Sexual Minority Identity Development

Psychiatric TimesPsychiatric Times Vol 28 No 12
Volume 28
Issue 12

Sexual identity development is a complex, multidimensional, and often fluid process. One must consider cognitive, social, emotional, cultural, and familial complexities among other aspects of the individual’s experience to contextualize a narrative concerning sexual identity development.

Sexual identity development is a complex, multidimensional, and often fluid process. One must consider cognitive, social, emotional, cultural, and familial complexities among other aspects of the individual’s experience to contextualize a narrative concerning sexual identity development.

Sexual minority youth is a term used to describe adolescents who are not exclusively heterosexual. Definitions and labels ascribed to sexual minority youth may not describe their sexual attractions, relationships, fantasies, or behaviors. It is important to understand an individual’s personal experience as well as his or her self-identification without making assumptions.

The Internet, public discourse about “gay rights,” Gay-Straight Alliances in the schools, and a growing visibility of gay and lesbian role models in the media have helped challenge mainstream notions of what is considered “normal” sexual development. The fluidity of adolescent sexual identity development is as complicated as any aspect of identity development. Adolescents in the 21st century are, in many parts of the world, growing up in a culture that embraces diversity in sexual expression in a manner foreign to their parents’ generation. Despite the fact that sexual minority youth have greater access to resources that provide support than did previous generations, there continue to be schools, communities, and homes in which adolescents still experience rejection, bullying, ostracism, and violence because of their differences from mainstream society.

As child and adolescent clinicians, we often see the most vulnerable youth. This vulnerability occurs secondarily to the complex interactions of adolescents within their family, their culture, and society. Therapy for adolescents should explore friendships and romantic and sexual relationships, as well as attractions. Clinicians should be aware of the research that has shown that there are higher rates of mental health risks in sexual minority adolescent populations. Both protective and risk factors for healthy emotional and physical development need to be understood.

Risk assessment

When assessing risk for sexual minority youth, consider the defenses used to cope with both internal and external stressors. Fear of stigma, rejection, and other ramifications can lead sexual minority adolescents to defensive compartmentalization to protect and hide their sexual identity. This compartmentalization can affect normal development and impede overall identity development.

Compartmentalizing may be a conscious or unconscious mechanism that helps sexual minority adolescents cope with rejection by family members, peers, communities, and religious affiliations. They may fear harm or may already have been the target of violence and emotional abuse. A segment of these youths may be at higher risk for mental health issues because they may not have developed the internal coping mechanisms or they may lack social support and community to help them face these challenges.

Child and adolescent psychiatrists, as well as other clinicians, can play an important role by identifying those who are at risk for mental health problems and by providing support and treatment when needed.

The development of sexual identity

Sexual behavior in adolescence and one’s identity as heterosexual, gay, lesbian, or bisexual may change over time. “The fluidity of sexual desire, behavior, and identity may be a fundamental characteristic of sexuality during the teenage years.”1(ppxi,323) Complicated cultural and social identities influence sexual identity as well, but not necessarily sexual behavior.

Savin-Williams and Diamond2 compared the sexes and looked at sexual identity trajectories among sexual minority youth. They concluded that differences among youths cannot be explained by gender alone. “No singular sexual identity model is capable of representing the diverse trajectories of male and female sexual identity development.”2 These researchers found that the context for sexual identity development is more likely to be emotionally oriented for female adolescents and sexually oriented for male adolescents.2 Diamond has written extensively on the development of female same-sex orientation. Women appear more likely than men to exhibit situational and environmental plasticity in sexual attractions, behavior, and identifications.3

Developmental considerations

Attitudes toward homosexuality have shifted in our culture and in politics. In 1973, homosexuality was deleted from DSM. This followed the Stonewall Rebellion in 1969, when the visibility of the gay, lesbian, bisexual, and transgendered community was greater in the media. The social movement that began at that time has accelerated with the help of popular culture. Six states have legalized same-sex marriage in the past 5 years.

Although the dominant culture is changing, each adolescent may or may not find like-minded individuals and communities for external support who can help navigate internal conflicts that may arise when one recognizes that one is “different” from the dominant culture and, in most cases, “different” from one’s parents.

As cultural attitudes and mores have evolved, researchers have changed in their approach to identify and understand this population. Initially, much of the research was done with adolescents who were attending community centers for sexual minority youth. It was necessary to use classifications and ask about self-identifying labels, such as gay or lesbian, to capture raw data about this underserved population. For many, these classifications still have a high level of congruence with their sexuality. However, as we begin to understand sexuality better, we find that there is a large degree of variance in sexual desires, fantasies, gender roles, gender identifications, sexual orientations, sexual behaviors, and romantic attractions that these classifications do not capture.4

Over the past decade, there has been a significant decrease in the age at which sexual minority youths are self-identifying. Recent studies have shown that boys are aware of same-sex feelings at about age 10, and girls at about age 11.1 Self-labeling occurs, on average, 5 years after initial awareness. Same-sex contact occurs a year or two before a boy’s gay identification; a girl is more likely to have her first same-sex contact after identifying herself as a lesbian.1 More than ever, sexual minority youth are self-identifying while they are still in high school and living at home, even if they are not sexually active.1

The National Longitudinal Study of Adolescent Health is the most comprehensive survey of adolescents in the United States. Of the approximately 12,000 youth who participated, 7% reported having same-sex attractions or relationships. (This was slightly more common among males.) Youth were not asked specifically about sexual identity but rather about experiences and attractions. This broadened the sample from previous studies.5

Russell and Joyner6 looked at the data of this study to attempt to better understand previous reports of risk of suicidality in sexual minority youth. They found that “regardless of age and family background, males and females who reported same-sex romantic attraction or relationships were more likely than their peers to report suicidal thoughts.” Their results were consistent with those of a 1989 government report, which showed that youths with same-sex orientation were twice as likely as their same-sex peers to attempt suicide and were more likely to report suicidal thoughts than their peers.7

Sexual minority youths with suicidal ideation or who had attempted suicide are more likely to abuse alcohol and to feel hopeless, depressed, and victimized.6 They are also more likely to have had a close relative or peer attempt suicide. Furthermore, even though these risk factors are similar to suicide risk factors for all adolescents, “there is a strong link between same-sex sexual orientation and adolescent suicidal thoughts and attempts.” The exact cause is unclear. However, “sexual orientation has an independent association with suicide attempts for males, while for females the association of sexual orientation with suicidality may be mediated by drug use and violence/victimization.”8

Youths who identify as bisexual are 2 to 3 times more likely to attempt suicide than gay and lesbian youths.9 A lack of social support may be one possible cause. Those who acknowledge a more fluid sexual orientation may feel ostracized from both the heterosexual and homosexual communities.

For the adolescent who is also a member of an ethnic minority, the task of identity development becomes more complex. One must concurrently develop a sexual and ethnic identity that differs from the dominant culture. Research has shown these processes occur independently and that these adolescents are at increased risk for stigma and ostracism because of their double minority status.10,11 For some, this may increase the risk of poor mental health outcomes because cultural mores of the ethnic identity may reject their sexual identity more than the dominant culture.

Problems associated with disclosing sexual identity

Asserting one’s sexuality is empowering, but doing so may be riddled with connotations and stereotypes. D’Augelli and Hershberger12 looked at self-identified gay, lesbian, and bisexual youth during the periods of 1987 through 1989 and 1995 through 1997 at community centers. There was some geographical as well as cultural diversity in the study sample. Of the 542 youths, 81% reported experiencing verbal abuse related to being a sexual minority youth, “38% had been threatened with physical attacks, 22% had objects thrown at them, 15% had been physically assaulted, 6% had been assaulted with a weapon, and 16% had been sexually assaulted.”

Youths who are aware of their minority sexual orientation at relatively early ages, who self-identify earlier, and who self-disclose earlier encounter more lifetime victimization.1 Highly effeminate boys are targeted more than others.13

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.


Although definitions may vary in the literature and in clinical discussion, some core concepts are defined here.

Gender identity refers to one’s internally perceived gender, regardless of chromosomal constitution, gonadal/hormonal secretions, or genitalia. Most children develop a stable gender identity that is concordant with their biology at about the age of 3 years. This process is probably driven by biological determinants, but environmental or psychosocial factors may also play a role.

Gender role refers to culturally underwritten masculine and feminine behaviors, attitudes, and personality traits that are partly biologically driven and partly shaped by the environment. This is often noticeable as early as age 2 or 3 years, although in some children there can be flexibility until age 5 or later.

Transgender youth identify with or express a gender identity that differs from the one that corresponds to the person’s sex at birth. This definition does not capture the complexity of an individual’s experience. Transgender youth may share issues and experiences addressed in this article; however, this group is not discussed here because of the need to understand them as a distinct population. References to literature that specifically addresses this population and the topic of gender dysphoria in children and adolescents appear at the end of this article.

Sexual orientation is the predominance of erotic feelings, thoughts, and fantasies one has for members of one’s sex, or both sexes. Savin-Williams and Diamond2 posit that sexual orientation exists along a continuum; a multitude of expressions are possible over a person’s life span. Sexual orientation may not be within conscious control. It may shift along a bisexual continuum for some and for others remain fixed.

Sexual identity describes one’s broader feelings towards one’s gender and sexual attractions. It describes how one consciously labels one’s sexuality.

Resources for Parents and Adolescents

Parents, Families and Friends of Lesbians and Gays (PFLAG) is a support, education, and advocacy organization that promotes the health and well-being of sexual minorities in more than 400 communities:

Gay-Straight Alliances (GSA) are student organizations that are intended to provide a safe and supportive environment for sexual minorities. The goal of most, if not all, GSAs is to make schools welcoming to all students regardless of sexual orientation and gender identity:

Gay, Lesbian, and Straight Education Network (GLSEN) strives to ensure that each member of every school community is valued and respected regardless of sexual orientation or gender identity/expression: is a Web site created by GLSEN that promotes education on the potentially negative impacts of language and bullying on sexual minorities:

Gender Spectrum Education and Training provides education, resources, and training to create a more gender-sensitive and supportive environment for all people, including gender-variant and transgender youth:

The Family Acceptance Project is a community research, intervention, and education initiative to study the impact of family acceptance and rejection on the health, mental health, and well-being of sexual minority youth:




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