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Impact of change in sexual identity on mental health risks among sexual minority adolescents

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Impact of change in sexual identity on mental health risks among sexual minority adolescents

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IMPACT OF CHANGE IN SEXUAL IDENTITY ON MENTAL HEALTH RISKS AMONG
SEXUAL MINORITY ADOLESCENTS

By

Ankur Srivastava

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(SOCIAL WORK)

May 2021
ii
Dedication
To Mummy and Papa

iii
Acknowledgements
The saying, ‘It takes a village to raise a child’, is most befitting to this experience. This
journey would not be possible without the support of so many people. These past six years have
been the most challenging, yet immensely valuable in shaping my academic and research
trajectory. This is an earnest attempt to acknowledge the few of many who supported me and my
work.
I am deeply appreciative of Dr. Jeremy Goldbach, for investing an immense amount of
time and energy into my education; and for believing in me. You have added purpose and
meaning to my work by being an exemplary mentor and researcher that I continue to admire. To
Drs. Eric Rice (my unofficial mentor) and Jordan Davis, my statistics gurus, for your patience
and guidance as I worked through my analytic and modeling struggles. And, to Drs. Stanley
Huey, Jade Winn and Michael Hurlburt, for your invaluable guidance and constant support.
To Lindsey, Yoewon, Jose and Joshua, for sharing this journey with me.
I am humbled by the support my family and friends have given me through all these
years. To my parents, sister and brother-in-law, for encouraging me to follow my dreams; to
Vaishno, Rashi and Durgesh, for their untiring support and friendship, to Vicky sir, for believing
in me; and to Sheetal, Gauri and Andy, for being my family here in California.
To Swapnil, for your unwavering love and support; and to Kalpesh, for holding my hand
to the finish line. To my niece, Cherry, for giving me a reason to smile every day!
And to all the sexual minority participants in this study, for their contribution to science
and their resilience against all the odds.

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Table of Contents

Dedication ..................................................................................................................................... ii
Acknowledgements ...................................................................................................................... iii
List of Tables .................................................................................................................................vi
List of Figures ............................................................................................................................. vii
Abstract ...................................................................................................................................... viii

Chapter 1: Introduction and Background ......................................................................................1
Dissertation Project ................................................................................................3
Background ............................................................................................................4
Theoretical Frameworks .........................................................................................8
References ............................................................................................................11
Chapter 2: Sexual identity change and associated health outcomes among adolescents and
young adults: A Systematic Review.............................................................................................18
Introduction ..........................................................................................................18
Methods ................................................................................................................20
Results ..................................................................................................................22
Discussion ............................................................................................................40
Limitations of the review .....................................................................................44
References ............................................................................................................46
Chapter 3: Change in sexual identity and depressive symptoms among sexual minority
adolescents: A longitudinal investigation ....................................................................................52
Introduction ..........................................................................................................52
Methods ................................................................................................................54
Results ..................................................................................................................59
Discussion ............................................................................................................63
Limitations and Conclusion .................................................................................66
References ............................................................................................................68
v

Chapter 4: Sexual identity change, identity management stress and depression among a national
sample of sexual minority adolescents ..........................................................................................74
Introduction ..........................................................................................................74
Methods ................................................................................................................77
Results ..................................................................................................................81
Discussion ............................................................................................................88
Limitations and Conclusion .................................................................................91
References ............................................................................................................93

Chapter 5: Implications and Future Directions ............................................................................100
Major Findings ...................................................................................................100
Future Research and Next Steps ........................................................................102
Implications ........................................................................................................103
Limitations and Conclusion ...............................................................................104
References ..........................................................................................................107

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List of Tables
Table 1.1 Descriptive Summary of 29 Reviewed Articles ............................................................24
Table 1.2 Linked Publications Included in the Review .................................................................27
Table 2.1 Sample Characteristics (N = 1077) ................................................................................60
Table 2.2 Sexual identity change by Sex assigned at birth ............................................................61
Table 2.3 Multi-group latent growth curve with time-varying covariates .....................................62
Table 3.1 Participant Characteristics (N = 1077)...........................................................................82
Table 3.2 Goodness of fit statistics for the ARCL Models ............................................................84
Table 3.3 Unstandardized estimates and standard errors for the ARCL Model 1 .........................84
Table 3.4 Unstandardized estimates and standard errors for the ARCL Model 2 .........................88

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List of Figures
Figure 1.1 PRISMA Flow Diagram ...............................................................................................23
Figure 1.2 Time Varying Co-variate Model ..................................................................................59
Figure 3.1A Time-sequential associations between depression symptoms and identity
management stress for females who reported change in sexual identity .......................................85
Figure 3.1B Time-sequential associations between depression symptoms and identity
management stress for females who did not report a change in sexual identity ............................86
Figure 3.2A Time-sequential associations between depression symptoms and identity
management stress for males who reported change in sexual identity ..........................................87
Figure 3.2B Time-sequential associations between depression symptoms and identity
management stress for males who did not report a change in sexual identity ...............................87

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Abstract
Sexual identity is mutable and evolving, particularly during adolescence and young
adulthood. Despite this recognition, there is a lack of research on how changes in sexual
identities over time may be associated with changes in mental health. This dissertation is
organized as a three-paper project; and aims to develop new knowledge about sexual identity
change among sexual minority adolescents and examine the impact of changes in identities on
mental health outcomes.
Paper 1: Systematic Review
A systematic review was conducted of empirical research that has been completed in the
last two decades, 2000-2020 among adolescent and young adult populations to synthesize
information on sexual identity change. The review aimed to summarize the approaches to
measure sexual identity change, the prevalence, patterns and directionality of change in sexual
identity, and how changes in sexual identity relates to health outcomes among adolescents and
youth adult samples. The studies reviewed lacked agreement in operationalization and
measurement of sexual identity changes. Rates of change in sexual identity differed by birth sex,
where cisgender females were more likely to report a change than males. In addition, adolescents
and youth identifying as non-heterosexual or sexual minority at baseline were more likely to
report a change in sexual identity. Few studies reported on the impact of change in sexual
identity on behavioral health outcomes. Adolescents who either reported same-sex orientation at
the baseline, and those who reported a shift towards same-sex orientation had greater likelihood
for reporting depressive symptomology, suicidality and substance use, compared to those who
did not report a change or reported consistent heterosexuality.

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Paper 2: Sexual Identity Change and Depression
Using a national longitudinal data from sexual minority adolescents aged 14–17 years,
this paper examined changes in sexual minority identity and their association with depressive
symptoms. In the sample, 40% of sexual minority adolescents reported reported at least one
change in sexual identity over 4 time-points over 18-month period. Additionally, in the sample
greater number of participants assigned female at birth reported a change in sexual identity
compared to their male counterparts (46.9% versus 26.6%). In addition, adolescents identified
female at birth reported a negative effect of sexual identity on depressive symptoms over time.
However, a decrease in depressive symptoms associated by sexual identity change was reported
only among female group and not the group with males.
Paper 3: Sexual Identity Change, Depression and Identity Management Stress
This paper used the information gathered from the review and the analyses from previous
chapters to test if relationship between identity management stress and depression over time
differs by sexual identity change status? and if these association look different among cisgender
females compared to males? The analyses reported a temporal cross-lagged effect between
depression and identity management stress among females who reported a change in sexual
identity; and no cross-lagged effect was reported among those females who did not report a
change in sexual identity. However, among male sample depression predicted subsequent
identity management stress, irrespective of their change in sexual identity status.
Implications and Conclusion:
This study has reported important information on how we understand identity change, the
variation in these processes by birth sex, and how identity change relates to two important
processes (depression and identity management stress). However, these results also point to the
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multiple unknowns, that may better help us understand and interpret these results. The future
research must examine pathways of identity integration and development, underscoring the
importance of non-linear and non-static pathways. Building on the evidence between change in
identity and health risks, future work is needed on examining how support and resilience in form
of social networks may impact sexual identity change and development. One of the most
important areas of work that is needed, is examination of the difference in sexual identity
development and change processes by birth sex. Exploring the context in which sexual identities
develop among cisgender females and males, will help us answer some of these questions, and
provide lenses to interpret these evidences.
This dissertation is the first to examine the relationship between sexual identity change
and mental health in a nationwide sample of sexual minority adolescents. Given pervasive
homonegative social and political climates in many areas, sexual minority adolescents will
continue to experience sexual identity development in less supportive environments, resulting in
changes in identities over time. The expanding evidence that sexual identity changes are
associated with negative mental health outcomes is essential in ways we understand sexual
identity development among adolescents. Hence, the mechanisms underlying the change in
sexual identity and subsequent change in health outcomes need more exploration, along with
research on variation by demographic variables including sex and gender.
1
CHAPTER 1
Introduction and Background
Sexual minority adolescents (e.g., lesbian, gay, bisexual, pansexual) report increased risk
of suicidality and mental health disorder symptoms compared to heterosexual youth (Castellví et
al., 2017; Marshal et al., 2011). For example, results from the 2017 Youth Risk Behavior Survey
indicate the prevalence of reporting suicidal ideation in the past year was higher among gay,
lesbian, and bisexual students (48%) compared with their heterosexual (13%) peers (Kann et al.,
2018). Similarly, meta-analytic work reports significantly higher rates of suicidality (odds ratio
[OR] = 2.92) and depression symptoms (standardized mean difference, d = .33) among sexual
minority adolescents compared with heterosexual youth (Marshal et al., 2011). Additionally, the
literature has suggested within-group differences in health. For example, some studies report that
bisexual-identified individuals reported higher rates of depression and self-harm compared to
their gay and lesbian peers (Jorm et al., 2002; Ross et al., 2014).
One aspect that further complicates our understanding of health patterns among sexual
minority adolescents is a recognition that sexual identities are not immutable and may change
over time (Diamond et al., 2017; Katz-Wise, 2015; Ott et al., 2011). Sexual identity development
is a natural part of adolescent development (Perrin, 2002; Savin-Williams & Cohen, 2004);
however, experiences and processes of sexual identity development may differ for sexual
minority adolescents. Some adolescents may identify with a fixed sexual identity (remain
consistent over time), whereas others may present instability in sexual identification (identities
change over time) (Diamond et al., 2017; Katz-Wise & Hyde, 2015; Ott et al., 2011). For
example, Savin-William, Joyner, and Rieger (2012) reported that among individuals who self-
reported on a sexual orientation identity scale as 100% homosexual presented with the most
2
stable identities, whereas participants who had identities indicating some attraction to both sexes
were most likely to experience a change in 1 year. In a retrospective study, bisexual participants
reported larger post adolescent changes in their sexual attractions, compared with participants
who reported exclusive same-sex or exclusive other-sex attractions (Diamond et al., 2017).
Though most studies have reported change on sexual orientation identity scale, a few studies
have reported on change in sexual identities over time (Mock & Eibach, 2012; Ott et al., 2011).
This is unfortunate given prior work has noted changes in sexual identities for over a decade. For
example, in a longitudinal study with 156 sexual minority adolescents 72% reported stable
identities over time, whereas 17% reported changing their identities from bisexual to gay or
lesbian (Rosario et al., 2006).
Changes in sexual identity may also have implications for behavioral health outcomes.
On one hand, sexual identity change may represent a stressor as individuals experience a shift in
their identity (Katz-Wise et al., 2018; Ott et al., 2011; Rosario et al., 2011). Social identity theory
would suggest that, because identity is in part derived from membership in a certain group (Stets
& Burke, 2000; Tajfel & Turner, 1979), experiencing the loss of support from one identity group
during a shift in identity may be stressful (Everett, 2015; Granic, 2005). That is, identity change
may be associated with cognitive and emotional disruptions as sexual minority adolescents
reconfigure self-relevant schemas and navigate social support networks (Haslam et al., 2009;
Rosario at al., 2011). Some support for this exists; Everett (2015) reported changes in sexual
identity toward a more same-sex orientation was associated with increased depressive symptoms,
but stronger associations were found among those who identified as 100% heterosexual at
baseline (as opposed to those moving from one sexual minority identity toward another; e.g.,
bisexual to gay or lesbian).
3
On the other hand, a shift towards an identity that is more authentic and congruent with
self may act as a protective factor and mitigate health risks. For example, Meyer (2003) has
argued this point, suggesting that valence and identity integration are related to self-acceptance
and diminishment of internalized homophobia, wherein an individual’s acceptance of, and pride
in, their identity may help in coping with stressors. For example, Rosario and colleagues (2011),
in their study with 156 sexual minority adolescents, reported that youth who presented greater
sexual identity integration reported lesser depressive and anxious symptoms and higher self-
esteem, both cross-sectionally and longitudinally. This association, between stability in sexual
identity and depressive symptoms, was also reported by Everett (2015), in which participants
with stable sexual orientation presented no differences in depressive symptoms during 1 year.
Thus, further interrogation of the relation between sexual identity change and mental health is
warranted.
Dissertation Project
Given the importance of identity formation in healthy adolescent development (Erickson,
1982; Vaughan & Waehler, 2010), it is concerning that a dearth of research has explored how
changes in sexual identities may influence health risks among sexual minority adolescents. This
dissertation is organized as a three-paper project; and aims to develop new knowledge about
sexual identity change among sexual minority adolescents and examine the impact of changes in
identities on mental health outcomes. The first paper presents results from a systematic review of
all studies related to reported prevalence of sexual identity change and their impact on mental
health outcomes among sexual minority adolescents and young adults published between
January 2000 to September 2020. Key results and recommendations of identified articles are
summarized, and implications for future research discussed. Additionally, results from the
4
review helped guide the next two papers of the dissertation, in examining the effect of sexual
identity change on depressive symptoms over time and understanding the relationship between
depressive symptoms and identity management stress as it relates to sexual identity change.
Papers 2 and 3 are built upon an ongoing longitudinal study (1R01MD012252) which is
following 1,077 sexual minority adolescents (age at enrollment, 14-17) over a period of three
years, with assessments at every 6 months; with a successful retention rate of 85%. This
dissertation work included the data points from baseline through 18-month follow-up. The
project employed longitudinal quantitative methodology including a time-varying covariate
latent growth, autoregressive cross-lagged and multigroup analysis, to examine changes in health
risk over time as they associate with change in sexual identities.
The aims for this dissertation study are:
Aim 1: Conduct a systematic review of literature examining changes in sexual identity
among youth and its impact of health outcomes.
Aim 2: Examine the effect of sexual identity change on mental health risk (depression)
over time.
Aim 3: Examine the association between mental health risk (depression) and minority
stress over time by change in sexual identity.
This novel project leverages 1) the previous work of dissertation chair (Goldbach), to
better measure sexual minority adolescents stress (1R21HD082813; 1R01MD012252); 2) the
longitudinal sexual minority adolescents suicide research of student researcher (Srivastava); and,
3) the support of an established scholars with expertise on longitudinal methods.

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Background
Sexual identity development and adolescence
Adolescence is an important period for sexual identity development (Perrin, 2002; Savin-
Williams & Cohen, 2004). However, experiences and processes of sexual identity development
may differ for sexual minority adolescents; some adolescents may identify with a fixed sexual
identity (remain consistent over time), whereas others may present instability in sexual
identification (identities change over time) (Diamond et al., 2017; Katz-Wise & Hyde, 2015; Ott
et al., 2011). These changes in sexual identities have been referred to as sexual identity fluidity
or sexual identity mobility (Everett et al., 2016; Scheitle & Wolf, 2018). Social scientists have
documented a recent shift in application of sexual identity labels, including an increase in
reported diversity and fluidity in adolescents’ sexual identity labels (Katz-Wise, 2015; Russell et
al., 2009) and a rise in nontraditional youth identities, like queer and questioning (Horner, 2007).
Current research and practice with sexual minority adolescents is not reflective of
contemporary evidence of sexual identity change (Katz-Wise, 2015; Russell et al., 2009).
Additionally, most referred sexual identity development models, including Cass (1979),
Coleman (1982), McCarn & Fassinger (1996), and D’Augelli (1994), purport a linear
progression towards a fixed sexual identity (Greene & Britton, 2012; Savin-Williams, 2011). For
example, Cass’s (1979) homosexual identity development model falls short of explaining
identity changes during adolescence, leaving a dearth of knowledge to support identity
development among adolescents and young adults. Similarly, most longitudinal studies have
failed to collect and report on sexual identity over time; and have rather reported or controlled
for sexual identity only at baseline (Burton et al., 2013; Dermody et al., 2014; Hatzenbuehler et
al., 2008).
6
Sexual identity development is a natural part of adolescent development (Perrin, 2002;
Savin-Williams & Cohen, 2004) and research has suggested the role of enabling environment in
healthy identity development (Legate et al, 2019). Studies have suggested that adolescents with
unsupportive or homophobic familial environment, delay their coming out processes or even try
to meet the heterosexual expectations of their predominately heterosexual families (Cox et al.,
2010; Legate et al, 2019; Waldner & Magrader, 1999). For example, a study with 502
adolescents reported less acceptance and greater difficulty with disclosure were associated with
higher scores on internalized homophobia (negative self-perceptions and self-devaluation for
being non-heterosexual) (Cox et al., 2010). Another retrospective study with 257 sexual minority
adults reported lasting impact of parental rejection on internalized homophobia and
psychological adjustments (Puckett et al., 2015). In short, lack of enabling environment may
result in delaying of identity integration, resulting in development of less-authentic identities
likely to change later.
Minority stressors and sexual identity
Sexual minorities are exposed to heightened stress related to a variety of stigma and
discrimination-related experiences based on their non-heterosexual status, often referred to as
sexual minority stress (Meyer, 2003). Some of these stressors include experiences of prejudice
and violence, negative attitudes toward homosexuality, and discomfort with homosexuality
(Rosario et al., 2002), and have been extensively linked with negative behavioral health
outcomes among sexual minority adolescents (e.g., Goldbach et al., 2014; Marshal et al., 2011;
Rosario et al., 2002). Additionally, for many adolescents, the experience of navigating
potentially hostile social environments (families, peers, schools) may impede sexual identity
development and add to the stress. For example, multiple studies have reported on peer-
7
victimization, bullying and homophobic name calling as antecedent to negative mental health
outcomes among sexual minority adolescents (Collier et al., 2013; Espelage et al., 2008; Moyano
& del Mar Sánchez-Fuentes, 2020). Similarly, others have noted a relationship between
homophobic familial environment and internalized homophobia, with decrease in self-esteem
and disclosure of identity (Cox et al., 2010; Puckett et al., 2015).
Additionally, sexual minority adolescents may experience a change in one or more
aspects of their sexual identity over time (e.g., change in sexual attraction, behavior or labels; Ott
et al., 2011). This change, referred to as sexual identity change, may represent an additional
understudied sexual minority stressor (Katz-Wise et al., 2018). Sexual identity changes may be
associated with cognitive and emotional disruptions as sexual minority adolescents reconfigure
self-relevant schemas and navigate social support networks. For example, adolescents moving
from a heterosexual to a same-sex identity, may experience stress because of the loss of support
from their existing network. Similarly, navigating new identity experiences and new social
networks may add to the stress. Notably, no empirically published studies have documented the
stress experiences among sexual minority adolescents as they relate to sexual identity
development and change.
However, there is limited evidence that among those who report change in sexual
identity, also experience change in their behavioral health outcomes (Everett, 2015; Ott et al.,
2011). Research suggests that adolescents with discordant identities (disagreement between
sexual behavior or attraction, and sexual identification) or are in process sexual identity change,
are more likely to be associated with psychological distress (Clark et al., 2015; Everett, 2015).
For example, a study with a national U.S. sample of sexual minority women ages 18–25,
reported that the number of changes in sexual identity was positively associated with weekly
8
alcohol consumption and depression (Feinstein et al., 2019). Similarly, Everett (2015) reported
changes in sexual identity toward a more same-sex orientation identity was associated with
increased depressive symptoms. Thus, further interrogation of the relation between sexual
identity change and mental health; and the underlying processes of minority stress is warranted.
Theoretical Frameworks
This dissertation employed two theoretical frameworks, sexual minority stress theory and social
identity theory. The theories were helpful in examining the overlapping and parallel processes of
minority stress and intergroup membership as influencers of identity development and change
among sexual minority adolescents. These theories also helped to understand and investigate the
social environmental context in which minority identities develop and contextualize the impact
of identity mobility on mental health outcomes.
Sexual Minority Stress Theory.
The presence of stigma, prejudice, and discrimination (Meyer, 2003) related to non-
heterosexual behavior and identity create unique stress experiences for sexual minority
individuals and are correlated with behavioral and mental health outcomes (Goldbach et al.,
2015; Goldbach et al., 2014). The integral components of the models as they relate to sexual
identity development and change are as follows. Environmental context and minority status:
Environmental circumstances and minority status are associated with exposure to stressors,
which may include advantages and disadvantages in wider environment and personal
dispositions (Meyer, 2003). In the context of sexual identity development, environmental context
is embedded in the familial perception of nonheterosexual identities, religious or cultural
perceptions, peer influences, and access to lesbian, gay, bisexual, transgender and queer
resources and support groups. A nonaccepting or stigmatizing social environment may be an
9
impediment toward positive self-acceptance and identity development. Minority stress processes:
Meyer (2003) described minority stress as a combination of distal (prejudicial events and
experiences of discrimination and violence) and proximal (expectations of rejections,
concealment, and internalized homophobia) factors. These processes are also associated with
identity development among adolescents, wherein negative experiences or expectations of
rejections, concealment, and internalized homophobia may delay or restrict individual self-
realization and positive identity growth. These stressful experiences may also result in less-
authentic self-identity or discordant identity (i.e., disagreement between sexual behavior or
attraction, and sexual identification), and hence likely to change with more enabling
environment. Stress and identity: Meyer (2003) identified prominence, valence, and integration
of identity as associated with stress and mental health outcomes. Prominence of identity may
exacerbate stress, where an increase self-identification with an identity can lead to greater
emotional impact of stressors in that domain. Similarly, valence is related to self-acceptance and
diminishment of internalized homophobia, wherein an individual’s acceptance of and pride in
their identity may help in coping with stressors. While, sexual identity integration, where a
movement or change in identity that is more authentic and is congruent with one’s self, may help
in mitigating the negative mental health outcomes.
Social Identity Theory.
Social identity theory is an intergroup behavior theory of cognitive motivation developed
by Tajfel and Turner and is considered one of the most comprehensive approaches to group
membership (Stets & Burke, 2000; Turner & Oakes, 1986). The various concepts of personal
and social categorization and association with identities, were helpful to understand the
relevance of sexual identification. It was used to analyze and explain the mechanisms and role of
10
sexual identities in an individual’s life and the importance of societal attitude towards them
(example, social marginalization, negative disclosure experience, family rejection, homonegative
climate). Additionally, the theory was used to understand how change in sexual identity maybe
seen as a change in membership from one group to the other. For example, identity change may
be associated with cognitive and emotional disruptions among sexual minority adolescents as
they experience the loss of support from one identity group during a shift in identity to another
identity group (Everett, 2015; Granic, 2005). In-group relations and group behavior: The
emphasis on group distinctiveness can act as a motivational force, wherein conflict and
uncertainty to apply an identity label is influenced by group norms and behavior, making the
decision something that would increase cohesiveness and group belongingness. This is an
important concept that also furthers and explains the conflict among groups and identities and
were helpful in examining sexual identity change. In effect, this was helpful in explaining why
some individuals experience changes in identities, and why these changes are associated with
change in their health risks.

11
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18
CHAPTER 2 (Study 1)
Sexual identity change and associated health outcomes among adolescents and young
adults: A Systematic Review

Introduction
Recent years have documented a shift in the application of sexual identity labels,
including an increase in reported changes in youth’s sexual identity (Katz-Wise, 2015; Russell et
al., 2009). These changes in one’s sexual identity are more prominent in adolescence and young
adulthood, which are considered important periods for sexual identity development (Perrin,
2002; Savin-Williams & Cohen, 2004). However, experiences and processes of sexual identity
development may differ; some sexual minority youth may identify with a fixed sexual identity
(remain consistent over time), whereas others may present instability in sexual identification
(identities change over time) (Diamond et al., 2017; Katz-Wise & Hyde, 2015; Ott et al., 2011).
Additionally, youth may experience a change in one or more aspects of their sexual identity over
time (e.g., change in sexual attraction, behavior or labels; Ott et al., 2011). These changes in
sexual identities have also been referred to as sexual identity fluidity or sexual identity mobility
(Everett et al., 2016; Scheitle & Wolf, 2018).
Changes in sexual identity may also have implications for behavioral health outcomes
(Everett, 2015; Fish & Pasley, 2015; Ott et al., 2013; Needham, 2012). For example, sexual
identity change may be stressful for some individuals; where a shift in their identity may
accompany a loss of support from old identity group or stress of navigating through the social
networks of the new sexual identity group (Katz-Wise et al., 2018; Ott et al., 2011; Rosario et al.,
2011). Some support for this exists; Everett (2015) reported changes in sexual identity were
19
associated with increased depressive symptoms (this association was stronger among those who
identified as exclusively heterosexual at baseline as opposed to those moving from one sexual
minority identity toward another; e.g., bisexual to gay or lesbian).
However, not all changes in sexual identity may result in additional stress. For example, a
shift towards an identity that is more authentic and congruent with self may act as a protective
factor and mitigate health risks. Theoretical support for this hypothesis can be found. Meyer
(2003; Sexual Minority Stress Model) argues that valence and identity integration are related to
self-acceptance and diminishment of internalized homophobia, wherein an individual’s
acceptance of, and pride in, their identity may help in coping with stressors. For example,
Rosario and colleagues (2011), in their study with 156 sexual minority adolescents, reported that
youth who presented greater sexual identity integration reported lesser depressive and anxious
symptoms and higher self-esteem, both cross-sectionally and longitudinally.
Recent reviews of sexual identity change in literature have reported on sexual fluidity in
identification among cisgender males and females, and on inconsistencies among sexual
attraction, behavior, and identity (Apostolou, 2018; Hunt & Hunt, 2018). For example, Hunt &
Hunt (2018) in their integrative review of sexual identity change, reported on sexual fluidity
among cisgender females, and binary sexual orientation experiences (hetero/homosexuality)
among cisgender males. Diamond (2016) in their review of evidence of sexual identity change,
reported longitudinal change in sexual attractions and discordance among sexual attraction,
behavior, and identity. Though these reviews have provided summative evidence of sexual
identity change; sexual identity change among adolescence and young adulthood, and the
relationship between identity change and health outcomes remain unknown.

20
In the current systematic review, we conduct a synthesis of empirical research that has
been completed in the last two decades, 2000-2020 among adolescent and young adult
populations. We aim to answer the following questions: (1) how do studies measure sexual
identity change?; (2) how common is sexual identity change?; (3) are there patterns in the
direction of change reported?; and (4) what is the relationship of sexual identity change to health
outcomes? Our review summarizes the approaches to measure sexual identity change, the
prevalence, patterns and directionality of change in sexual identity, and how changes in sexual
identity relates to health outcomes among adolescents and youth adult samples. The goal of this
review is to describe, summarize and evaluate literature in this area, and in doing so, develop
recommendations for future research for sexual minority adolescent and young adult population.
Methods
Operationalization
Sexual identification is considered a multi-dimensional concept, comprised of sexual
identity, sexual attraction, and sexual behaviors (Laumann et al, 1994), as well as other possible
dimensions. Many studies assess sexual identification by using only a single component of this
multi-dimensional construct (Fu et al., 2019). However, there is less agreement on how to best
operationalize and measure sexual orientation identification; and these vary depending on survey
and research practices and preferences (Mishel, 2019). In this review, we use sexual identity as
an umbrella term to encompass the various aspects of sexual identification, including orientation,
attraction, and labels. Similarly, there is a varied range of vocabulary that has been reported in to
refer to a change in sexual identity, these include, fluidity, mobility, instability, and transitions.
However, for the purpose of this review we use the term ‘sexual identity change’ encompassing
the experience of reported changes in sexual identification among youth.
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Search Protocol
To identify studies for inclusion in this review, two researchers searched the electronic
databases, PubMed, PsyArticles & PsychInfo, Cochrane, GenderWatch, EBSCO (LGBT+
Source), and Google Scholar. Search terms were based on the relevance to change in sexual
identity or orientation among youth and included: adolescent/youth/young adult and sexual
identity change/mobility/fluidity/stability/transition. Words indicating sexual orientation/ sexual
identity orientation were added. Specific keywords such as, sexual orientation trajectory,
mobility metrics, and longitudinal study were tested, as well. Two researchers conducted the
same searches of electronic databases to ensure all studies were identified. Additionally, each
time an article showed up as a match, the Google Scholar search tools “related articles” and
“cited by” were used. Citations in relevant studies were then reviewed to determine if any
referenced articles fit the search parameters.
Inclusion and Exclusion Criteria
The first author reviewed the abstracts to determine which studies met the review’s
inclusion criteria. To be included, studies must have (a) been published between January 2000
and September 2020; (b) published in a peer-review journal; (c) been empirically based; (d)
reported original research findings; (e) published in English language; (f) study samples must
include sexual minority or non-heterosexual adolescents or young adults, aged 12-26 years at the
baseline; and (g) examined or reported changes in sexual identity or orientation. We excluded
studies that either (a) did not access changes in sexual identity or orientation; (b) were outside of
the sample age range.
All studies were independently reviewed by two authors and abstracted using a
standardized form. The first author reconciled the work of the two reviewers and organized the
22
summaries into one database that allowed aspects of all included studies to be compared and
summarized. Full-text review was conducted before a decision about the inclusion or exclusion
were made; these decisions were made by the first author in consultation with a coauthor.
Results
Our search resulted in a total of 2746 (included 4 records from portal suggestions)
records identified through database searching. Out of these 352 records were excluded for not
meeting the requirements of empirical and peer-reviewed publications (these included, books and
book chapters (n = 100), dissertations (n = 195), essays and grey literature (n = 41), and non-
English language (n = 16). A total of 2394 records were screened; out of these 2080 articles were
excluded for meeting the primary inclusion criteria (i.e., examine or report changes in sexual
identity or orientation). A total of 314 articles reviewed, and of those 265 records were excluded
(duplicates; n = 249); theoretical or review papers; n = 16). Out of the reviewed articles, 49
articles met the requirements, and full texts were assessed for eligibility. A total of 20 articles
were excluded for not meeting the age requirement (n = 18) and sample demographics
(transgender only sample; n = 2). Outcomes of applying the inclusion and exclusion criteria to
the retrieved articles are presented in Figure 1.1. In the end, 29 studies were included in the
review. The reviewed studies differed in their research foci and approaches, and key aspects of
each study are summarized in Table 1.1. The majority of studies were conducted in the United
States (n = 26); one each in Australia, Croatia and New Zealand. As shown in Table 1.2, several
articles were based on common data sources.
23
Figure 1.1: PRISMA Flow Diagram
Table 1.1: Descriptive Summary of 29 Reviewed Articles
Author Country Sample
Size
Age (at
baseline)
Frequency of
measure
Birth
Sex
Sexual
Minority
(%)
Sexuality
measure
Identity
change
Outcome Studied
Berona et al.
(2018)
US (NE) 2450 14 years Annually (9
years)
F 41.2% SI; SA;
SP; RP
1.6
changes
(SD=1.5)
Change in orientation
based on sexual
identity latent class
Campbell et al.
(2020)
Australia 16870 18-23
years
2013, 2014,
2015, 2017
F 34.5% SI 30.6% Prevalence and Pattern
of change
Cohen e al.
(2020)
Croatia 1844 Avg 16.1
& 15.8
5 time points
(5-6 months
apart)
F, M 13.9% SA 7 – 9.2% Association with
religiosity
Cranney (2016) US 26 18-26
years
Wave 3 and
Wave 4
F, M --- SA --- Temporal stability of
lack of sexual
attraction
Diamond
(2000)
US (NE) 80 16-23 2-year follow-
up. Interviews
F 100% SA 29-32% Sexual identity and
attraction over time
Diamond
(2003)
US (NE) 80 18-25 3-time points
over 5 years
F 100% SA 49% Sexual identity and
attraction over time
Diamond
(2008)
US (NE) 79 18-25 5-time points
over 5 years
F 100% SA 66.7% Bisexuality and stability
Dickson et al.
(2013)
New
Zealand
925 21 At the ages,
21, 26, 32, 38
F, M 8.3% SI, SO, SA 2.9-4.2%
M; 11.8-
16.3% F
Stability and change in
same-sex attraction
Everett (2015) US 11727 18-26 Wave 3 and
Wave 4
F, M 10.8% SO 11.8% Depressive Symptoms
Feinstein et al.
(2019)
US 1057 18-25 4 time points
(over 36
months)
F 100% SI 34% Alcohol Use and
Depression
Fish & Pasley
(2015)
US 12679 13-18 Wave 1-4 F, M --- SO, SA,
RP
11.8% Mental health and
alcohol use
Fricke & Sironi
(2020)
US 11349 18-26 Wave 3-4 F, M 13.6% SO 12.4% Physical health, BMI
24
Hu et al. (2016) US 10106 12-21 Waves 1-4 F, M 18.7% SA, RP 18.5% Stability of sexual
attraction
Kaestle (2019) US 6864 16-18 Waves 1, 3, 4 F, M 12.6%
(M),
26.2% (F)
SO, SA,
RP
--- Sexual orientation
pathways for male and
female
Katz-Wise &
Hyde (2015)
US
(MidWest)
188 18-26 Cross-
sectional
F, M 100% SF 48% F,
34% M
Sexual fluidity
Katz-Wise
(2015)
US
(MidWest)
199 18-26 Cross-
sectional
F, M 100% SF, SI 49% F,
36% M
Sexual fluidity
Katz-Wise et al.
(2017)
US
(MidWest)
18 19-26 Qualitative All
genders
100% Interview ---- Sexual fluidity
Katz-Wise et al.
(2019)
US
(MidWest)
421 18-26 Cross-
sectional
All
genders
42.8% SF, SI 28.5% Sexual fluidity
Liu et al. (2019) US 7840 12-18 Waves 1 and 4 F, M 21.9% SO, SA,
RP
15.9% Diabetes
Morgan et al.
(2018)
US (NE) 15 15-19 4 time points
(3 months
apart);
Qualitative
M 100% SA, SI, SB 53.3% Change in identity
black bisexual
identified men
Needham
(2012)
US 8322 11-21 Waves 1-4 F, M 6.4% SO, SA 11.1% Trajectories of mental
health and substance
use
Oi & Wilkinson
(2018)
US 15678 Avg 16-
17
Waves 1-4 F, M --- SO, SA,
RP
16.4% Trajectories of Suicidal
Ideation
Ott et al.
(2011)
US 13840 12-25 1999, 2001,
03, 05
F, M --- SO 11.1% M;
19.2% F
Transitions and
mobility
Ott et al.
(2013)
US 10515 12-27 1999,
2001,03,05,07
F, M 18.3% SO 16.4% M;
26.8% F
Substance Use
Rosario et al.
(2006)
US (NE) 156 14-21 3 time points
(6 months
apart)
F, M 100% SI, SO 28% Consistency and
change over time
Sabia (2015) US 11273 18-24 Waves 3- 4 F, M --- SO, SA 10.6%
(5.0% M,
15.9% F)
Earned wages
25
Savin-Williams
(2012)
US 12287 18-24 Waves 3- 4 F, M 10.2% SO 17.8 and
6.2% (F,
M)
Stability of sexual
orientation
Silva (2018) US 12630 18-26 Waves 3-4 F, M 21.4% F;
7.4% M
SO, SA,
RP
18.6% F;
6.8% M
Predicting straight
identification
Stewart et al.
(2019)
US (SE) 744 14-17 Annually (3
years)
F, M 86.9% SI, SO 26% F;
11% M
Development patterns
of sexual identity
Notes: SO/I Measure: SI = Sexual Identity; SO = Sexual Orientation; SA = Sexual Attraction; SP = Sexual Partnering; RP = Romantic
Partnering; SB= Sexual Behavior; SF = Sexual Fluidity; Birth Sex: F = Female, M = Male
26
Table 1.2: Linked Publications Included in the Review
Data Source Publications
National Longitudinal Study of Adolescent to Adult Health (Add Health), Waves 1-4 Fish & Pasley (2015); Hu et al. (2016); Needham
(2012); Oi & Wilkinson (2018)
National Longitudinal Study of Adolescent to Adult Health (Add Health), Waves 1, 3 and 4 Kaestle (2019)
National Longitudinal Study of Adolescent to Adult Health (Add Health), Waves 1 and 4 Liu et al. (2019)
National Longitudinal Study of Adolescent to Adult Health (Add Health), Waves 3 & 4 Cranney (2016); Everett (2015); Fricke & Sironi
(2020); Sabia (2015); Savin-Williams (2012); Silva
(2018)
The Growing Up Today Study Ott et al. (2011); Ott et al. (2013)
Study with 80 young sexual-minority women Diamond (2000); Diamond (2003); Diamond (2008)
Sexual fluidity in young adult women and men Katz-Wise & Hyde (2015); Katz-Wise (2015)
Note: Ott et al. (2011) used 4 waves of data and Ott et al. (2013) used 5 waves of data. Diamond (2000) used 2 time points, Diamond
(2003) used 3 time points, Diamond (2008) used 5 time points. Katz-Wise & Hyde (2015) and Katz-Wise (2015) used cross-sectional
data.
27
28
Study Designs and Participants
Most studies that were reviewed were quantitative (n = 24); two were qualitative only;
and three studies reported a mix of quantitative and qualitative results. With a few exceptions,
most studies reported results from longitudinal investigation (n = 25). Multiple studies included
in the review used same data source (e.g., National Longitudinal Study of Adolescent to Adult
Health (Add Health); Table 2). The studies using cross-sectional approach, had direct measures
of sexual fluidity and change, attitudes and prevalence, reported both retrospectively and
prospectively (Katz-Wise & Hyde, 2015; Katz-Wise, 2015; Katz-Wise et al., 2019). Studies
reporting from nonprobability samples recruited participants from lesbian, gay, bisexual,
transgender and queer-specific venues, university campuses, etc. However, probability samples
included nationally representative school-based samples (e.g., Cranney, 2016; Everett, 2015;
Fricke & Sironi, 2020); Savin-Williams, 2012; Silva, 2018)) or followed youth based on birth-
cohorts (e.g., Campbell et al., 2020; Dickson et al., 2013).
Most studies included samples of both male and female participants, with exception to six
studies reporting from all-female and one from all-male samples (e.g., Cohen et al., 2020;
Cranney, 2016; Dickson et al., 2013; Everett, 2015; Liu et al., 2019). Additionally, two studies
reported data from a more inclusive sample of genders (including, transgender and another
genders) (Katz-Wise et al., 2017; Katz-Wise et al., 2019). Race and ethnicity composition of the
sample was reported in all the studies. Morgan and colleagues (2018) conducted a qualitative
investigation with 4 time points (3 months apart) with only black men. Others reported more
diverse composition; for example, Stewart et al. (2018), reported racial composition of their
study as, White, 24% Hispanic/Latinx, 21% Black/African American. While, Berona et al.
(2018) in their study found that racial/ethnic minority status was associated with membership in
29
the primarily other-sex attraction class (OR = 1.5; 95% CI, 1.2–1.8; p < .001) and the primarily
same-sex attraction class (OR = 2.1; 95% CI, 1.3–3.5; p < .01). The age ranged from 12-26 years
at the time of first enrollment or the baseline. However, the age spanned over decades once
recruited and followed up in studies. For example, the birth-cohort study from New Zealand,
measured changes in sexual identity and orientation, with data collected at the ages 21, 26, 32
and 38 years. Similarly, Diamond (2000, 2008) followed a sample of sexual minority cisgender
females aged 16-23 years at enrollment for over 10 years.
With an exception to 9 studies, all other studies reported results from a sample of
heterosexual and non-heterosexual identified youth at the baseline. The proportion of non-
heterosexual identification at baseline ranged from 6.4% to 86.9%. Exclusively heterosexual
identification was used to measure non-heterosexual proportion in the studies. Additionally, the
sample size of the studies also varied depending on the methods and approach, with smallest
sample being 15 from a qualitative sample (Morgan et al., 2018) to 15,678 from a probability
national sample (Needham, 2012).
Measuring Sexual Identity Change
The studies in our review differed in terms of measurement of sexual identification. Many
studies collected data on more than one aspect of sexuality, including sexual identity or labels,
sexual orientation, sexual and/or romantic attraction, and sexual behavior. Most studies used a
Likert-scale based on Kinsey’s sexual orientation spectrum; exclusively heterosexual (or, 100%
heterosexual) to exclusively homosexual (or, 100% homosexual). However, AddHealth in their
last wave (2008-09), added an additional option to the scale as, ‘not sexually attracted to either
males or females’ to capture no sexual attraction or asexuality (Cranney, 2016).
30
Sexual attraction was also measured using similar scale as Kinsey, though capturing
attraction towards sex rather than sexual identification. For example, Cohen et al. (2020) in their
surveys captured romantic or sexual attraction by asking respondents attraction towards, 1 =
exclusively of the other sex, 2 = mostly of the other sex, 3 = equally of the other and same sex, 4
= mostly of my sex, 5 = exclusively of my sex. Others captured sexual attraction in terms of
fantasies and sexual thoughts by asking, “the extent to which their recent sexual attractions,
thoughts, and fantasies were focused on the same or the other sex (a) when in the presence of
other individuals, (b) while masturbating, dreaming, or daydreaming, and (c) when viewing
erotic material in films, magazines, or books” (Rosario et al., 2006).
Three studies measured sexual labels and identities (Dickson et al., 2013, Feinstein et al.,
2019; Rosario et al., 2006). Feinstein et al. (2019) at each wave of data collection asked
participants to report their sexual identity; while Rosario et al. (2006), offered response items,
“When you think about sex, do you think of yourself as lesbian/gay, bisexual or straight”; and
Dickson et al. (2013), provided response items as Heterosexual, Homosexual, Lesbian/Gay,
Bisexual, Other. A few studies also used ‘romantic partnering’ and ‘sexual behavior’ to capture
one’s sexual identity; however, they were used in conjunction with other variables, like, sexual
identity, attraction or orientation. While, one of the studies used ‘same-sex experience’ to capture
sexual identification. Oi & Wilkinson (2018) operationalized same-sex experience as reporting a
same-sex romantic attraction, listing a same-sex romantic relationship, or reporting one or more
same-sex sexual encounters.
Qualitative assessment (five studies) differed from quantitative assessment of sexual
attraction and used more innovative techniques to capture sexual attraction. For example,
Diamond (2000, 2003, 2008) to assess same-sex attractions used a blank pie chart divided into
31
16 equal regions totaling 100%. Participants were asked to fill this in to represent the percentage
of their current sexual attractions that are directed toward the same sex on a day-to-day basis.
While, Katz-Wise and colleagues (2017) did a narrative and descriptive assessment of sexual
identity development and fluidity.
Except cross-sectional studies, all studies used repeated measures on sexual identity
(including, labels, orientation, attraction and behavior) to examine changes. This approach was
used in varied forms by most studies reviewed and accounted for both (a) any change in sexual
identity; (b) number of changes over time (Campbell et al., 2020; Cohen et al., 2020; Everett,
2015; Oi & Wilkinson, 2018). With an exception to a few studies, most studies used repeated
measures on single or multiple components of sexuality (identity, attraction, orientation,
behavior) to measure change in the follow-up waves. Typically, an endorsement on these
variables as different from their past wave was measured as a change, and number of changes or
transitions made were used to count total of changes. Additionally, since most studies used
Kinsey-informed Likert scales; they measured changes in form directionality: stable identities
(heterosexual, homosexual, bisexual) and unstable identities as ‘transitioning towards’ same-sex
or 100% homosexual’ or ‘transitioning towards opposite-sex or 100% heterosexual).
Unlike longitudinal studies, cross-sectional studies relied on retrospective reporting
identity change or attitudes on sexual fluidity (Katz-Wise, 2015; Katz-Wise & Hyde, 2015; Katz-
Wise et al., 2019); For example, Katz-Wise & Hyde (2015); asked a series of questions to
capture their changes in sexual identity. Participants were asked if they have ever experienced a
change in attractions to others over time; and if they did, the age of initial change, and was
change in attraction resulted in a change in sexual label. They were also asked number of
changes they have made and likelihood of future changes. In addition to reported change in
32
sexual attraction; participants were also asked to report on Attitudes Regarding Bisexual Scale;
and on a 5-items Sexual Fluidity Belief Scale (developed by authors). In their another studies,
Katz-Wise et al. (2019), in addition to reporting on changes and attitudes; also measured
entity/incremental views of sexual orientation based on two subscales: (1) sexual orientation
based and (2) person based. (for example, A person’s sexual orientation is something very basic
about them that can’t change; A person’s sexual orientation is something very basic about them
that they can’t change). All items were measured on a 7-points continuous scale from (strongly
disagree to strongly agree).
Sexual Identity Change Prevalence
The prevalence and rate of sexual identity differed across the studies, based on sample
composition, demographics, sampling techniques and measurements. These rates in sexual
identity change ranged from 6-30% in probability samples of heterosexual and non-heterosexual
youth; while, 28%-67% in nonprobability samples of sexual minority youth (Cohen et al., 2020;
Diamond, 2008; Morgan et al., 2018; Silva, 2018). Studies examined changes in sexual identity
between two consecutive time points was reported my multiple studies. For example, Campbell
and colleagues (2020) reported incidence of change in sexual identity label as 19.3% (wave to
wave); while, Cohen and colleagues (2020) found a total of 7.0% - 9.2% of sample reported a
change between consecutive time points. Similarly, Everett (2015) reported 12% change in
sexual orientation identity between two waves, of which 70% changed their sexual orientation to
a more same-sex-oriented identity (on identity scale: exclusively heterosexual, mostly
heterosexual, bisexual, or mostly gay/lesbian, and exclusively gay/lesbian).
In addition to reporting any sexual identity change, some studies also reported number of
sexual identity changes in identity over time. For example, Feinstein et al. (2019) found that a
33
total of 34.4% of participants reported at least one change in sexual identity during the study
period, with 24.6% reporting one change and 9.8% reporting two or more changes. Similarly,
Diamond (2008) found that in their sample of sexual minority women, one third of the sample
changed sexual identity two or more times; while, Katz-Wise & Hyde (2015) found multiple
changes in attractions reported by 21% of cisgender females (M=2.58 changes) and 19% of
cisgender males (M=2.75 changes).
In addition, two studies reported on the qualitative aspects of sexual identity development
and change. Morgan et al. (2018) interviewed 15 black bisexual-identified men at 4-time points,
3-months apart. In their sample, out of 15 bisexual-identified participants at baseline, only 7
consistently identified as bisexual and 8 reported a change to gay or questioning. Those who
consistently identified as bisexual, also also described similar experiences related to same- and
other-sex sexual and romantic attractions and more consistently described same- and other-sex
sexual behaviors. While, the those who reported a change in sexual identity, they also described
change in same- and other sex sexual romantic attractions over time.
Change in Sexual Identity by Sex
Reported change in sexual identity also differed by sex at birth. Compared to cisgender
male, cisgender females were significantly more likely to report changes in identity between
waves (Everett, 2015; Dickson et al., 2013; Savin-Williams et al., 2012). In Oi & Wilkinson
(2018) 13.3% of males and 19.3% of cisgender females reported transition between exclusively
heterosexual to same-sex experience; while this reported change in sexual identity between
cisgender females and cisgender males were higher in other studies, Fricke & Sironi, 2020 (18%
vs 6.2%), Savin-Williams et al., 2012 (17.8% vs 6.2%), and Stewart et al., 2018 (26% vs 11%).
This difference was further elaborated in results from Katz-Wise & Hyde (2015), where they
34
reported that cisgender females were more likely than males to endorse sexual fluidity beliefs
and to believe that sexuality is changeable; and cisgender females were more likely than males to
endorse the belief that sexuality is influenced by the environment. Other studies (Diamond, 2003,
2008, 2008) further supports the argument of sexual fluidity among women. Over 10 years, two
thirds of cisgender females changed the identity labels, and one third changed sexual identity
labels two or more times (Diamond, 2008). More evidently, multiple studies reported lesser
proportion of cisgender females than males reporting exclusive heterosexuality at baseline
(Cohen et al., 2020). For example, Kaestle (2019) reported 74% of cisgender females compared
to 87% of cisgender men fell into the heterosexual class. Similarly, Fish & Pasley (2015),
reported that more cisgender women were likely to report heteroflexibility (6.45%) and later
bisexual identification (3.32%). Additionally, more cisgender females reported a change in
identity away from heterosexuality (Campbell et al., 2020). For example, Needham (2012)
found that those who reported a transition to lesbian/ gay/ bisexual attraction were
disproportionately female (75%), whereas those who reported a transition to heterosexual
attraction were disproportionately male (59%).
Change in Sexual Identity by Other Covariates
Only two studies provided an examination of change in identity with covariates other
than gender. Silva (2018) found Non-Latino mixed-race men, as compared to non-Latino white
men, had higher odds of changing to a straight identity by 8.39 (p<.05). Additionally, cisgender
females for whom religion become more important, as compared to less important, had higher
odds of changing to a straight identity by 1.97 (p < 0.01). Cohen et al. (2020) in their study found
that religiosity was associated with initial sexual attraction (more religious individuals were more
35
likely to report exclusively heterosexual attraction), but not with changes in romantic and sexual
attraction over time.
Patterns and Directionality of Change
Some studies, in addition to reporting on prevalence of change, provided information on
patterns and directionality of sexual identity change in their samples. For example, Berona et al.
(2018) reported that the proportion of individuals endorsing same-sex and bisexual orientation
within each class increased over time. They reported that 63.2% participants reported at least one
change in sexual orientation; where the primarily same-sex class reported more frequent sexual
orientation changes than the bisexual class and the primarily other-sex class.
Two studies used life stages to categorize identity development over time (Hu et al.,
2016; Liu et al., 2019). For example, Liu et al. (2019) reported four categories by life stage: (1)
early sexual minority status continuing into adulthood (reported same-sex sexuality in both
adolescence and adulthood; 7.4% cisgender females and 4.5% cisgender men), (2) late sexual
minority status (reported same-sex sexuality in adulthood only; 10.1% cisgender females and
3.1% cisgender males), (3) early sexual minority status that did not continue into adulthood
(reported same-sex sexuality in adolescence only; 7.8% cisgender females and 10.2% cisgender
males), and (4) the reference category: heterosexual throughout adolescence and young
adulthood (did not report same-sexuality in adolescence or adulthood; 74.7% cisgender females
and 82.2% cisgender males).
The changes reported in sexual identity were also found to be associated with
endorsement on sexual identity labels and attraction. For example, most studies reported
exclusive heterosexual identity labels remained stable over time (Campbell et al., 2020; Fish &
Pasley, 2015); however, among those identifying as non-heterosexual identified, same-sex
36
attraction were found to be more stable over time compared to both-sex attraction (Hu et al.,
2016). For example, Cohen et al. (2020) found that in their sample, stability of attraction was
observed in 91.5%-96.1% of exclusively heterosexually attracted adolescents, respectively, and
in only 28.5%- 33.7% of other attracted adolescents.
Bisexual, mostly heterosexual, or mostly homosexual identities were found to be least
stable. For example, Savin-Williams et al. (2012) reported that bisexual-identified cisgender
males and cisgender females were more likely to report a high rate of temporal shifts compared
to exclusive same or opposite sex attraction; and in addition, over time more bisexual and mostly
heterosexual identified young adults of both sexes moved toward heterosexuality than toward
homosexuality. Similar findings were reported by Feinstein et al. (2019), where they found that
cisgender females who initially identified as bisexual were more likely to report two or more
changes than those who initially identified as lesbian, and this difference was significant (b =
0.61, p = .026).
Directionality of Change
A few studies reported on the directionality of sexual identity change. For example, Sabia
(2015) reported that, among those who reported a change, 11.1% towards same-sex; and 4.9%
away from same-sex among female respondents, and 3.0% towards same-sex, and 1.9% away
from same-sex among male respondents. Similarly, Silva (2018) found only 4.3% of sample
reported a change towards heterosexual identity and 8.4% towards non-heterosexual identity.
Similarly, Everett (2015) reported among those who reported a change in sexual orientation,
70% changed their sexual orientation to a more same-sex-oriented identity.
In another study, Ott et al. (2011), found difference in directionality of change by both
age and gender. In their study, among younger males (12-15), 2.3% reported a change towards
37
completely heterosexual, 5.1% towards Lesbian, Gay and Bisexual and 3.5% reported a
multidirectional change; and among older males (15 or older), 1.9% towards completely
heterosexual, 5.2% towards lesbian/ gay/ bisexual and 3.5% reported a multidirectional change.
Similarly, among younger cisgender females, 3.0% reported a change towards completely
heterosexual, 8.9% towards lesbian, gay and bisexual and 6.7% reported a multidirectional
change; and among older cisgender females, 4.4% towards completely heterosexual, 8.9%
towards lesbian, gay and bisexual and 6.5% reported a multidirectional change. This
directionality was change was also observed in sexual minority sample. Rosario et al. (2006) in a
sexual minority sample found that change in sexual identity was reported as 18% transitioning
towards gay/lesbian identity, while, 5% transitioned from bisexual, and 5% towards straight.
Relationship with Health Outcomes
A total of six out of twenty-nine studies measured a mental health or substance use
outcome associated with change in sexual identities. These studies used directionality of change
(a shift in identity towards or away from a same-sex identity) to examine association of identity
change with behavioral health outcome. For example, Everett (2015) reported that only changes
in sexual identity toward same-sex-oriented identities were associated with increases in
depressive symptoms. This directionality of change was also reported by grouping identity
change experience. For example, one study reported that sexual minority groups (heteroflexible,
later bisexually identified, and lesbian, gay and bisexual identified) experienced greater
depressive symptomology and suicidality compared to groups characterized by opposite-sex
attraction, behavior and identities (heterosexual early daters and heterosexual late daters) (Fish &
Pasley, 2015).
38
A few studies reported the impact on health outcomes by gender. For example, Needham
(2012) reported cisgender females who reported transitioning (lesbian/ bisexual or hetero)
reported higher levels of tobacco smoking and marijuana use compared to those who report
consistent heterosexual attraction; and those cisgender females who report consistent gay/
lesbian or bisexual attraction at the beginning of the study period reported significantly higher
levels of depressive symptoms and suicidal thoughts than those who report consistent
heterosexual attraction. However, young men who transitioned to heterosexual attraction
reported initial higher levels of smoking, heavy drinking, and marijuana use compared to those
who report consistent heterosexual attraction. Similarly, Oi & Wilkinson (2018) reported that
men and cisgender females who reported same-sex experience in both adolescence and
adulthood had the greatest risk of suicidal ideation. However, cisgender females with first same-
sex experience in adulthood had less decline in suicidal ideation over time, relative to those with
no same-sex experience and those with same-sex experience in adolescence only.
One study examined the impact of number of changes in sexual identity on mental health
and substance use; where the number of changes in sexual identity was found to be positively
associated with typical weekly alcohol consumption and depression (Feinstein et al., 2019).
Additionally, one study examined the association between sexual orientation identity mobility
scores and substance use outcomes. Ott et al. (2013) found higher levels of reported mobility
were associated with higher levels of substance use (marijuana and substance use). More
specifically, the research found, differences by age and gender. For example, female and male
adolescent with a mobility score of 1 had 3.2 and 1.9 higher odds? of marijuana-use than those
with mobility score of 0. Similarly, for smoking among males regardless of age, those in the
39
‘Toward Completely Homosexual’ group had a greater risk of smoking in past month than the
Immobile group (consistent reporting on sexual identity).
Other Health-Related Outcomes
Three studies reported on outcomes other than mental health and substance use; they
included- physical activity and Body Mass Index (BMI), diabetes and earned wages. Fricke &
Sironi (2020) found that in their sample, men who reported a change towards a more homosexual
identity indicated significantly more physical activity and lower BMI, and those who reported a
change towards a more heterosexual identity indicated less physical activity and higher BMI,
compared to those who did not report a change. However, for women, a change toward a more
homosexual identity is significantly associated with more physical activity and lower odds of
being obese compared to no change.
Using all 4 waves of AddHealth data, Liu et al. (2019) reported that respondents who
reported sexual minority status in adulthood only and those who reported sexual minority status
in both adolescence and adulthood, had significantly higher odds of having diabetes compared to
heterosexual respondents. Additionally, cisgender females with sexual minority status in both
adolescence and adulthood had significantly higher odds of having diabetes than heterosexual
cisgender females. Sabia (2015) reported on earned wages and sexual identity change. The study
found that among males those who transitioned from heterosexual to bisexual or transitioned
away from same-sex identity earned lower wages, compared to their heterosexual peers.
Similarly, among cisgender females, those who transitioned towards a same-sex identity also
reported lowered wages (4.0-5.5%).

40
Discussion
The present literature search has furthered the integrative review of sexual fluidity
conducted by Hunt & Hunt (2018), who studied sexuality continuum, sexual fluidity among
cisgender females, sexual agency and hetero/homosexuality binary of cisgender males; using
peer and non-peer reviewed articles, fiction, historical and theoretical works published since
1990. The current study has identified 29 articles published between January 2000 – October
2020 with youth aged 12-26 years. Overall, studies varied in measurement, study designs, and
outcomes studied. Key thematic points are divided in four areas: 1) measuring change in sexual
identity, 2) reported rate of change and directionality, 3) co-variates and sexual identity change,
4) outcomes associated with sexual identity change; 5) future research.
The studies reviewed lacked agreement in operationalization and measurement of sexual
identity changes; where studies used repeated measures of one or more aspects of sexuality (e.g.,
sexual identity, orientation, attraction, partnering and behaviors) to report change. The difference
in measurement technique has important implications in ways the results from the studies are
understood and applied in future work. For example, future work may further explore what
aspects of sexuality are more likely to change, and how these changes are associated with other
aspects of sexuality. However, studies reporting on sexual identity labels and changes are
advantageous in capturing the contemporary vocabulary and associated meanings. For example,
sexual identity labels like pansexual, demisexual, queer, in multiple ways are based on expanded
understanding of self, both in terms of sexual and gender, and at times, outside of the binary
(Belous & Bauman, 2017; Horner, 2007; Morandini et al., 2017; Russell et al., 2009). While, the
more traditional measurement of sexual attraction, have a more binary operationalization of
sexes (male and female) to capture attraction, and also heterosexual and homosexuality as two
41
opposite and definitive ends. Additionally, a few studies also asked participants to report their
attitudes on sexual fluidity and if they have experienced changes (Diamond, 2008; Katz-Wise &
Hyde, 2015; Katz-Wise, 2015). Such measurements are important to capture participant’s self-
perception reporting of identity change; to reflect if these changes were part of a conscious
individual decision (Carter, 2017).
Rates of change in sexual identity differed by gender, where cisgender females were
more likely to report a change than cisgender males (over 10 percent point difference) (Fricke &
Sironi, 2020, Oi & Wilkinson, 2018; Savin-Williams et al., 2012; Stewart et al., 2018). The
higher rates of change reported among cisgender females is consistent with the literature of
sexual fluidity (Diamond, 2016; Francis, 2020; Hunt & Hunt, 2020). Diamond (2016) in the
review of studies also found that sexual identity change was somewhat more common among
cisgender females than cisgender males, however, no conclusions about the extent of gender
difference in sexual fluidity and the causes of such differences could not be determined;
contrarily, Apostolou (2018) found that great majority of cisgender females do not have a fluid
sexuality, but have instead stable attractions over time. These lower rates among males could be
associated with stricter notions of masculinity, social and cultural expectations on gender, and
more negative attitudes towards gay men by heterosexual men (Breen & Karpinski, 2013;
Kilianski, 2003), however, these differences and underlying factors are yet to be examined.
Diamond (2016) in the review of studies also found that sexual identity change was somewhat
more common among cisgender females than cisgender males, however, no conclusions about
the extent of gender difference in sexual fluidity and the causes of such differences could not be
determined. Although the extant research suggests that all of these phenomena are somewhat
more common in cisgender females than in cisgender males, it is difficult to draw reliable
42
conclusions about the extent of gender differences in sexual fluidity, and the cause of such
gender differences.
Additionally, only two studies examined other covariates as they associate with change in
sexual identity. Non-Latino mixed-race cisgender males, as compared to non-Latino white
cisgender males, had higher odds of changing to a straight identity (Silva, 2018); and religiosity
was associated with initial sexual attraction (more religious individuals were more likely to
report exclusively heterosexual attraction), but not with changes in romantic and sexual
attraction over time (Cohen et al., 2020). However, both associations of race and religion with
sexual identity change were not further explored or discussed. It is imperative to further examine
how multiple minority identities (like, race, religion, region) may be associated with sexual
identity development and how this relationship changes over time.
In the review, participants identifying as non-heterosexual or sexual minority at baseline
were more likely to report a change in sexual identity (Cohen et al., 2020). These rates in sexual
identity change ranged from 6-30% in probability samples of heterosexual and non-heterosexual
youth; while, 28-67% in nonprobability samples of sexual minority youth (Cohen et al., 2020;
Diamond, 2008; Morgan et al., 2018; Silva, 2018). Studies have found multiple pathways in
terms of directionality of change, with more studies reporting a change in direction of same-sex
identity rather than towards a heterosexual-identity (Sabia, 2015; Silva, 2018). However, the
directionality of change was observed, towards heterosexual, towards same-sex, and those who
reported changes in both directions. Samples who reported a non-heterosexual or bisexual
identity orientation at baseline, were more likely to report a change towards a more same-sex
identity. Most studies used Kinsey scale to operationalize sexuality, with orientation ranging
from completely heterosexual to completely homosexual. These finding are consistent with Hunt
43
& Hunt (2018) and Morgan (2013), where they traditional and contemporary models of sexual
identity development, identity development trajectories and change in sexual identity over time.
Few studies examined impact of change in sexual identity on behavioral health outcomes.
However, this association was examined using the directionality of such change (e.g., a shift
away or towards same-sex identities). Studies found that those who reported changes in sexual
identity toward more same-sex-oriented identities were associated with increase in depressive
symptoms (Everett, 2015); or those who reported heteroflexibility or same-sex orientation had
greater likelihood for reporting depressive symptomology, suicidality and substance use (Fish &
Pasley, 2015; Needham, 2012; Oi & Wilkinson, 2018), compared to those who did not report a
change or reported consistent heterosexuality. In addition, a greater number of changes in sexual
identity was found to be associated with depression and substance use (Feinstein et al., 2019; Ott
et al., 2013). One of the plausible explanations for these association is that sexual identity
changes may be associated with unique stressors in form of cognitive and emotional disruptions,
as one reconfigures self-relevant schemas and navigate social support networks. This could be
characterized as either a loss of existing social support associated with a past-identity, or stress
with navigating new identity experiences and new social networks. However, this complicated
relationship with identity change and health outcomes need further exploration.
The future studies should address the gaps in the literature on impact of sexual identity
changes on behavioral health outcomes, while also addresses the methodological challenges.
There is a need to longitudinally investigate the complex relationship with various aspects of
sexuality, especially, sexual identity labels, as they change over time. Caplan (2017) found that
discordance between sexual identity labels and one’s sexual attraction and behavior is positively
associated with higher depression. Given this complex interplay among various aspects of
44
sexuality, it is important to examine the association among identity labels and other aspects over
time. This would include collecting information on their beliefs and attitudes towards sexual
identity development and change. For example, literature on social identity change suggests that
the more severe one perceives their experience of identity change to be, the greater their level of
negative mental health outcome, however, when one perceives that the direction of their identity
change is progressive (rather than regressive), they are less likely to be depressed (Carter, 2017).
Applying similar theoretical enquiry, research on sexual identity change must also include
measurement of self-perceptions regarding the magnitude and direction of one’s experience of
sexual identity change. Additionally, the future research needs to further explore how
demographic information and particularly, other minority identities are associated with changes
in sexual identity. This examination is imperative in understanding sexual identity development
in a multiple minority processes framework (e.g., internalized homophobia, racial and
homophobic discrimination). More importantly, with limited understanding of the relationship
between sexual identity change and health outcomes, the future research must examine
underlying factors and processes like, minority stressors, social networks, and community access
and belongingness, as associated with this relationship over time. Finally, given the
contemporary evidence of sexual identity labels as both non-binary and gender diverse, research
must be cognizant of dichotomous understanding of gender and orientation suggested in sexual
orientation measures (Horner, 2007; Morandini et al., 2017; Russell et al., 2009).
Limitations of the Review
The conclusions are based on a selection of studies that we were able to identify for
inclusion in our review and those that met the inclusion and exclusion criteria for this review.
We used six electronic databases for our literature search, and it is possible some relevant studies
45
may have been overlooked. Studies that are published in a language other than English, and
those that were not published in a peer-reviewed journal were not represented here. Additionally,
as with any literature review, we would like to note publication bias, where significant findings
are given precedence over null finings in publications. Moreover, given the diversity in capturing
the various aspects of sexuality (identity, labels, attraction, and orientation), and the extent to
which some older studies may apply to contemporary evidence is unclear. For example, studies
in this review have captured more traditional sexual identities (gay, lesbian, bisexual); while the
recent studies have documented a rise in nontraditional youth identities, like queer and
questioning (Russell et al., 2009). It is also not possible to construct a clear historical narrative
on how sexual identity change has been measured and reported because of the varied study
settings and measurements used in the studies. Finally, a very small proportion of studies have
examined the association between change in sexual identity and health outcomes, limiting our
ability to conclude how changes and directionality of changes may apply to health outcomes in
various settings; or understand the underlying mechanisms driving these associations.
46
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of sexual orientation. Industrial Relations: A Journal of Economy and Society, 54(1), 33-
58.
Savin-Williams, R. C., & Cohen, K. M. (2004). Homoerotic development during childhood and
adolescence. Child and Adolescent Psychiatric Clinics of North America, 13(3), 529–549.
Savin-Williams, R. C., Joyner, K., & Rieger, G. (2012). Prevalence and stability of self-reported
sexual orientation identity during young adulthood. Archives of Sexual Behavior, 41(1),
103-110.
Scheitle, C. P., & Wolf, J. K. (2018). Religion and sexual identity fluidity in a national three-
wave panel of US adults. Archives of Sexual Behavior, 47(4), 1085-1094.
Silva, T. (2018). A quantitative test of Critical Heterosexuality Theory: Predicting straight
identification in a nationally representative Sample. Sexuality Research and Social
Policy, 15(3), 353-366.
Stewart, J. L., Spivey, L. A., Widman, L., Choukas-Bradley, S., & Prinstein, M. J. (2019).
Developmental patterns of sexual identity, romantic attraction, and sexual behavior
among adolescents over three years. Journal of Adolescence, 77, 90-97.

52
CHAPTER 3 (Study 2)
Change in sexual identity and depressive symptoms among sexual minority adolescents: A
longitudinal investigation

Introduction
Adolescents who identify as a sexual minority (e.g., lesbian, gay, bisexual, pansexual)
consistently report greater mental health symptoms, including depression, compared to
heterosexual youth (Castellví et al., 2017; Marshal et al., 2011). For example, early meta-analytic
work reports significantly higher rates of depression symptoms (standardized mean difference, d
= .33) among sexual minority adolescents compared to their heterosexual peers (Marshal et al.,
2011). While sexual minority adolescents are at risk of multiple mental health problems,
depressive symptoms are particularly relevant when studying adolescents (Martin-Storey &
Crosnoe, 2012). For example, depression occurs at an increasing rate during adolescence (Cole et
al., 2002); and is also known to have harmful effects on multiple developmental outcomes
including likelihood of poor mental health and lowered educational attainment in their late
adolescence and early adulthood (Bulhões et al., 2002; Dekker et al., 2007; Fergusson et al.,
2007). In addition, the literature has suggested within-group heterogeneity in depressive
symptoms such that some studies note bisexual-identified individuals report higher rates of
depression compared to their gay and lesbian peers (Jormn et al., 2002; Ross et al., 2014). Hence,
not only sexual minority adolescents present heightened depressive symptoms, these rates of
depression vary by sexual identities and labels.
Complicating our understanding of the relationship between sexual identity and health
patterns among sexual minority adolescents is a recognition that sexual identities are not
53
immutable and thus may change over time (Diamond et al., 2017; Katz-Wise, 2015; Ott et al.,
2011). Indeed, sexual identity development is a natural part of adolescent development (Perrin,
2002; Savin-Williams & Cohen, 2004) and, white some adolescents may report more stable
sexual identities over time, others may report change in sexual identity (Brown-Saracino, 2015;
Diamond et al., 2017; Katz-Wise & Hyde, 2015; Ott et al., 2011). For example, Savin-William,
Joyner, and Rieger (2012) reported participants who identify as 100% homosexual presented
with the most stable identities, whereas participants who had identities indicating some attraction
to both sexes were most likely to experience a change in 1 year. In a retrospective study, bisexual
participants reported larger post-adolescent changes in their sexual attractions, compared with
participants who reported exclusive same-sex or exclusive other-sex attractions (Diamond et al.,
2017). Although studies have reported on changes in sexual attraction over time (e.g., Cohen et
al., 2020; Cranney, 2016), few studies have reported on change in sexual identities (Mock &
Eibach, 2012; Ott et al., 2011). One longitudinal study with 156 sexual minority youth noted that
72% reported stable identities over time, whereas 17% reported changing their identities from
bisexual to gay or lesbian (Rosario et al., 2006).
In addition, research suggests that cisgender females may be more likely to report a
change compared to males over time (Fricke & Sironi, 2020; Savin-Williams et al., 2012;
Stewart et al., 2019; Oi & Wilkinson, 2018). Indeed, in a recent systematic review, Diamond
(2016) reported that sexual identity change was somewhat more common among cisgender
females than males; however, no conclusions about the extent of difference by birth sex in sexual
identity change and the causes of such differences have not be determined. Some of these
differences in sexual identification and change by birth sex could be associated with stricter
notions of masculinity and variation in sexual identity development trajectories (Breen &
54
Karpinski, 2013; Diamond, 2016; Kilianski, 2003). For example, some evidence suggests that
cisgender males typically describe their sexuality often as continuous and unchanging; however,
cisgender females often describe it as more fluid, evolving and contextual (Diamond, 2008;
Kinnish et al., 2005; Radtke, 2013).
Given the established relationship between identity and behavioral health, changes in
sexual identity may have implications for changes in mental health. However, whether these
changes would result in positive or negative outcomes remains unclear. On the one hand, sexual
identity change may represent a stressful experience as individuals experience a shift in their
identity (Katz-Wise et al., 2018; Ott et al., 2011; Rosario et al., 2011). For example, social
identity theory would suggest that because identity is in part derived from membership in a
certain group (Stets & Burke, 2000; Tajfel & Turner, 1979), and therefore experiencing the loss
of support from one identity group during a shift in identity would be detrimental to one’s health
(Everett, 2015; Granic, 2005) by way of a disruption in self-relevant schemas and social support
networks (Haslam et al., 2009; Rosario at al., 2011). Some support for this exists; Everett (2015)
found changes in sexual identity toward a more same-sex orientation was associated with
increased depressive symptoms. Alternatively, a shift toward an identity that is more authentic
and congruent may act as a protective factor, mitigating stress. Meyer (2003; sexual minority
stress model) has argued this point, suggesting that identity integration is related to self-
acceptance and diminishment of internalized homophobia, wherein an individual’s acceptance of
and pride in their sexual identity may help in coping with stressors.
Current Study and Hypotheses
Given the importance of identity formation in healthy adolescent development (Vaughan
& Waehler, 2010), the present study examined changes in sexual minority identity and their
55
association with mental health outcomes, in a national longitudinal data from sexual minority
adolescents aged 14–17 years. We ask the following research questions: (1) does prevalence of
change in sexual identity differ by birth sex? and (2) if change in sexual identity has an effect on
depressive symptoms over time? Given some empirical evidence on sexual fluidity among
females, and theoretical framework suggesting difference in gender expectations and social
identification by birth sex, we hypothesized that some youth would report a change in sexual
identity and this change in identity would be higher among females assigned at birth. For the
second question, we hypothesized that there will be an effect of change in sexual identity on
depressive symptoms; however, we were uncertain as to whether changes in identity would be
associated with improved or worsened mental health. While we did not start with directional
hypotheses for our second question, in line with theories of sexual concordance and integration,
change in identity may have a positive effect on depressive symptoms over time. However, in
line with social identity theory suggesting shift in identity as loss of existing social support and
network, change in identity may have a negative effect on depressive symptoms over time.
Moreover, given some evidence on difference in sexual identification and change by birth-sex, it
is also important to understand if the effect of change in sexual identity on depressive symptoms
looks different for cisgender males and cisgender females.
Methods
Participants and Procedures
A national community sample of sexual minority adolescents was recruited for a
longitudinal investigation via targeted social media advertising (Facebook, Instagram, YouTube)
based on geography and urbanicity to purposefully recruit adolescents from across the United
States and in both urban and rural areas. A brief screener determined study eligibility (aged 14–
56
17, identified as cisgender, provided a U.S.-based ZIP code, and reported a sexual attraction
other than heterosexual or straight). Data come from a parent study of cisgender, sexual minority
adolescents aimed at understanding experiences of sexual minority stress and behavioral health
during adolescence. To ensure data integrity, several checks for fraud (e.g., duplicate email
address or contact information, screening out on first attempt and re-entering with false
responses to get through the screener) and data quality (e.g., unrealistic survey completion times,
low validation scores based on attention check measures, or decline to answer numerous
questions) were completed before respondents were included in the finalized baseline data.
Participants considered to be nonfraudulent were given the opportunity to refer up to three other
adolescents into the study. All participants provided online assent prior to completing the survey.
A total of 1077 participants completed baseline of the longitudinal investigation, and they were
contacted for follow-up survey at every six-months. The current analyses use 3 time-points
(baseline, 6-months, 12-months and 18-months follow-up). Participants received $15 for
completing the baseline survey and could earn another $10 for each of the three people they
referred to the study. Participants were paid incrementally for their participation in follow-up
surveys. All study methods were approved by the authors’ University Institutional Review Board
(IRB#: UP-17-00538).
Measures
Demographics.
Demographic characteristics (age, race and ethnicity, sex at birth, sexual orientation, and
socioeconomic status) were assessed with items created by the authors. The race and ethnicity
item had six response options (Native American, American Indian, or Alaska Native; Asian or
Pacific Islander; Black or African American; White; Latino or Hispanic; and race and ethnicity
57
not listed); respondents could choose all categories with which they identified. Participants who
chose multiple racial and ethnic categories were coded as multiracial. For analytic purposes, this
variable was collapsed into six categories (White, Latino or Hispanic, multiracial or multiethnic,
Black or African American, Asian or Pacific Islander, and Native American, American Indian, or
Alaska Native). To assess sex, participants were asked “What was your sex assigned at birth?”
Response options were “male” and “female.”
Sexual orientation/identity was assessed by asking an open-ended question, “What would
you say is your sexual orientation or identity?” The research team used existing literature, prior
work with sexual identity variables, and a range of responses on this question to design a
qualitative coding scheme. The responses were coded as gay, lesbian, bisexual, pansexual,
bisexual or pansexual, complex or multiple identities (e.g., gay pansexual, bisexual lesbian),
queer, straight or mostly straight, asexual, and another identity (e.g., demisexual, agrosexual).
Change in sexual identity.
Change in sexual identity was measured as a reported change in sexual identity between
two consecutive waves. A different identity reported between time point t and t + 1 was coded as
1, whereas reporting the same identity at time point t and t + 1 was coded as 0.
Depressive Symptoms.
Symptoms of depression were measured using the Center for Epidemiologic Studies
Depression Scale Short Form (CES-D-4), which contains four items assessing the frequency of
depression symptoms during the past week. Items include “I felt lonely” and “I had crying
spells.” Participants responded on a Likert scale with response options ranging from 0 (rarely or
none of the time [less than 1 day]) to 3 (most or all of the time [5 –7 days]); scores were summed
(0–12; Melchior et al., 1993).
58
Analytic Plan
Chi-square tests were run to explore differences in change in sexual identity status and
number of changes in identity by birth sex (male and female). To address the aims of the study, a
multi-step process was employed to examine the effect of sexual identity change on depressive
symptoms. A time-varying covariate latent growth model (Figure 2.1) was used to examine how
changes in sexual identity influence contemporaneous change in depressive symptomology
(Grimm, Ram & Estabrook, 2017). A taxonomy of models was tested to determine if the effect
of sexual identity change is a stable effect (i.e., constrained to be equal over time) versus a
varying effect (i.e., allowed to be estimated freely). In the next step, each time-varying covariate
latent growth model was modeled in a multiple group analysis framework using birth sex (male
and female) to examine if the difference in the effect of sexual identity change on depressive
symptoms vary by birth sex. A total of 1077 participants completed baseline; while the
missingness at timepoint 2 was 9.9% (n = 107), followed up 12.2% (n = 131) at timepoint 3, and
15.2% (n = 164) at timepoint 4. Those who were missing at follow up surveys did not differ from
those who completed the follow up surveys on age, birth sex, sexual minority stress, race and
depressive symptoms. However, a greater number of males missed timepoint 2 (13.7% vs 8.1%;
χ
2
(1) = 8.6, p = .003) timepoint 3 (16.8% vs 9.9%; χ
2
(1) = 10.8, p = .001) timepoint 4 (21.0% vs
12.4%; χ
2
(1) = 13.8, p < .001), compared to those reported females at birth. Analyses were
carried out in the structural equation modeling (SEM) framework using Mplus 8.0; and the
skewness and missing values of the outcome variables will be addressed by using a robust
estimation method, MLR, implemented in Mplus 8 (Muthén & Muthén, 2009).

59
Figure 2.1: Time Varying Co-variate Model

Results
Sample Description
Table 2.1 contains demographic information. At baseline, the average age of the
participants was 15.9 years (SD = 1.0); most reported sex assigned at birth as female (66.8%; n =
720). 58% (n = 626) of the sample identified as White or Caucasian, followed by Latino or
Hispanic (13.7%; n = 147), multi-racial (10.3%; n = 111), Black or African American (9.4%; n =
90), Asian or Pacific Islander (6.7%; n = 72) and Native American, American Indian, or Alaska
Native (2.9%; n = 31). In terms of sexual identity, 38.8% (n = 418) identified as gay or lesbian,
followed by bisexual (33.5%; n = 361), pansexual (12.4%; n = 133), bisexual or pansexual
(4.0%; n = 43), complex or multiple identities (3.1%; n = 33), queer (2.7%; n = 29), questioning
(1.7%; n = 18), asexual (1.6%; n = 16), mostly straight (1.3%; n = 14) and another identity
(1.0%; n =11).

60
Table 2.1: Sample Characteristics (N = 1077)
n (%) or M (SD)

Age (Time 1) 15.86 (0.98)
Male 357 (33.2%)
Female 720 (66.8%)
Race
White/ Caucasian 626 (58.1%)
Latino/Hispanic 147 (13.7%)
Black or African American 90 (9.4%)
Asian or Pacific Islander 72 (6.7%)
Native American or American
Indian
31 (2.9%)
Multi-racial or multi-ethnic 111 (10.3%)

Sexual Identity

Gay 239 (22.2%)
Lesbian 179 (16.6%)
Bisexual 361 (33.5%)
Pansexual 133 (12.4%)
Bisexual or Pansexual 43 (4.0%)
Complex or Multiple Identity 33 (3.1%)
Mostly Straight 14 (1.3%)
Queer 29 (2.7%)
Questioning 18 (1.7%)
Asexual 17 (1.6%)
Another Identity 11 (1.0%)

Change in Sexual Identity

Number of changes
0 591 (59.6%)
1 228 (23.0%)
2 138 (13.9%)
3 35 (3.5%)
Depression
Time 1 6.49 (3.40)
Time 2 6.27 (3.46)
Time 3 5.90 (3.43)
Time 4 6.02 (3.39)
61
Change in Sexual Identity
Around 40% of the sample (n = 401) reported at least one change in sexual identity over
4 time-points. In terms of number of changes, 23.0% (n=228) reported one change, followed by
two changes (13.9%; n = 138), and three changes (3.5%; n = 35).
In the chi-square analyses (Table 2.2), those who identified as female at birth were more
likely to report at least one change in sexual identity (46.9% vs 26.6%, χ
2
(1) = 36.9, p < .0001),
compared to those who identified as male at birth. Similarly, those who identified female at birth
were more likely to report a greater number of changes in sexual identity as compared to their
counterparts; two changes and three changes (χ
2
(3) = 38.1, p < .0001).
Table 2.2: Sexual identity change by Sex assigned at birth
Change in
Sexual Identity
All Sample
n (%)
Males
n (%)
Females
n (%)
Chi Square
(d.f.)

At least one
change

401 (40.4%)

84 (26.6%)

317 (46.9%)

36.89 (1) *

Number of
changes

0 time 591 (59.6%) 232 (73.4%) 359 (53.1%)
1 time 228 (23.0%) 52 (16.5%) 176 (26.0%)
2 times 138 (13.9%) 27 (8.5%) 111 (16.4%)
3 times 35 (3.5%) 5 (1.6%) 30 (4.4%) 38.09 (3) *

Note: Number of changes were counted as change in sexual identity reported between two
consecutive time-points. * indicates significance at p < 0.05.

Effects of change in sexual identity on depressive symptoms
Results of our model fitting process indicated a model where effect of change in sexual
identity was constrained to be equal over time in our time-varying covariate latent growth
models. As shown in Table 2.3, change in sexual identity was significantly associated with
62
reporting fewer depressive symptoms (b = -0.591, SE = 0.02, p = 0.004). The model controlled
for birth sex, race and age (Model 1).
In the next step (Model 2), we examined the difference in the effect of sexual identity
change on depressive symptoms by birth sex. Change in sexual identity was significantly
associated with reporting fewer depressive symptoms for those identifying as female at birth (b =
-0.591, SE = 0.02, p < 0.01). However, there was no significant effect of change in sexual
identity on depressive symptoms among those identifying as male at birth (b = -0.718, SE = 0.49,
p = 0.15). The models controlled for age and race.
Table 2.3: Multi-group latent growth curve with time-varying covariates
Model 1 Model 2
Variable Est. (SE) Est. (SE) Est. (SE)

Male Female
Change 1 on Depression (Time 2) -0.616 (0.22) * -0.718 (0.49) -0.591 (0.02) *

Change 2 on Depression (Time 3) -0.616 (0.22) * -0.718 (0.49) -0.591 (0.02) *
Change 3 on Depression (Time 4) -0.616 (0.22) * -0.718 (0.49) -0.591 (0.02) *
Growth parameters

Intercept 9.987 (1.69) * 6.263 (3.01) * 12.836 (2.03) *
Slope -1.709 (0.91) -3.028 (1.65) -0.996 (1.09)
Variance
Intercept 7.153 (0.65) * 7.376 (1.14) * 6.904 (0.78)
Slope 0.904 (0.29) * 1.148 (0.50) * 0.791 (0.35) *

Note: Change = change in sexual identity; Est. = unstandardized estimates; SE = standard error.
Model 1 controlled for birth sex (reference: male), race (reference: white) and age. Model 2
controlled for race (reference: white) and age * indicates significance at p < 0.05.

Discussion
The current study sought to expand our understanding of changes in sexual identities and
whether they are associated with changes in health risk over time. The study examined effects of
changes in sexual identities on depression among sexual minority adolescents using a multigroup
63
time-varying covariate latent growth model. In the study, instead of employing sexual attraction
or orientation (scale-based), we used sexual identity labels to assess change over time.
In the sample, 40% of sexual minority adolescents reported at least one change in sexual
identity over 4 time-points over 18-month period. Additionally, in terms of number of changes,
23.0% (n=228) reported one change, followed by two changes (13.9%; n = 138), and three
changes (3.5%; n = 35). This finding is consistent with the literature, where 28-67% of sexual
minority adolescents and youth have reported change in sexual identity orientation over time
(Cohen et al., 2020; Diamond, 2008; Morgan et al., 2018; Silva, 2018). We believe higher
reporting on sexual identity change is probably because of employing a longer time frame (6
months) compared to a shorter period and reporting on change in sexual identity instead of using
a sexual orientation scale as in other studies (Diamond et al., 2017; Ott et al., 2011; Katz-Wise et
al, 2018; Savin-William et al., 2012).
With regards to our first research question (i.e. rate of change in sexual identity differ by
birth sex), we found significant difference in reported change and number of changes in sexual
identity by birth sex. This supports our hypothesis that adolescents assigned female at birth, are
more likely to report a change in sexual identity compared to their male counterparts. As with
prior research (Fricke & Sironi, 2020; Savin-Williams et al., 2012; Stewart et al., 2019; Oi &
Wilkinson, 2018), in our study a greater number of participants assigned female at birth reported
a change in sexual identity compared to their male counterparts (46.9% versus 26.6%). This
difference was also found in total number of changes, where females were more likely to report a
greater number of changes than males. This finding in particular is important to advance our
understanding of how identification and labeling may vary by sex, and supports the evidence of
sexual fluidity among females (Fricke & Sironi, 2020; Savin-Williams et al., 2012; Stewart et al.,
64
2019; Oi & Wilkinson, 2018). These lower rates among males could be associated with stricter
notions of masculinity, social and cultural expectations on gender, and more negative attitudes
towards gay men and homosexuality (Breen & Karpinski, 2013; Kilianski, 2003), however, these
differences and underlying factors are yet to be examined. Although the extant research suggests
that all of these phenomena are somewhat more common in females than in males, it is difficult
to draw reliable conclusions about the cause of such differences by birth sex.
We found change in sexual identity was significantly associated with reporting fewer
depressive symptoms over time among sexual minority adolescents. The finding on the negative
effect of change in sexual identity on depressive symptoms points to the conflicted evidence on
sexual identity change and changes in mental health outcomes. For example, Everett (2015), in
the National Longitudinal Study of Adolescent to Adult Health, found that youth who reported
changes in sexual identity were more likely to report an increase in depressive symptoms.
Contrarily, Rosario and colleagues (2011) suggested that identity change toward greater identity
integration is associated with decreased depressive symptoms. This is in line with Meyer’s
(2003) proposed model of sexual minority stress, wherein he argued identity integration is
related to self-acceptance and a decline in internalized homophobia and may help people cope
with stressors. However, we believe these underlying mechanisms, like minority stress, exposure
to community, and support, may be driving this reported change, and there is a need to further
investigate factors associated with change in identity to better understand the processes of
identity development among adolescents.
In addition, in our multigroup model, we only found significant effect of sexual identity
change on depressive symptoms for female adolescents and not for their male counterparts. We
believe, this variation is in parts due to the directionality of change in sexual identity which
65
remains unclear. Given the fact that this study used sexual identity labels and not scale-based
attraction, the issue of directionality becomes more complex. Since, the sexual integration may
differ from individual to individual, it is difficult to measure it in this sample. However, in this
sample, 85% of males identified as gay or bisexual at baseline, compared to only 66%
identifying as lesbian or bisexual at the baseline. One of the reasons for more change reported
among females compared to males, could also be attributed to sexual identification at the
baseline. Post-hoc analyses of the sample also revealed that those identifying as gay/lesbian or
bisexual are least likely to report a change in the subsequent time-point (14.1% versus 49.3%; χ
2
= 132.1, p < .0001). Given the variations in reported change and reasons for change, there needs
to be more in-depth analyses to understand cause of such differences by sex-at-birth.
The results from this study, particularly those regarding change in identities, have
important public health implications. First, findings challenge the traditional methods of
gathering and using data on sexual identities. The study aimed to further our understanding of
sexual identities in non-static ways by examining changes in identities over time.
Methodological lessons from the study would be beneficial in informing nationwide longitudinal
studies; for example, how national surveys like the Youth Risk Behavior Surveillance System or
National Youth Survey may gather data on identities in non-static and multidimensional ways.
The results add to the limited knowledge on the complex relationship between sexual identity
change and mental health risks over time among adolescents. Future research with adolescents
should be cautious of non-static development of sexual identities and must also understand needs
of adolescent’s experiences of sexual identity changes.

66
Limitations and Conclusion
This study had several limitations. This study focused on cisgender youth, it does not
discuss the disparities experienced by transgender and gender nonbinary adolescents (Srivastava
et al., 2020). Internet survey research has distinct advantages, especially for reaching
marginalized, geographically dispersed minority populations. We were able to recruit a large
sample of diverse sexual minority adolescents from both urban and rural areas of United States.
However, internet-based recruitment and data collection also have limitations and challenges. In
terms of generalizability our findings are limited to those adolescents who have access to internet
and online spaces. Additionally, internet survey research also has validity concerns (e.g.,
duplicate participations). However, our study protocols addressed these concerns through
rigorous validity checks. All data were self-reported; however, anonymity was ensured by not
collecting any identifying information, which minimized response-bias. Changes of sexual
identity were measured as a difference in response to sexual identity question between two time-
points, however, this may not be a conscious change on adolescent’s part.
Despite these limitations, to our knowledge, this paper is the first to examine the
relationship between sexual identity change and mental health in a nationwide sample of sexual
minority adolescents. Given pervasive homonegative social and political climates in many areas,
sexual minority adolescents will continue to experience sexual identity development in less
supportive environments, resulting in changes in identities over time. The expanding evidence
that sexual identity changes are associated with negative mental health outcomes is essential in
ways we understand sexual identity development among adolescents. Hence, the mechanisms
underlying the change in sexual identity and subsequent change in health outcomes need more
67
exploration, along with research on variation by demographic variables including sex and
gender.

68
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CHAPTER 4 (Study 3)
Sexual identity change, identity management stress and depression among a national
sample of sexual minority adolescents

Introduction
Adolescence comes with the slow move away from parents and toward peers (Brown &
Bakken, 2011; Nickerson & Nagle, 2005), the onset of romantic relationships (Connolly et al.,
2014), and a strengthening sense of sexuality (Tolman & McClelland, 2011). Additionally,
adolescence is an important developmental period for sexual identity development (Perrin, 2002;
Savin-Williams & Cohen, 2004); though, experiences and processes of sexual identity
development may differ among sexual minority adolescents. For example, some adolescents may
experience a more linear pathway of sexual identity development (Cass, 1984; Halpin & Allen,
2004), while for some adolescents this process is non-linear, and they may adopt multiple sexual
identity labels as they develop (Morgan, 2013; Rosario et al., 2011). Identity control theory
posits the importance of identity alignment among the individual and their internal assessment on
how they are performing their identity (Burke, 2006). With respect to sexual identities it would
mean that different aspects of sexuality (attraction, behavior and identity) must have coherence
and concordance (Igartua et al., 2009; Rosario et al., 2011). However, discordance among these
aspects of sexuality or difference in identity development processes may result in one or more
change in sexual identity over time (Rosario et al., 2011). Some adolescents may identify with a
fixed sexual identity (remain consistent over time), whereas others may present changes in
sexual identification (identities change over time) (Diamond et al., 2017; Katz-Wise & Hyde,
2015; Ott et al., 2011). Previous studies on sexual identity changes among youth have ranged
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from 28% to 67% in samples of sexual minority youth (Cohen et al., 2020; Diamond, 2008;
Morgan et al., 2018; Silva, 2018).
In addition, these processes of sexual identity development may differ by birth sex. Some
evidence suggests that cisgender males typically describe their sexuality often as continuous and
unchanging; however, cisgender females often describe it as more fluid, evolving and contextual
(Diamond, 2008; Kinnish et al., 2005; Radtke, 2013), leading to different pathways to identity
development. This difference in identity development by birth sex could be extended to
differential rates of change by sexuality identity between cisgender males and females. For
example, research suggests that cisgender females may be more likely to report a change
compared to males over time (e.g., Oi & Wilkinson, 2018 (19.3% versus 13.3%); Fricke &
Sironi, 2020 (18% vs 6.2%), Savin-Williams et al., 2012 (17.8% vs 6.2%), and Stewart et al.,
2019 (26% vs 11%)).); however, no conclusions about the extent of difference by birth sex in
sexual identity change and the causes of such differences have not be determined. Though, from
a feminist theoretical standpoint, some of these differences can be explained by dominant notions
of masculinity for males and more acceptability of fluidity in sexuality for females (Breen &
Karpinski, 2013; Diamond, 2016; Kilianski, 2003).
Another important consideration of sexual identity development is that these processes
could be stressful for some adolescents. The internal process of understanding, internalizing, and
confusion in regard to one’s sexual identity may represent an additional sexual minority stressor
(Katz-Wise et al., 2018), referred to as identity management stress (e.g., Goldbach, Schrager &
Mamey, 2017). For example, discordance among aspects of sexuality (Igartua et al., 2009) or
developing identity in a homonegative climate (Page et al., 2013) could lead to negative
experience of sexual identity. Indeed, some research has found confusion between various sexual
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identities and discordance between sexual behavior or attraction, and sexual identification may
lead to identity dissatisfaction, and stress (Horley & Clarke, 2016; Ott et al., 2011).
Moreover, based on decades of theoretical and empirical evidence we know chronic
stress can lead to negative mental health outcomes (Marin et al., 2011; Pearlin, 1999). Meyer
(2003) argues that sexual minority adolescents are exposed to heightened stress related to a
variety of stigma and discrimination-related experiences based on their non-heterosexual status,
often referred to as sexual minority stress (Goldbach et al., 2014; Marshal et al., 2011; Meyer,
2003). Research suggests that adolescents experiencing stress associated with identity
management (e.g., disagreement between sexual behavior or attraction, and sexual identification)
may report more symptoms of depression (Caplan, 2017; Clark et al., 2015; Everett, 2015).
Among sexual minority risk of depressive symptoms are particularly relevant when studying
adolescents (Martin-Storey & Crosnoe, 2012). For example, depression occurs at an increasing
rate during adolescence (Cole et al., 2002); and is also known to have harmful effects on multiple
developmental outcomes through their late adolescence and early adulthood (Bulhões et al.,
2002; Dekker et al., 2007; Fergusson et al., 2007).
Current Study and Hypotheses
Evidence suggests the importance of examining stressful experiences associated with
identity management, and depressive symptomology among sexual minority adolescents.
However, we do not know how this stress specific to identity management relates to depressive
symptoms over time. In addition, it is unknown if these two processes (stress and depression)
look different for those who report a change in sexual identity versus those who did not.
Moreover, given empirical evidence that sexual identity change rates different by birth sex, it is
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also important to understand if the relationship between identity management stress, depression,
and sexual identity change differs by birth sex.
To address these gaps, this paper studied time-sequential associations between two
processes (identity management stress and depression) over time, in a national longitudinal data
from sexual minority adolescents aged 14–17 years. We ask the following research questions: if
relationship between identity management stress and depression over time differs by sexual
identity change status? and if these association look different among cisgender females compared
to males. We hypothesized that the temporal association between depression and identity
management stress differ by sexual identity change; however, we were uncertain of the effects of
these relationships. Similarly, given theoretical and empirical on difference in sexual identity
development and change by birth-sex, we hypothesize that the temporal association between
identity management stress and depression by sexual identity change status will look different
for cisgender females and males.
Methods
Participants and Procedures
A national community sample of sexual minority adolescents was recruited for a
longitudinal investigation via targeted social media advertising (Facebook, Instagram, YouTube)
based on geography and urbanicity to purposefully recruit adolescents from across the United
States and in both urban and rural areas. A brief screener determined study eligibility (aged 14–
17, identified as cisgender, provided a U.S.-based ZIP code, and reported a sexual attraction
other than heterosexual or straight). Data come from a parent study of cisgender, sexual minority
adolescents aimed at understanding experiences of sexual minority stress and behavioral health
during adolescence. To ensure data integrity, several checks for fraud (e.g., duplicate email
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address or contact information, screening out on first attempt and re-entering with false
responses to get through the screener) and data quality (e.g., unrealistic survey completion times,
low validation scores based on attention check measures, or decline to answer numerous
questions) were completed before respondents were included in the finalized baseline data.
Participants considered to be nonfraudulent were given the opportunity to refer up to three other
adolescents into the study. All participants provided online assent prior to completing the survey.
A total of 1077 participants completed baseline of the longitudinal investigation, and they were
contacted for follow-up survey at every six-months. The current analyses use 3 time-points
(baseline, 6-months, 12-months and 18-months follow-up). Participants received $15 for
completing the baseline survey and could earn another $10 for each of the three people they
referred to the study. Participants were paid incrementally for their participation in follow-up
surveys. All study methods were approved by the authors’ University Institutional Review Board
(IRB#: UP-17-00538).
Measures
Demographics
Demographic characteristics (age, race and ethnicity, sex at birth, sexual orientation, and
socioeconomic status) were assessed with items created by the authors. The race and ethnicity
item had six response options (Native American, American Indian, or Alaska Native; Asian or
Pacific Islander; Black or African American; White; Latino or Hispanic; and race and ethnicity
not listed); respondents could choose all categories with which they identified. Participants who
chose multiple racial and ethnic categories were coded as multiracial. For analytic purposes, this
variable was collapsed into six categories (White, Latino or Hispanic, multiracial or multiethnic,
Black or African American, Asian or Pacific Islander, and Native American, American Indian, or
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Alaska Native). To assess sex, participants were asked “What was your sex assigned at birth?”
Response options were “male” and “female.”
Sexual orientation/identity was assessed by asking an open-ended question, “What would
you say is your sexual orientation or identity?” The research team used existing literature, prior
work with sexual identity variables, and a range of responses on this question to design a
qualitative coding scheme. The responses were coded as gay, lesbian, bisexual, pansexual,
bisexual or pansexual, complex or multiple identities (e.g., gay pansexual, bisexual lesbian),
queer, straight or mostly straight, asexual, and another identity (e.g., demisexual, agrosexual).
Change in sexual identity
Change in sexual identity was measured as a reported change in sexual orientation or
identity between two consecutive waves. A different identity reported from the previous time-
point was coded as 1, and no difference between two time-points was coded as 0. For the
purpose of analysis, a change in identity was coded as 1 for reported at least one change in
sexual identity over 4 time-points, and 0 for consistently reporting sexual identity across time-
points.
Identity Management Stress
To assess sexual identity specific stress, we used a subscale ‘Identity Management’ from
the 54-item Sexual Minority Adolescent Stress Inventory (α = .98). The subscale included 3
items (‘I am questioning how to label my sexual orientation’; ‘I am having trouble accepting that
I am LGBTQ.’; ‘I feel pressured to label myself as gay or lesbian.’); and responses to items were
scored in a binary fashion: “Yes” responses are coded as 1, “No” responses are coded as 0. The
subscale was administered for endorsement on items in the past 30 days at each time-point
(baseline to 18-month follow up). The 30-day subscale scores are created as percentages of
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endorsed statements (Cronbach α = 0.79; Composite reliability =0.92; Schrager, Goldbach &
Mamey, 2018).
Depressive Symptoms.
Symptoms of depression were measured using the Center for Epidemiologic Studies
Depression Scale Short Form (CES-D-4; α = 0.843), which contains four items assessing the
frequency of depression symptoms during the past week. Items include “I felt lonely” and “I had
crying spells.” Participants responded on a Likert scale with response options ranging from 0
(rarely or none of the time [less than 1 day]) to 3 (most or all of the time [5 –7 days]); scores
were summed (0–12; Melchior et al., 1993).
Analytic Plan
The paper examines if there is a difference in time-sequential associations between
mental health outcomes (depression) and identity management stress, by sexual identity change
status (no change versus change) using a multigroup autoregressive cross-lagged (ARCL) model.
The cross-lagged design comprises two or more variables at two or more time points. It yields
three types of effects: synchronous associations (correlations between different variables
measured at the same time), stability effects (correlations between the same variable measured at
different times), and cross-lagged effects. The cross-lagged effects refer to the prediction of one
or more variables by other (temporarily preceding) variables, controlling for the baseline level of
the predicted variable. A multi-step process was employed to time-sequential associations
between health outcomes and minority stress, by identity change status.
In Step 1, each variable was allowed to predict subsequent follow-up assessment of itself,
measuring the stability of individual differences in the construct from one occasion to the next.
Cross-lagged effects were estimated, controlling for the previous level of the construct being
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predicted. Thus, when depression at Wave 1 was predicted by identity management stress at
baseline, depression at baseline was controlled to rule out the possibility that the cross-lagged
effect is simply due to correlations between depression and stress at baseline (Anyan, Rios &
Hjemdal, 2020). In Step 2, models were tested in a multiple group analysis framework using
sexual identity change and birth sex variables to permit direct comparisons of the association
between change in depressive symptoms and stress between groups. The model fit was evaluated
using several indices: the comparative fit index (CFI), the root mean square error of
approximation (RMSEA), the Tucker–Lewis Index (TLI), and p of Close Fit (PCLOSE).
A total of 1077 participants completed baseline; while the missingness at timepoint 2 was
9.9% (n = 107), followed up 12.2% (n = 131) at timepoint 3, and 15.2% (n = 164) at timepoint 4.
Those who were missing at follow up surveys did not differ from those who completed the
follow up surveys on age, birth sex, sexual minority stress, race and depressive symptoms.
However, a greater number of males missed timepoint 2 (13.7% vs 8.1%; χ
2
(1) = 8.6, p = .003)
timepoint 3 (16.8% vs 9.9%; χ
2
(1) = 10.8, p = .001) timepoint 4 (21.0% vs 12.4%; χ
2
(1) = 13.8,
p < .001), compared to those reported females at birth. Analyses were carried out in the structural
equation modeling (SEM) framework using Mplus 8.0; and the skewness and missing values of
the outcome variables were addressed by using a robust estimation method, MLR, implemented
in Mplus (Muthén & Muthén, 2009).
Results
Sample Description
Table 3.1 contains demographic information. At baseline, the average age of the
participants was 15.9 years (SD = 1.0); most reported sex assigned at birth as female (66.8%; n =
720). In terms of sexual identity, 38.8% (n = 418) identified as gay or lesbian, followed by
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bisexual (33.5%; n = 361), pansexual (12.4%; n = 133), bisexual or pansexual (4.0%; n = 43),
complex or multiple identities (3.1%; n = 33), queer (2.7%; n = 29), questioning (1.7%; n = 18),
asexual (1.6%; n = 16), mostly straight (1.3%; n = 14) and another identity (1.0%; n =11). In the
sample, 58.2% (n=626) identified as White/Caucasian, followed by Latino/Hispanic (13.7%; n =
147), Multi-racial (10.3%; n = 111), Black/African American (8.4%; n = 90), Asian/Pacific
Islander (6.7%; n = 72), and Native American/ America Indian (2.9%; n = 31). Around 40% of
the sample (n = 401) reported at least one change in sexual identity over 4 time-points. In terms
of number of changes, 23.0% (n=228) reported one change, followed by two or more changes
(17.4%; n = 173).
Table 3.1: Participant Characteristics (N = 1077)
n (%) or M (SD)

Age (Time 1) 15.86 (0.98)
Male 357 (33.2%)
Female 720 (66.8%)
Race
White/ Caucasian 626 (58.1%)
Latino/Hispanic 147 (13.7%)
Black or African American 90 (9.4%)
Asian or Pacific Islander 72 (6.7%)
Native American or American
Indian
31 (2.9%)
Multi-racial or multi-ethnic 111 (10.3%)
Sexual Identity
Gay 239 (22.2%)
Lesbian 179 (16.6%)
Bisexual 361 (33.5%)
Pansexual 133 (12.4%)
Bisexual or Pansexual 43 (4.0%)
Complex or Multiple Identity 33 (3.1%)
Mostly Straight 14 (1.3%)
Queer 29 (2.7%)
Questioning 18 (1.7%)
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Asexual 17 (1.6%)
Another Identity 11 (1.0%)
Change in Sexual Identity
At least one change 401 (40.4%)
Number of changes
0 times 591 (59.6%)
1 time 228 (23.0%)
2 or more times 173 (17.4%)
Identity Management Stress
Time 1 30.21 (32.24)
Time 2 26.69 (31.47)
Time 3 26.87 (31.18)
Time 4 26.95 (30.07)
Depression
Time 1 6.49 (3.40)
Time 2 6.27 (3.46)
Time 3 5.90 (3.43)
Time 4 6.02 (3.39)

Depression and Identity Management Stress
Results of our model fitting process indicated a model where effect of autoregressive
components and cross-lagged were constrained to be equal over time in our multi-group ARCL
models. Both our models resulted in adequate model fit (Model 1: grouping by sexual identity
change status; CFI = .85, TLI = 0.80, RMSEA = .08) (Model 2: grouping by sexual identity
change status and birth sex; CFI = .85, TLI = 0.80, RMSEA = .08). Prior work has shown
RMSEA values between .05 and .08 to be close to good fit criteria, as RMSEA is one index that
is not affected by sample size. Our CFI value indicates poor to adequate model fit (Table 3.2).

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Table 3.2: Goodness of fit statistics for the Mental Health and Minority Stress ARCL Models
df Χ
2
p CFI TLI RMSEA
Model 1 124 474.14 p < .0001 0.85 0.80 0.075
Model 2 224 551.85 p < .0001 0.84 0.79 0.077

Note: df = degrees of freedom; χ2 = chi-square values; p = probability values; CFI = comparative
fit index; TLI = Tucker-Lewis index; RMSEA = root mean square error approximation

Cross-lagged effects
Model 1 examined the temporal association between identity management stress and
depression by sexual identity status (Table 3.3). We found that depression predicted subsequent
identity management stress for both groups, those who reported a change in sexual identity (Est.
= 0.828; SE = 0.25; p < 0.001) and those who did not report a change (Est. = 0.657; SE = 0.18; p
= 0.001). Interestingly, we did not find that identity management stress predicted subsequent
depression.

Table 3.3: Unstandardized estimates and standard errors for the ARCL Model 1 (grouping by
sexual identity change status)
MODEL 1
NO CHANGE CHANGE
EST. (SE) EST. (SE)

DEP (T2) ON STRESS (T1)

0.002 (0.002)

0.005 (0.003)
DEP (T3) ON STRESS (T2) 0.002 (0.002) 0.005 (0.003)
DEP (T4) ON STRESS (T3) 0.002 (0.002) 0.005 (0.003)
STRESS (T2) ON DEP (T1) 0.657 (0.18) * 0.828 (0.25) *
STRESS (T3) ON DEP (T2) 0.657 (0.18) * 0.828 (0.25) *
STRESS (T4) ON DEP (T3) 0.657 (0.18) * 0.828 (0.25) *
DEP (T2) ON DEP (T1) 0.582 (0.02) * 0.563 (0.03) *
DEP (T3) ON DEP (T2) 0.582 (0.02) * 0.563 (0.03) *
DEP (T4) ON DEP (T3) 0.582 (0.02) * 0.563 (0.03) *
STRESS (T2) ON STRESS (T1) 0.462 (0.02) * 0.432 (0.03) *
STRESS (T3) ON STRESS (T2) 0.462 (0.02) * 0.432 (0.03) *
STRESS (T4) ON STRESS (T3) 0.462 (0.02) * 0.432 (0.03) *

85
Note: Models controlled for age, birth sex (reference: male) and race (reference: white). No
Change= No change in sexual identity; Change= At least one change in sexual identity across 4
time points. DEP= Depressive symptoms, STRESS= Identity Management Stress; T1-T4= Time
point 1- Time point 4; EST= Unstandardized Estimates; SE= Standard Error; * = significance at
p value < 0.05

Difference by birth sex
Our final model examined the temporal association between identity management stress
and depression by sexual identity status and birth sex (Table 3.4). Among females, those who
reported a change in sexual identity, we found a reciprocal effect of identity management stress
and depression over time (Figure 3.1A). Depression predicted subsequent identity management
stress (Est. = 0.433; SE = 0.25; p <0.05), and identity management stress predicted subsequent
depression (Est. = 0.006; SE = 0.003; p <0.05). However, among those females who did not
report a change in sexual identity, we did not find any cross-lagged effects (Figure 3.1B).

Figure 3.1A: Time-sequential associations between depression symptoms and identity
management stress for females who reported change in sexual identity

Note: Arrows represent significant effect at p < 0.05; 1-4= Time point 1- Time point 4; All
models controlled for age, and race (reference: white).

86
Figure 3.1B: Time-sequential associations between depression symptoms and identity
management stress for females who did not report a change in sexual identity

Note: Arrows represent significant effect at p < 0.05; 1-4= Time point 1- Time point 4; All
models controlled for age, and race (reference: white).

Among males, we found that depression predicted subsequent identity management stress
for both groups, those who reported a change in sexual identity (Est. = 1.173; SE = 0.50; p
<0.05; Figure 3.2A) and those who did not report a change (Est. = 0.678; SE = 0.27; p <0.05;
Figure 3.2B). Interestingly, we did not find that identity management stress predicted subsequent
depression in both male groups.
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Figure 3.2A: Time-sequential associations between depression symptoms and identity
management stress for males who reported change in sexual identity

Note: Arrows represent significant effect at p < 0.05; 1-4= Time point 1- Time point 4; All
models controlled for age, and race (reference: white).

Figure 3.2B: Time-sequential associations between depression symptoms and identity
management stress for males who did not report a change in sexual identity

Note: Arrows represent significant effect at p < 0.05; 1-4= Time point 1- Time point 4; All
models controlled for age, and race (reference: white).

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Table 3.4: Unstandardized estimates and standard errors for the ARCL Model 2 (grouping by
sexual identity change status and birth sex)
MODEL 2
FEMALES MALES
NO CHANGE CHANGE NO CHANGE CHANGE
EST. (SE) EST. (SE) EST. (SE) EST. (SE)

DEP (T2) ON STRESS (T1)

0.002 (0.003)

0.006 (0.003) *

-0.005 (0.004)

-0.002 (0.005)
DEP (T3) ON STRESS (T2) 0.002 (0.003) 0.006 (0.003) * -0.005 (0.004) -0.002 (0.005)
DEP (T4) ON STRESS (T3) 0.002 (0.003) 0.006 (0.003) * -0.005 (0.004) -0.002 (0.005)
STRESS (T2) ON DEP (T1) 0.433 (0.25) 0.638 (0.30) * 0.678 (0.27) * 1.173 (0.50) *
STRESS (T3) ON DEP (T2) 0.433 (0.25) 0.638 (0.30) * 0.678 (0.27) * 1.173 (0.50) *
STRESS (T4) ON DEP (T3) 0.433 (0.25) 0.638 (0.30) * 0.678 (0.27) * 1.173 (0.50) *
DEP (T2) ON DEP (T1) 0.571 (0.03) * 0.540 (0.03) * 0.509 (0.03) * 0.629 (0.05) *
DEP (T3) ON DEP (T2) 0.571 (0.03) * 0.540 (0.03) * 0.509 (0.03) * 0.629 (0.05) *
DEP (T4) ON DEP (T3) 0.571 (0.03) * 0.540 (0.03) * 0.509 (0.03) * 0.629 (0.05) *
STRESS (T2) ON STRESS (T1) 0.460 (0.03) * 0.436 (0.03) * 0.449 (0.03) * 0.411 (0.05) *
STRESS (T3) ON STRESS (T2) 0.460 (0.03) * 0.436 (0.03) * 0.449 (0.03) * 0.411 (0.05) *
STRESS (T4) ON STRESS (T3) 0.460 (0.03) * 0.436 (0.03) * 0.449 (0.03) * 0.411 (0.05) *

Note: All the models controlled for age and race (reference: white). No Change= No change in
sexual identity; Change= At least one change in sexual identity across 4 time points. DEP=
Depressive symptoms, STRESS= Identity Management Stress; T1-T4= Time point 1- Time point
4; EST= Unstandardized Estimates; SE= Standard Error; * = significance at p value < 0.05

Discussion
The current study advances our understanding of changes in sexual identity, and its
association with depression and identity management stress over time. The study examined
difference in time-sequential associations between depression and identity management stress,
by identity change status using a multigroup autoregressive cross-lagged model. In the sample,
40% of sexual minority adolescents reported reported at least one change in sexual identity over
4 time-points over 18-month period. This finding is consistent with the literature, where 28-67%
of sexual minority adolescents and youth have reported change in sexual identity orientation over
time (Cohen e al., 2020; Diamond, 2008; Morgan et al., 2018; Silva, 2018).
89
With regard to our research question (i.e., if temporal relationship between identity
management stress and depression over time differs by sexual identity change status), we found
that depression predicted subsequent identity management stress, irrespective of sexual identity
change status. However, in our second model (grouping by change in sexuality and birth sex), we
found that association between depression and identity management stress over time differed by
sexual identity change for females, but not for males. Among females who reported a change in
sexual identity, we found a reciprocal effect of identity management stress and depression over
time (depression predicted subsequent identity management stress, and identity management
stress predicted subsequent depression). However, among those females who did not report a
change in sexual identity, we did not find any cross-lagged effects. Among males, we found that
depression predicted subsequent identity management stress, irrespective of change in sexual
identity status. This finding draws support from limited evidence where adolescents with
discordant or instable sexual identity labels are more likely to report higher rates of depression
(Caplan, 2017; Everett, 2015). For example, Caplan (2017) reported that in their school sample,
those with a concordant sexual orientation (agreement between sexual behavior or attraction, and
sexual identification) report significantly lower depressive symptoms scores than do those with a
discordant sexual orientation. Our findings suggest that among female adolescents, sexual
identity changes are associated with cognitive and emotional disruptions as they reconfigure their
identities and navigate social support networks, leading to heightened stress and depressive
symptomology. Additionally, prior research examining impact of sexual identity change on
mental health risks have looked at change from the point of directionality (a change towards
same-sex identities or a change towards heterosexual identities, e.g., Everett, 2015). However, in
our study, we examined changes in sexual identity labels, and not changes in sexual orientation
90
changes on a Likert scale. Hence, we are not able to assess directionality of change, as the
understanding of authentic sexual identity and a shift towards or away from it would differ from
individual to individual.
Our results indicate that sexual identity change process differs between cisgender females
and males. Among males, the association between these two processes (identity management
stress and depression) did not differ by sexual identity change status. This could also mean that
for some males the change matters in a positive direction and for some in a negative so that on
the whole, the average change appears to be nothing. The suggested difference in that sexual
identity change process between cisgender females and males, could be attributed to difference
in sexual identity development and related experiences by birth sex (Diamond, 2008; Kinnish et
al., 2005; Radtke, 2013). For example, Glover and colleagues (2009) reported that in their study
males used more traditional label (e.g., gay), whereas females presented greater variability in
attraction and self-labels of sexual orientation, and were more likely to experience nonexclusive
attractions, thus making sexual orientation and identification a much more fluid process
compared to males. Some of these differences can be explained by dominant notions of
masculinity for males and more acceptability of fluidity in sexuality for females (Breen &
Karpinski, 2013; Diamond, 2016; Kilianski, 2003); however, the nuances associated with sexual
identity development and processes of change as they differ between cisgender females and
males need further investigation.
Current research and practice with sexual minority adolescents has suggested role of
enabling environment in healthy identity development among sexual minority adolescents
(Legate et al., 2019; Perrin, 2002; Savin-Williams & Cohen, 2004). Studies suggest that
adolescents with unsupportive or homophobic familial environment, delay their coming out
91
processes or even try to meet the heterosexual expectations of their predominately heterosexual
families (Cox et al., 2010; Legate et al, 2019; Waldner & Magrader, 1999). For example, a study
with 502 adolescents reported less acceptance and greater difficulty with disclosure were
associated with higher scores on internalized homophobia (negative self-perceptions and self-
devaluation for being non-heterosexual) (Cox et al., 2010). Additionally, confusion about one’s
sexual identity can also delay endorsement and integration of sexual identity label (Rosario et al.,
2011; Igartua et al., 2009). In short, lack of enabling environment may result in delaying of
identity integration, resulting in development of less-authentic identities likely to change later.
We believe some adolescents are more likely to report a change in sexual identity than others,
which may be because of underlying factors like access to community and support, relationship
status, presence of a role model, etc. Moreover, these processes of change could also be an
additional stressor among sexual minority adolescents. The results add to the limited knowledge
on the complex relationship between minority stress and depression as it relates to sexual identity
change.
Limitations and Conclusion
This study had several limitations. This study focused on cisgender youth, it does not
discuss the disparities experienced by transgender and gender nonbinary adolescents (Srivastava
et al., 2020). Internet survey research has distinct advantages, especially for reaching
marginalized, geographically dispersed minority populations. We were able to recruit a large
sample of diverse sexual minority adolescents from both urban and rural areas of United States.
However, internet-based recruitment and data collection also have limitations and challenges. In
terms of generalizability our findings are limited to those adolescents who have access to internet
and online spaces. Additionally, internet survey research also has validity concerns (e.g.,
92
duplicate participations). However, our study protocols addressed these concerns through
rigorous validity checks. All data were self-reported; however, anonymity was ensured by not
collecting any identifying information, which minimized response-bias. Changes of sexual
identity were measured as a difference in response to sexual identity question between two time-
points, however, this may not be a conscious change on adolescent’s part.
Despite these limitations, to our knowledge, this paper is the first to examine the
difference in relationship between mental health symptomology and minority stress experience
by sexual identity change status in a nationwide sample of sexual minority adolescents. Given
pervasive homonegative social and political climates in many areas, sexual minority adolescents
will continue to experience sexual identity development in less supportive environments, adding
to the minority stress experiences. Among females, the evidence of relationship between stress
and depression as it associates with sexual identity change is important to support female
adolescents through their healthy identity development processes. However, the underlying and
understudied variations by sex and gender need further examination.

93
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100
CHAPTER 5
Implications and Future Directions
Major Findings
This dissertation sought to expand our understanding of changes in sexual identities and
its relationship with changes in health risk over time among sexual minority adolescents. This
dissertation organized as a three-paper project, aimed to develop new knowledge about sexual
identity change among adolescents, variations by birth sex and the impact of changes in
identities on depressive symptoms. Key findings from each chapter are discussed below:
For Chapter 2 we conducted a systematic review of empirical research that has been
completed in the last two decades, 2000-2020 among adolescent and young adult populations to
synthesize information on sexual identity change. The review aimed to summarize the
approaches to measure sexual identity change, the prevalence, patterns and directionality of
change in sexual identity, and how changes in sexual identity relates to health outcomes among
adolescents and youth adult samples. The studies reviewed lacked agreement in
operationalization and measurement of sexual identity changes; where studies used repeated
measures of one or more aspects of sexuality (e.g., sexual identity, orientation, attraction,
partnering and behaviors) to report change. Rates of change in sexual identity differed by birth
sex, where cisgender females were more likely to report a change than males. In addition,
adolescents and youth identifying as non-heterosexual or sexual minority at baseline were more
likely to report a change in sexual identity. Few studies reported on the impact of change in
sexual identity on behavioral health outcomes; however, this association was examined using the
directionality of such change (e.g., a shift away or towards same-sex identities). Adolescents
who either reported same-sex orientation at the baseline, and those who reported a shift towards
101
same-sex orientation had greater likelihood for reporting depressive symptomology, suicidality
and substance use, compared to those who did not report a change or reported consistent
heterosexuality.
Chapter 3 examined changes in sexual minority identity and their association with
depressive symptoms, in a national longitudinal data from sexual minority adolescents aged 14–
17 years. In these results, 40% of sexual minority adolescents reported reported at least one
change in sexual identity over 4 time-points over 18-month period. Additionally, in the sample
greater number of participants assigned female at birth reported a change in sexual identity
compared to their male counterparts (46.9% versus 26.6%). This result in particular is important
to advance our understanding of how identification and labeling may vary by sex and supports
the evidence of sexual fluidity among females. In the sample adolescents identified female at
birth reported a negative effect of sexual identity on depressive symptoms over time. However, a
decrease in depressive symptoms associated by sexual identity change was reported only among
female group and not the group with males.
Chapter 4 used the information gathered from the review and the analyses from previous
chapters to test if relationship between identity management stress and depression over time
differs by sexual identity change status? and if these association look different among cisgender
females compared to males? The analyses reported a a temporal cross-lagged effect between
depression and identity management stress among females who reported a change in sexual
identity; and no cross-lagged effect was reported among those females who did not report a
change in sexual identity. However, among male sample depression predicted subsequent
identity management stress, irrespective of their change in sexual identity status.
102
Our results are consistent with the literature, where 28-67% of sexual minority
adolescents and youth have reported change in sexual identity orientation over time (Cohen e al.,
2020; Diamond, 2008; Morgan et al., 2018; Silva, 2018). The higher reporting on sexual identity
change in this sample is probably because of employing a longer time frame (18 months) and
studying changes in sexual identity labels compared to a shorter period and change reported on
sexual attraction/orientation in other studies (Diamond et al., 2017; Ott et al., 2011; Katz-Wise et
al, 2019; Savin-William et al., 2012). We also believe, sexual identity changes are associated
with cognitive and emotional disruptions as sexual minority adolescents reconfigure their
identities and navigate social support networks, leading to heightened stress and depressive
symptomology among cisgender females (though we did not detect any difference in associations
by sexual identity among males). We believe, that suggested difference in that sexual identity
change process between cisgender females and males could be attributed to difference in sexual
identity development and related experiences by birth sex (Diamond, 2008; Kinnish et al., 2005;
Radtke, 2013). However, the nuances associated with sexual identity development and processes
of change as they differ between cisgender females and males need further investigation.
Future Research and Next Steps
This study has reported important information on how we understand identity change, the
variation in these processes by birth sex, and how identity change relates to two important
processes (depression and identity management stress). However, these results also point to the
multiple unknowns, that may better help us understand and interpret these results. The future
research must examine pathways of identity integration and development, underscoring the
importance of non-linear and non-static pathways. These investigations must also examine
conscious and unconscious reporting of sexual identity change, and reasons for such changes. In
103
addition, the current knowledge on directionality of sexual identity change is limited. Research
has explored directionality in form of a shift towards or away same-sex attraction or orientation;
however, we do not understand empirically or theoretically how to understand and interpret
directionality of change for sexual identity labels. Building on the evidence between change in
identity and health risks, future work is needed on examining how support and resilience in form
of social networks may impact sexual identity change and development. More importantly,
research must also examine other minority experiences (e.g., family rejection, internalized
homophobia) as they relate to sexual identity change. One of the most important areas of work
that is needed, is examination of the difference in sexual identity development and change
processes by birth sex. Though, empirical evidence exists on the difference in rates and
prevalence of sexual identity change between cisgender females and males; theoretically we lack
an understanding of why cisgender females are more likely to apply more flexible identity labels
(e.g., queer, pansexual, demisexual, etc.), report change in sexual identity, and differ in their
association with other health processes. Exploring the context in which sexual identities develop
among cisgender females and males, will help us answer some of these questions, and also
provide lenses to interpret these findings.
Implications
Several important implications emerged from these results. The results from this study,
particularly those regarding change in identities, have important public health implications. First,
results challenge the traditional methods of gathering and using data on sexual identities. The
study aimed to further our understanding of sexual identities in non-static ways by examining
changes in identities over time. Methodological lessons from the study are beneficial in
informing nationwide longitudinal studies; for example, how national surveys like the Youth
104
Risk Behavior Surveillance System or National Youth Survey may gather data on identities in
non-static and multidimensional ways.
Current research and practice with sexual minority adolescents suggest an integral role of
enabling environment in healthy identity development among sexual minority adolescents
(Legate et al., 2019; Perrin, 2002; Savin-Williams & Cohen, 2004). Prior research has reported
that adolescents with unsupportive or homophobic familial environment often delay their coming
out processes or even try to meet the heterosexual expectations (Cox et al., 2010; Legate et al,
2019; Waldner & Magrader, 1999). In addition, confusion about one’s sexual identity can also
delay endorsement and integration of sexual identity label (Rosario et al., 2011; Igartua et al.,
2009). In short, lack of enabling environment may result in delaying of identity integration,
resulting in development of less-authentic identities likely to change later. We believe some
adolescents are more likely to report a change in sexual identity than others, which may be
because of underlying factors like access to community and support, relationship status, presence
of a role model, etc. Moreover, these processes of change could also be an additional stressor
among sexual minority adolescents. The results add to the limited knowledge on the complex
relationship between minority stress and depression as it relates to sexual identity change. Future
research with adolescents should be cautious of non-static development of sexual identities and
must also understand needs of adolescent’s experiences of sexual identity changes.
Limitations and Conclusion
This dissertation had several limitations. We recognize that because this project focused
on cisgender youth, it ignored the important disparities experienced by transgender and gender
nonbinary adolescents (Srivastava et al., 2020). Internet survey research has distinct advantages,
especially for reaching marginalized, geographically dispersed minority populations. We were
105
able to recruit a large sample of diverse sexual minority adolescents from both urban and rural
areas of United States. However, internet-based recruitment and data collection also have
limitations and challenges. In terms of generalizability our findings are limited to those
adolescents who have access to internet and online spaces. Additionally, internet survey research
also has validity concerns (e.g., duplicate participations). However, our study protocols
addressed these concerns through rigorous validity checks. All data were self-reported; however,
anonymity was ensured by not collecting any identifying information, which minimized
response-bias.
Changes in sexual identity were measured as a difference in response to sexual identity
question between two time-points, however, this may not be a conscious change on adolescent’s
part. We believe, asking a more direct question about one’s perception of change in their sexual
identity since the previous time-point would have added to more nuance in our understanding of
change. In addition, we examined the temporal association between identity management stress
and depression, and how they vary for those who reported a change versus those who presented
stable identities. However, potentially there are multiple underlying factors and processes that
are associated with sexual identity development and changes that need further examination. We
also found differences in reporting of sexual identity change and its impact on depression by
birth sex. Future research in the field of sexual identity development should include further
examination of the differences by birth sex to help determine what experiences and processes are
associated with sexual identification that are specific to cisgender males versus females.
Despite these limitations, to our knowledge, this dissertation is the first to examine the
relationship between sexual identity change and mental health in a nationwide sample of sexual
minority adolescents. Given pervasive homonegative social and political climates in many areas,
106
sexual minority adolescents will continue to experience sexual identity development in less
supportive environments, resulting in changes in identities over time. The expanding evidence
that sexual identity changes are associated with negative mental health outcomes is essential in
ways we understand sexual identity development among adolescents. Hence, the mechanisms
underlying the change in sexual identity and subsequent change in health outcomes need more
exploration, along with research on variation by demographic variables including sex and
gender.
107
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and Sexual Attraction and the Role of Religiosity: A Longitudinal Assessment in Two
Independent Samples of Croatian Adolescents. Archives of Sexual Behavior, 49, 1477-
1488.
Cox, N., Dewaele, A., Van Houtte, M., & Vincke, J. (2010). Stress-related growth, coming out,
and internalized homonegativity in lesbian, gay, and bisexual youth. An examination of
stress-related growth within the minority stress model. Journal of Homosexuality, 58(1),
117-137.
Diamond, L. M. (2008). Female bisexuality from adolescence to adulthood: results from a 10-
year longitudinal study. Developmental Psychology, 44(1), 5.
Diamond, L. M., Dickenson, J. A., & Blair, K. L. (2017). Stability of sexual attractions across
different timescales: The roles of bisexuality and gender. Archives of Sexual Behavior,
46, 193–204.
Igartua, K., Thombs, B. D., Burgos, G., & Montoro, R. (2009). Concordance and discrepancy in
sexual identity, attraction, and behavior among adolescents. Journal of Adolescent
Health, 45(6), 602-608.
Legate, N., Weinstein, N., Ryan, W. S., DeHaan, C. R., & Ryan, R. M. (2019). Parental
autonomy support predicts lower internalized homophobia and better psychological
health indirectly through lower shame in lesbian, gay and bisexual adults. Stigma and
Health, 4(4), 367.
Katz-Wise, S. L., Stamoulis, C., Allison, C. M., & Hyde, J. S. (2019). Attitudes Toward
Bisexuality and Other Beliefs and Attitudes Related to Sexual Fluidity in Attractions
108
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22.
Kinnish, K. K., Strassberg, D. S., & Turner, C. W. (2005). Sex differences in the flexibility of
sexual orientation: A multidimensional retrospective assessment. Archives of Sexual
Behavior, 34, 173–183.
Ott, M. Q., Corliss, H. L., Wypij, D., Rosario, M., & Austin, S. B. (2011). Stability and change
in self-reported sexual orientation identity in young people: Application of mobility
metrics. Archives of Sexual Behavior, 40, 519–532.
Perrin, E. C. (2002). Sexual orientation in child and adolescent health care. Dordrecht,
Netherlands: Kluwer Academic/Plenum.
Radtke, S. (2013). Sexual fluidity in women: How feminist research influenced evolutionary
studies of same-sex behavior. Journal of Social, Evolutionary, and Cultural Psychology,
7(4), 336.
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development over time: Implications for the psychological adjustment of lesbian, gay,
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Abstract (if available)

Abstract Sexual identity is mutable and evolving, particularly during adolescence and young adulthood. Despite this recognition, there is a lack of research on how changes in sexual identities over time may be associated with changes in mental health. This dissertation is organized as a three-paper project

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator Srivastava, Ankur (author)

Core Title Impact of change in sexual identity on mental health risks among sexual minority adolescents

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 04/15/2021

Defense Date 03/18/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Depression,LGBTQ,mental health risks,OAI-PMH Harvest,sexual identity change,sexual minority adolescents

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Goldbach, Jeremy T. (committee chair), Davis, Jordan P. (committee member), Huey, Stanley J., Jr. (committee member), Rice, Eric (committee member)

Creator Email ankur.hst@gmail.com,ankursri@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-444687

Unique identifier UC11668435

Identifier etd-Srivastava-9466.pdf (filename),usctheses-c89-444687 (legacy record id)

Legacy Identifier etd-Srivastava-9466.pdf

Dmrecord 444687

Document Type Dissertation

Rights Srivastava, Ankur

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA