	Minority stress (full)	Concealment (GMSR)	Small to moderate positive correlations with gender dysphoria factors (GCLS).
Lloyd et al. (2019)	England	358	Longitudinal survey	Minority stress (partial)	Nondisclosure (GMSR)	Small positive correlations with depression, anxiety, and stress (DASS-21), but failed to predict them over a 12-month period or mediate a relationship between discrimination (GMSR) and DASS-21 scores in full structural model.
Puckett et al. (2024)^a	USA	158	Cross-sectional survey	Minority stress (full)	Nondisclosure (GMSR)	No correlations with depression or anxiety (PROMIS).
Scandurra et al. (2020)	Italy	203	Cross-sectional survey	Minority stress (full)	Nondisclosure (GMSR)	Small positive correlations with depression (SMDA), anxiety (SMGAD), and stress (PSS).
Tebbe et al. (2022)	USA	301	Cross-sectional survey	Minority stress (partial)	Nondisclosure (GMSR)	Small positive correlations with depression (CES-D), anxiety (BuAI), and hopelessness (HHH). Sense of belonging (SBI) mediated its effect on anxiety for a subset of participants only.
Testa et al. (2015)	USA, Canada	844	Scale development	Minority stress (full)	Nondisclosure (GMSR)	Small positive correlations with depression (CES-D), anxiety (SPIN), and perceived life stress (PSS).
Testa et al. (2017)	USA, Canada	816	Cross-sectional survey	Minority stress (full)	Nondisclosure (GMSR)	Small positive correlation with suicidal ideation (SIS), not mediated by belongingness and burdensomeness (INQ-12). Did not mediate a relationship between any distal stress factor and suicidal ideation.
Watson et al. (2019)	USA	369	Scale development	Other	Nondisclosure (GMSR)	Small positive correlations with psychological distress (K-10) and perceived stress (PSS-S).
Disclosure/outness
van de Grift (2023)	Europe	903	Cross-sectional survey	Main	Condition openness (DSD-specific Coping)	Small negative effects on anxiety and depression (HADS) mediated by self-esteem (RSES) and life satisfaction (WHOQOL).
Huffman et al. (2021)	USA	263	Cross-sectional survey	Main	Gender identity openness	Small positive correlation with life satisfaction (SWLS).
Jardas et al. (2023)	USA	1943	Cross-sectional survey	Minority stress (full)	Outness	Small negative correlation with depression (CES-D), no correlation with anxiety (GAD-7). Mediated relationships between identifying as Asian and higher depression and anxiety.
Kcomt et al. (2020)	USA	27,715	Cross-sectional survey	Other	Disclosure, visual conformity	Participants with lower levels of disclosure were more likely to engage in frequent binge drinking. No associations with visual conformity.
McKay and Watson (2020)	USA	3624	Cross-sectional survey	Main	Disclosure	Less depression symptoms (KADS) and higher self-esteem (RSES) observed in participants who disclosed to “most” or “all” healthcare providers.
Osmetti and Allen (2023)^a	Australia	202	Cross-sectional survey	Main	Outness (NOS)	Moderate positive effect on psychological wellbeing (PWBS) partially mediated by authenticity (T-PIM) but not harassment.
Strain and Shuff (2010)	USA	105	Cross-sectional survey	Main	Outness Experiences	No correlations with depression (BDI-II), anxiety (BeAI), or self-esteem (RSES).
					Outness Attitudes	Small negative correlations with depression, anxiety, and self-esteem.
					Openness	Moderate negative correlations with depression and anxiety, small positive correlation with self-esteem.
Ünsal et al. (2023)	Europe	15,845	Cross-sectional survey	Main	Identity disclosure	Negatively mediated an association between community participation and depression, not moderated by country-level structural stigma.
Taube and Mussap (2022)^a	Intl.	951	Cross-sectional survey	Main	Outness	Small positive correlation with personal wellbeing (PWI-A), no direct correlation with psychological adjustment (DASS-21). Indirect effects on both through social support (MSPSS).
de Vries et al. (2023)	Ireland	279	Cross-sectional survey	Other	Being “out” in community	Moderately higher mental distress (DASS-21) in participants with lower levels of outness.
Wall et al. (2022)	USA	342	Cross-sectional survey	Main	Outness	No bivariate correlation with psychological distress (BSI). Direct negative effect on psychological distress moderated by community connectedness (GMSR) observed only when accounting for indirect positive effect through discrimination (GMSR).
White Hughto et al. (2020)	USA	288	Cross-sectional survey	Main	Social gender affirmation	Negative correlations with depression, anxiety, and stress (DASS-21) in multivariable models.
Yang et al. (2016)	China	209	Cross-sectional survey	Main	Disclosure of gender identity	Significantly more anxiety symptoms (SAS) for participants who had not disclosed to any friends. No effect for disclosure to family. Contributions to anxiety symptoms were not significant in overall regression models.
Zeluf et al. (2016)	Sweden	796	Cross-sectional survey	Other	Openness with being trans	No association with quality of life.
Zhou et al. (2021)	Japan	71	Cross-sectional survey	Main	Disclosure	Self-evaluation of mental state after coming out significantly higher than mental state before coming out.

^a Ahead of print at time of data collection. ^bNationality of sample not specified, assumed from author background. Unabbreviated names of mental health tools available in Appendix C.

Table

	Field	Query
S1	Index terms	"Transgender" OR "Transsexualism" OR "Gender Transition" OR "Gender Reassignment" OR "Gender Affirming Care" OR "Gender Nonbinary" OR "Gender Nonconforming" OR "Two-Spirit" OR "Intersex"
S2	Title, abstract, and keywords	"transgender*" OR "transexual*" OR "transsexual*" OR "trans people" OR "trans men" OR "trans women" OR "trans*men" OR "transfem*" OR "transmasc*” OR "trans spectrum" OR "gender diverse" OR "TGD" OR "TGNB" OR "gender minorit*" OR "gender nonconforming" OR "gender non-conforming" OR "nonbinary" OR "non-binary" OR "genderfluid" OR "gender-fluid" OR "genderqueer" OR "gender-queer" OR "two-spirit" OR "intersex"
S3	Index terms	"Coming Out"
S4	Title, abstract, and keywords	"outness" OR "disclos*" OR "nondisclos*" OR "conceal*" OR "openness" OR "closet*" OR "coming out"
S5	Index terms	"Mental Health" OR "Emotional Health" OR "Mental Disorders" OR "Affective Disorders" OR "Well Being" OR "Life Satisfaction" OR "Quality of Life" OR "Mental Status" OR "Self-Stigma" OR "Major Depression" OR "Anxiety" OR "Distress" OR "Gender Dysphoria" OR "Suicidal Behavior" OR "Attempted Suicide" OR "Suicidal Ideation" OR "Suicide" OR "Nonsuicidal Self-Injury"
S6	Title, abstract, and keywords	("mental" OR "psychological" OR "behavioral" OR "behavioral" OR "affective" OR "mood") N0 ("health" OR "wellbeing" OR "well-being" OR "illness" OR "suffer*" OR "adjustment" OR "disorder*") OR "distress*" OR "emotion*" OR "mood*" OR "affect" OR "depress*" OR "anxi*" OR "dysphoria" OR "suicid*" OR "self-injur*" OR "self-harm" OR "NSSI" OR "life satisfaction" OR "quality of life"
S7		S1 OR S2
S8		S3 OR S4
S9		S5 OR S6
S10		S7 AND S8 AND S9

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Data availability statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request.