The crucial role of family
Adolescents who disclose a sexual minority identity to their parents may experience increased family conflict as well as family rejection. A 2009 study by Ryan and colleagues14 asserts that sexual minority adolescents “who reported higher levels of family rejection during adolescence were 8.4 times more likely to report having attempted suicide, 5.9 times more likely to report high levels of depression, 3.4 times more likely to use illegal drugs, and 3.4 times more likely to report having engaged in unprotected sexual intercourse compared with their peers from families that reported no or low levels of family rejection.” Social service agencies have reported that approximately one-third of homeless youths in large urban centers are gay or lesbian.15 Many of these children have run away from home because of the violence and rejection they experienced.
A supportive family has repeatedly been shown to be the most important protective factor for sexual minority individuals.14,16 The importance of assessing the level of support perceived by adolescents as well as level of risks (including family rejection and violence) cannot be underestimated. Sexual minority youth from families they perceive to be either accepting or minimally rejecting are at significantly lower risk for depression, suicidality, illicit substance abuse, and risky sexual behaviors than those from highly rejecting families.14
Parents may experience an identity development process that parallels that of their sexual minority adolescent. There will often be a developmental lag between the parent and the child. The adolescent may have had many years to understand his identity and to repeatedly approach it; he may have backed away until timing and internal supports were strong enough for full acceptance of his sexuality. Yet, a parent may suddenly be faced with this realization without any prior notions that his or her child is not heterosexual. While some parents handle this news well, this information can engender many reactions, from rage to grief.
The goal of therapy is to help parents understand their own process of “coming out” while also supporting their child with identity development. While it may be difficult for the therapist to tolerate the potentially negative feelings a parent may have, helping a family navigate these emotions to a place of joining and support may be the single most powerful intervention a therapist can employ.
Importance of other relationships
Family relationships are an important supportive structure for adolescents, as are interpersonal platonic and romantic relationships. Withdrawal and isolation in sexual minority adolescents have been associated with negative mental health outcomes, and relationship-esteem is higher in those who have close interpersonal relationships.4 It can be easily theorized that this translates into increased self-esteem. However, there are significant obstacles, including fear of violence and ostracism, that prevent the establishment of close relationships.
In peer groups, the assumption of heterosexuality can make it difficult to be identified as gay or bisexual and to identify potential mates. This invisibility and fear of being known may induce feelings of anxiety and shame that are insurmountable and that increase isolation.4 For those in less populous areas, relatively small numbers of potential mates may also contribute to decreased relationships.
Geographical location is not protective, although in certain areas, Gay-Straight Alliances in the schools and community can provide support. Helping an adolescent to understand potential roadblocks to developing relationships and to navigate these roadblocks can have positive lifelong mental health benefits. Early relationship experiences help lay a foundation to negotiate future relationships. Healthy development around sexual identity is often built on successful platonic and romantic relationships, regardless of sexual orientation.
Working with sexual minority youths
Sexuality is a core aspect of identity. Sexual identity emerges over time and is affected by biological, familial, and environmental forces. For those whose identity outcome is not acceptable in their communities and families, development can be strained. In addition, the overwhelming psychological burden contributes to emotional illness and, for some, serious psychopathology.
Some sexual minority youth face stress and distress related to their sexual minority status that may lead them to consult a child psychiatrist for individual treatment. Remember that many sexual minority youth, as with all adolescents, traverse this stage of development with some difficulties, but without significant psychological distress. Savin-Williams17 wrote, “In actuality, the vast majority of gay male, bisexual, and lesbian youths cope with their daily, chronic stressors to become healthy individuals who make significant contributions to their culture.” While seeking individual treatment may be daunting for any adolescent, it may be more so for an adolescent who has faced significant shame and stigma about his sexuality. It is incumbent that the therapist address his or her own notions, discomfort, and anxieties about adolescent sexuality and, more specifically, about sexual minority identity development. The clinician’s role is to understand the child or adolescent’s sense of his own sexuality—regardless of what self-labels are used. This will help facilitate a healthy integration of the patient’s sexuality into his identity.
The hoped-for outcome is the emergence of a person less compartmentalized as a result of stigma and shame, whose identity is not hidden—a person well-equipped for the emotional growth needed to traverse developmental challenges in becoming a healthy, complex, and multidimensional individual. The Table provides suggestions for optimizing treatment when working with sexual minority youths.