Self-Acceptance and Distal Stressors
Most of the relevant included studies found that poorer LGBQ+ self-acceptance was associated with a lack of acceptance of one’s sexuality by family and friends. Two studies conducted in the U.S. and one in Israel found that self-acceptance of sexuality had a small negative relationship with lower levels of acceptance of participants’ LGBQ+ sexuality by either their family (r = − .19 to − .24) or friends (r = − .23 to − .25; Hershberger & D’Augelli, 1995; Leserman, Disantostefano, Perkins, & Evans, 1994; Shilo & Savaya, 2011). Elizur and Mintzer (2001, 2003) further found that the negative relationship between a lack of friends’ acceptance and LGBQ+ self-acceptance upheld while controlling for a lack of family acceptance (r = − .22). Overall, these findings are supported by theoretical approaches, which would suggest that a lack of support from others has a deleterious effect on self-acceptance for individuals who identify as LGBQ+ (Cass, 1979; Elizur & Mintzer, 2001; Meyer, 2003).
In contrast, Elizur and Mintzer (2001, 2003) did not find a significant association between family acceptance and self-acceptance of one’s sexuality (r = − .08) within their study conducted in Israel, unlike other studies conducted in Israel (r = − .24; Shilo & Savaya, 2011) or the U.S. (r = − .19; Leserman et al., 1994). While both studies conducted in Israel utilized similar measures and had similar methodological strengths, different findings may have been a consequence of the data being collected from varied samples. For example, Shilo and Savaya (2011) included participants who identified as lesbian, gay, or bisexual and were male or female with an average age of 18 years. Conversely, Elizur and Mintzer (2001, 2003) only included participants identifying as gay and male, with an average age of 32 years. It may be, as one example, that family acceptance of one’s minority sexuality is more important for younger participants who are still undergoing identity development. Future studies could investigate whether family acceptance of sexuality is more strongly associated with self-acceptance for younger than older LGBQ+ people.
Only one study included in this review investigated the relationship between self-acceptance of sexuality and victimization. Hershberger and D’Augelli’s (1995) U.S. study found that self-acceptance of sexuality had small significant positive relationships with aspects of self-reported heterosexist victimization, including the frequency of experienced verbal insults and threats (r = .17), and having personal property damaged, being chased, followed, or spat on (r = .21). No significant relationship was found between self-acceptance of sexuality and the frequency of experienced physical or sexual assault related to one’s sexuality (r = .14; Hershberger & D’Augelli, 1995). This is contrary to theoretical approaches, which would consider heterosexist victimization to have a deleterious impact on self-acceptance of sexuality (Cass, 1979; Elizur & Mintzer, 2001; Meyer, 2003). However, it is possible that there is a bidirectional relationship; for example, that people who are more self-accepting may be less likely to conceal their sexuality and therefore be exposed to greater risk of victimization. This finding may have also been impacted by limitations in the sampling procedure. For example, the sample was recruited from LGBTQ+ youth community centers. Individuals attending these centers are likely to be more self-accepting and have access to supportive LGBTQ+ peers, which may mean they had increased opportunities to process and reappraise the impact of their experiences of victimization on self-acceptance. Furthermore, while many of the samples reported experiencing at least one incident of verbal victimization, few reported experiencing physical victimization, which may not have provided a sufficient range of experience to reveal an association. Finally, victimization was measured using one item for a combination of different types of victimization (e.g., personal property damaged and being chased, followed, or spat on, all within one item), which may have confused participants if they experienced only one part of this item and not others. Therefore, further research is needed to clarify the relationship between LGBQ+ self-acceptance and victimization.
Self-Acceptance and Proximal Stressors
Sexuality self-acceptance had small to large negative associations with lower disclosure of one’s sexuality to others in general (r = − .27 to − .52) and to family members (r = – .25 to – .44) in four studies conducted in Israel and two in the U.S. (Elizur & Mintzer, 2001, 2003; Hershberger & D’Augelli, 1995; Ifrah, Shenkman, & Shmotkin, 2018; Leserman et al., 1994; Shilo & Savaya, 2011). Internalized heterosexism was also found to have a significant negative relationship with self-acceptance of sexuality in one study conducted in Russia (ρ = − .50; Yanykin & Nasledov, 2017). It has been suggested that internalized heterosexism often contributes to poor self-acceptance, and this in turn is associated with increased concealment of sexuality (e.g., Elizur & Mintzer, 2001; Meyer, 2003). Furthermore, it is suggested that attempting disclosure within a heterosexist environment can have a negative impact on self-acceptance, whereas disclosure to supportive and accepting others can facilitate access to affirmative and supportive experiences, thus improving self-acceptance (Elizur & Mintzer, 2001; Pepping et al., 2018; Pitoňák, 2017). This would be consistent with the findings of one study that the relationship between disclosure to others in general and self-acceptance of sexuality was no longer significant when controlling for family and friends’ support (Elizur & Mintzer, 2003).
While the relationship between disclosure to others and LGBQ+ self-acceptance was investigated in a number of cross-sectional studies with varying degrees of methodological strengths, internalized heterosexism was only investigated in one study that has comparatively increased limitations in the quality of reporting and attempts to reduce bias in the sample. Therefore, the possible bidirectional relationship between LGBQ+ self-acceptance and these processes requires further research, including with longitudinal or intervention/experimental research methods.
Self-Acceptance and Mental Health
The findings of this review generally suggest that self-acceptance of sexuality is associated with better mental health. Three studies conducted in Israel and one in the U.S. found that various measures of general psychological distress had a small to medium negative relationship with self-acceptance of sexuality (r = − .26 to − .46; Hershberger & D’Augelli, 1995; Shilo et al., 2015; Shilo & Mor, 2014; Shilo & Savaya, 2011). However, this was not the case in a study which measured distress using the Symptom Checklist-90-Revised (SCL-90-R) in a sample from Russia (ρ = − .10; Yanykin & Nasledov, 2017). Similarly, this study found no significant relationship between self-acceptance of sexuality and psychological well-being (ρ = .07), unlike three studies in Israel reporting a significant small positive relationship with self-acceptance of sexuality (r = .18 to –.23; Shilo et al., 2015; Shilo & Mor, 2014; Shilo & Savaya, 2011). Two Israeli studies found that the relationship between self-acceptance of sexuality, psychological distress, and well-being was maintained while controlling for demographic variables, outness about sexuality, distal and proximal harassment, family and friends’ support, LGBQ+ connectedness, religiosity, victimization, and being in a steady relationship (Shilo et al., 2015; Shilo & Mor, 2014).
Only one study, conducted in the U.S., investigated the association between depression and self-acceptance of sexuality, and provided mixed evidence regarding this relationship (Leserman et al., 1994). For HIV-negative gay men, depression had a negative relationship with self-acceptance of sexuality, and this relationship was maintained while controlling for age, race, and education (Leserman et al., 1994). However, for HIV-positive gay men, the same study found that there was no significant relationship between depression and self-acceptance. It is possible that for HIV-positive gay men, factors associated with their HIV-positive status may have a larger impact on potential depression symptoms than self-acceptance. Furthermore, such relationships may have been very different at the time of the study compared to the current situation, so this requires further research.
Only one study investigated self-acceptance of sexuality in relation to suicidality and found no significant relationship with suicidal ideation (r = − .05) or attempts (r = .10; Hershberger & D’Augelli, 1995). It is possible that suicidality may be less strongly associated with self-acceptance than with stressful events, such as LGBQ+ victimization (Gnan et al., 2019; Hershberger & D’Augelli, 1995). It is also possible that people whose self-acceptance is so problematic that they consider suicide will be less likely to report identifying with a minority sexual orientation in research, and those who completed suicide cannot be included in many research designs. However, Herberger and D’Augelli’s (1995) study had limitations regarding the reporting of their methods and findings, and they did not use validated measures of suicidality or self-acceptance; thus, further research is needed with improved measurement instruments and methodological quality.
Overall, the findings that self-acceptance of sexuality was associated with lower psychological distress and greater well-being, as well as lower depression symptoms in HIV-negative gay men, are consistent with suggestions from past research that poor self-acceptance of one’s minority sexuality may negatively affect mental health (Meyer, 2003; Vincke & Bolton, 1994) and that greater self-acceptance may reduce mental health difficulties by buffering the negative impact of heterosexism (Aristegui et al., 2018; Elizur & Mintzer, 2001; Hershberger & D’Augelli, 1995). However, the included studies investigated only a limited number of mental health outcomes and findings were not replicated with all self-report measures of psychological distress, well-being, or depression symptoms employed. For example, no relationship was found between self-acceptance and the SCL-90-R in a Russian sample (Yanykin & Nasledov, 2017) or the Profile of Mood States, Depression subscale in a U.S. sample (Leserman et al., 1994). However, it is not possible to draw any firm conclusions regarding these variations in findings as they may reflect sample differences; for example, no relationship between self-acceptance and psychological distress in a Russian sample may be a result of sampling bias. For instance, the participants willing to access and take part in research regarding their LGBQ+ sexual identity—in a culture with high levels of anti-LGBQ+ narratives and policies—may only do so if they had very high levels of self-acceptance and well-being. This is supported by more than half of participants within Yanykin and Nasledov’s (2017) study having the highest possible scores for self-acceptance and lowest possible for psychological distress. However, further research is needed to explore this suggestion.
Self-Acceptance Comparisons between Different Sexual Orientations
One study found that lesbian women had significantly lower self-acceptance of sexuality than gay men in a young adult sample from Israel, with a medium effect (d = 0.50; Ifrah et al., 2018). Another study conducted with adolescents and young adults from New York found that those who identified as gay or lesbian had significantly higher self-acceptance of sexuality than those who identified as bisexual over two time points with, small to medium effects (6 months: η2 = .07 and 12 months: η2 = .04; Rosario, Schrimshaw, Hunter, & Braun, 2006). In a subsample of female participants from Rosario et al. (2006), lesbian women who identified as masculine had significantly higher self-acceptance of sexuality than bisexual women who identified as feminine at a 12-month follow-up (large effect; η2 = .17), but there was no significant difference between these groups at the 6-month follow-up (η2 = .08; Rosario, Schrimshaw, Hunter, & Levy-Warren, 2009). There was also no significant difference between these groups and a sample of lesbian women who identified as feminine at both time points (Rosario et al., 2009). Finally, a study conducted in Israel with adolescents and young adults who identified as male or female found that bisexual individuals had lower self-acceptance of sexuality than lesbian or gay participants, with a large effect (d = 7.17; Shilo & Savaya, 2011). These findings support theory and research, which suggests that bisexual individuals and lesbian women are at increased risk of minority stressors related to their sexual orientation and other aspects of identity (e.g., gender conformity) compared with gay men, and thus, they may experience more difficulties with identity development (Feinstein & Dyar, 2017; Hequembourg & Brallier, 2009; Meyer, 2003). However, further studies are needed to confirm these differences using more robust sampling procedures and consistent self-acceptance measures.
For studies comparing LGBQ+ individuals with heterosexual participants, the findings of one study conducted in Israel and another in the U.S., with good methodological quality, demonstrated that non-heterosexual participants had lower levels of general self-acceptance compared with heterosexual individuals, with small to medium effects (d = 0.20–0.44; Gil, 2007; Riggle, Rostosky, & Danner, 2009). Conversely, another study conducted in the UK, with lower methodological quality, found that female participants identifying as LGBQ+ had higher general self-acceptance than female heterosexual participants, with a medium effect size (d = 0.46; Siegelman, 1979). It is difficult to interpret these contrasting findings due to the differences in study quality and self-report measures utilized. It is possible, however, that the LGBQ+ participants willing to take part in such research in the different social climate of the 1970s may have been those who tended to have higher self-acceptance. Overall, however, the findings that LGBQ+ individuals have lower general self-acceptance compared to heterosexual groups are congruent with theory, which suggests that the exposure to minority stressors leaves LGBQ+ individuals more vulnerable to difficulties with mental health and well-being—including difficulties with processes such as self-acceptance—compared to their heterosexual peers (Meyer, 2003; Pitoňák, 2017; Riggle et al., 2009).
Included Study Characteristics and Methodological Quality
The methodological quality of the included studies and attempts to reduce bias varied (Appendix 2 for AXIS tool ratings), which precluded firm conclusions about cross-study comparisons. An important general limitation was that all included studies were cross-sectional, and most were correlational. This prevents conclusions regarding any possible causal direction between the constructs investigated; for example, lower self-acceptance may result in greater perception of stigma processes rather than vice versa. Additionally, most studies utilized various self-report measures of self-acceptance and minority stressors. The variability in instruments impairs comparison of findings across the studies. It is also important to note that a third unmeasured variable, such as low mood, could influence self-reports of self-acceptance and minority stressors and thus explain the apparent associations found within this review (Althubaiti, 2016; Lewis, Cogburn, & Williams, 2015). Furthermore, the included studies investigated a limited number of minority stressors and mental health outcomes.
There was also an overreliance on using instruments that have seemingly not undergone the appropriate psychometric validation to ensure sufficient validity and reliability. Some of the included measures of sexuality self-acceptance (i.e., the Self-Acceptance Questionnaire; the Gay Identity Questionnaire, Acceptance of Homosexuality subscale; the modified Coping and Change Measure, and the modified Mayfield Internalized Homonegativity Inventory, Self-Acceptance subscale) had early evidence of factor structure and internal consistency, however, no known explicit investigation of test–retest stability, face/content validity, or construct validity. The singular items used to measure self-acceptance by the remaining studies (i.e., Hershberger & D’Augelli, 1995; Riggle et al., 2009) had no psychometric evaluation. Thus, the use of these measures may limit the reliability and validity of the findings. Many studies were excluded on the basis of using instruments to measure self-acceptance of sexuality that were originally designed to measure other distinct LGBQ-specific processes, such as internalized heterosexism, as their inclusion would impact the validity of the findings and cause conceptual confusion.
Most studies utilized convenience methods of sampling which are not likely to be representative of the target population and are more susceptible to bias. This is pertinent as individuals who chose not to take part may represent important subsamples of participants including those who are potentially difficult to engage in research regarding minority sexuality, such as those who are less self-accepting. However, it is acknowledged that it can be difficult to collect data on participants who decline to take part in research, to determine if they indeed represent a different subsample compared to those who participate. The majority of studies were also conducted in the U.S. or Israel, and most participants were White. This may hinder the ability to generalize findings outside of the countries or races/ethnicities examined within the included studies. Overall, studies included slightly more males than females, and there was no clear representation or attention to minority gender identities. Many studies also exclusively included lesbian or gay participants, which means there is a much smaller representation of bisexual and other minority sexual orientations. However, it is acknowledged that there are significant difficulties in recruiting marginalized populations such as LGBQ+ individuals, particularly those who are concealing their identity or are in the early stages of identity development, and where population-based research is not currently collecting sufficient demographic information for these groups. Therefore, considering all the methodological limitations, the conclusions drawn within this review should be treated as tentative and not generalized to under-studied sub-populations of the sexual and gender minority community.
Strengths and Limitations of the Current Review
With regard to the limitations of the current review, firstly, the inclusion of studies only published as journal articles means there is likely an over-representation of studies finding significant associations between study variables, as non-significant findings are less likely to be published (Rothstein, Sutton, & Brorenstein, 2005). Additionally, the exclusion of qualitative studies may mean potentially informative findings were not included in this review. Secondly, the initial screening of titles and abstracts was completed by only one researcher, which may mean potentially relevant articles may have been missed. Thirdly, there was a large amount of heterogeneity between different study populations and designs. For example, year of publication ranged from the 1970s until the 2010s, which represent very different social climates for LGBQ+ individuals and the self-acceptance of their minority identity. Measures of self-acceptance, sexual orientation, minority stressors, and mental health were not consistent across studies, which limited comparisons of findings.
Finally, many potentially relevant studies were excluded due to using measures originally designed to measure other variables such as internalized heterosexism, self-esteem, and other LGBQ-related processes, which the authors either adapted or used as a proxy for self-acceptance of sexuality. Studies were only included in this review if their self-acceptance of sexuality measures enquired directly about acceptance and/or comfort with one’s sexuality. However, the search strategy would not necessarily have identified studies that assessed constructs closely related to self-acceptance, such as comfort with sexuality—unless the author explicitly stated that they were using this as a proxy measure for self-acceptance. This may mean that potentially informative studies may have been excluded. However, it should be noted that the use of measures not designed to measure self-acceptance results in conceptual confusion and potentially invalid conclusions. For example, theoretical distinctions have been made between internalized heterosexism and lack of self-acceptance, and therefore, the authors of this review suggest that future research into self-acceptance should only utilize measures specifically designed to measure this construct. Similarly, self-acceptance of sexuality shares some conceptual overlap with other constructs such as self-affirmation. Despite these potential similarities, self-affirmation likely includes positive feelings toward the self, whereas self-acceptance can represent a more neutral acceptance of one’s sexuality. Therefore, research investigating self-affirmation was not included in this review as self-affirmation measures rely on items enquiring about pride and liking toward one’s sexuality (e.g., Mohr & Kendra, 2011).
Despite these limitations, the operationalized and systematic search strategy, which is replicable; the double ratings of the full text reviews; the inclusion of methodological quality ratings that were rated by two independent researchers; and the large number of participants considered across the included studies constitute strengths of this review.
Implications and Recommendations for Theory and Research
The findings of this review are mostly consistent with minority stress and identity development theories, which suggest that minority stressors negatively impact self-acceptance and that self-acceptance may ameliorate the negative effect of minority stress (Cass, 1979; Elizur & Mintzer, 2001; Meyer, 2003). However, minority stress theory specifies little about the possible mechanisms as to how this occurs. Identity development theories elaborate further about how self-acceptance processes are part of building a positive identity as a sexual minority; however, self-acceptance within these models is typically conflated with other identity development processes (e.g., disclosure) or minority stressors (e.g., internalized heterosexism). This limited theoretical attention to LGBQ+ self-acceptance processes may have contributed to the under-representation of this construct in research and the use of heterogeneous measurement instruments. Theories focusing on or including LGBQ+ self-acceptance may benefit from drawing on theories of general self-acceptance processes which further detail proposed mechanisms of how self-acceptance interacts with well-being, for example via a non-judgmental and willing approach to managing distressing emotional and relational experiences (e.g., Bernard, 2013; Ryff, 2014; Williams & Lynn, 2010). Resilience theories also suggest that self-acceptance has the potential to be an important process for managing minority stressors (e.g., Aristegui et al., 2018; Mimiaga et al., 2015), but this has not been adequately empirically tested.
Future research should utilize validated measures and longitudinal data to gain stronger information about possible causal relationships, alongside studies investigating mediating and moderating effects of self-acceptance. Additionally, future research should investigate a diverse range of minority stressors and mental health outcomes and assess which have the largest impact on self-acceptance, as well as any impact in the opposite direction. As sample differences may have contributed to discrepant findings within this review, future studies could also investigate differences in these associations between different cultures, age groups, sexual identities, or other sociodemographic groups. Samples in future research should additionally better investigate self-acceptance of sexuality in groups with sexual identities (e.g., pansexual) that are under-represented in the current research, to improve generalizability and reveal any differences between these groups. Sexuality and gender self-acceptance should also be specifically investigated in LGBQ+ individuals who also have a minority gender identity. Qualitative research may also provide useful information about possible psychological processes involved in sexuality self-acceptance, which requires further understanding if people can be adequately supported when they experience self-acceptance difficulties. Future systematic reviews exploring self-acceptance of sexuality may consider also including search terms for closely related processes, such as comfort with sexuality, and including qualitative studies to be more inclusive.
Implications and Recommendations for Clinical Practice
The relationship between self-acceptance, minority stressors, and mental health difficulties may suggest that low levels of self-acceptance should be addressed in interventions with LGBQ+ individuals aiming to improve psychological adjustment and well-being (American Psychological Association, 2012). Indeed, it has been suggested that self-acceptance is addressed in psychological interventions developed specifically for those identifying as LGBQ+, but there is no known evidence that these improve self-acceptance (e.g., Mustanski, Greene, Ryan, & Whitton, 2015; Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015; Safren et al., 2014). The American Psychological Association (2012) guidelines for psychological interventions with LGBQ+ individuals suggest self-acceptance can be improved by providing a supportive and bias-free environment to discuss relevant issues. More specifically, Mustanski et al. (2015) suggest that clinicians may help to promote LGBQ+ self-acceptance by supporting the person to build an understanding of their sexuality, helping them to explore how this fits within their wider social context, challenging internalized heterosexism, supporting them to connect with others with similar experiences, supporting problem solving around disclosing to others, and coping with experiences of heterosexism. Other LGBQ-affirmative interventions suggest that cognitive behavioral strategies can be used to build awareness of the negative effects of minority stress on one’s mental health and address unhelpful beliefs and behaviors, to help improve well-being in LGBQ+ populations (Lin, Israel, & Ryan, 2019; Pachankis, 2014).
In summary, the findings of this review tentatively suggest that self-acceptance of sexuality is negatively associated with the presence of some distal stressors (e.g., lack of acceptance by family and friends), proximal stressors (e.g., lack of disclosure to others), and mental health difficulties (e.g., greater global distress and depression, and lower psychological well-being). In contrast to theory, the findings of this review suggest self-acceptance of sexuality may be positively associated with heterosexist victimization and has no association with suicidality, although these results each represent the findings from only one study with low methodological quality. Additionally, on average individuals identifying as LGBQ+ had lower general self-acceptance than heterosexual people. Moreover, individuals identifying as bisexual also had lower self-acceptance of sexuality than lesbian and gay participants, and lesbian women had lower self-acceptance than gay men. These findings are largely consistent with minority stress and identity development theories. Unfortunately, the methodological limitations of the included studies, including their cross-sectional designs, limit the ability to draw firm conclusions. The findings suggest there is a clear need for further and more robust research investigating both self-acceptance of sexuality and general self-acceptance within LGBQ+ populations.