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Gay and Lesbian Issues in Child and Adolescent Psychiatry Training as Reported by Training Directors
Gay and Lesbian Issues in Child and Adolescent Psychiatry Training as Reported by Training Directors MARK H. TOWNSEND, M.D., MOLLIE M. WALLICK, PH.D., RICHARD R. PLEAK, M.D., AND KARL M. C A M B E , M.S.
ABSTRACT Objective: Although increased evidence of disproportionate psychosocial risk and other health problems encountered by lesbian, gay male, and bisexual (LGB) youths has emerged, no study has described how the topic of homosexuality is addressed within child and adolescent residency psychiatry training. Method: Residency training directors in U.S. child and adolescent psychiatry programs were asked questions about instruction on the topic of homosexuality and the care of LGB patients, the department’s view of whether homosexuality represents a pathological condition, the director’s awareness of LGB colleagues and residents, and the director’s opinion of LGB residents’ disclosure of their homosexuality to their patients and patients’ families. Asking similar questions facilitated a comparison of sutvey results with those of an earlier study of general psychiatry training directors. Results: The reported departmental attitudes about whether homosexuality represents a pathological condition were essentially equivalent in general and child programs. Child and adolescent training directors were, however, less likely to have a favorable view of disclosure of sexual orientation to patients, less likely to know LGB residents or faculty, and less likely to report LGB residents an asset to their departments. Conclusions: The prediction that the majority of child and adolescent training programs would reflect a heightened awareness of the vulnerability of LGB youths was not confirmed. J. Am. Acad. ChildAdolesc. Psychiatry, 1997, 36(6):764-768.Key Words: gay, lesbian, adolescent, residency training.
During the past decade, increased evidence of disproportionate psychosocial risk (Farrow, 1993; Remafedi et al., 1991) and other health problems (R.R. Pleak and D. Anderson, unpublished, 1995; Sanford, 1989) encountered by lesbian, gay, and bisexual (LGB) youths has emerged. Health professionals have recognized that LGB youths are especially vulnerable to family rejection, diminished education, relief of emotional pain via substance abuse, unsafe sexual contact, and suicidal ideation and behavior (Alcohol, Drug, and Mental Health Administration, 1989). Even so, no study has described how the topic of homosexuality is addressed within U.S. child and Accepted November 6, 1996 Drs. Townsend and Wallick are with the Department of Psychiatry, and Mr. Cambre is with the Department of Computer Services, LSU School of Medicine-New Orleans. Dr. Pleak is with the Division of Child and Adolescent Psychiany, Long Island Jewish Medical Center, Albert Einstein College of Medicine, New York. Reprint requests to Dr. Townsend, LSU School of Medicine-New Orleans, Department of Psychiatv, I542 Tulane Avenue, New Orleans, LA 70112. 0890-8567/97/3606-0764$03.00/0@31997 by the American Academy of Child and Adolescent Psychiatry.
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adolescent psychiatry residency training. In a recent survey of general psychiatry residency training directors (Townsend et al., 1995), 97% reported the inclusion of gay and lesbian issues in the curriculum, most frequently in the third postgraduate training year. Like psychiatry residents in an earlier study (Townsend et al., 1993), almost half of the training directors (47.3%) reported that homosexuality was considered a normal condition. Regarding disclosure of residents’ homosexuality to patients, however, only 3% of faculty considered the practice favorably, compared with the 30% of residents who reported that they did disclose to psychotherapy patients. In this study, we surveyed residency training directors in U.S. child and adolescent psychiatry programs. In addition to instruction on the topic of homosexuality and the care of LGB patients, we were interested in the department’s view of whether homosexuality represents a pathological condition, the directors’ awareness of their programs’ LGB colleagues and residents, and the directors’ opinions of LGB residents’ disclosure of their homosexuality to their patients and
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patients’ families. Asking similar questions allowed for a comparison of survey results with those of the previous study of general psychiatry training directors (Townsend et al., 1995). Our prediction was that the child and adolescent training- curriculum would reflect a heightened awareness of the vulnerability of LGB youths. METHOD We revised a one-page questionnaire, previously used to elicit general psychiatry training directors’ views of gay and lesbian issues in their departments (Townsend et al., 1995), to include issues relevant to child and adolescent psychiatry training. Topics addressed within the survey included the following: programmatic stance toward homosexuality, knowledge concerning the presence of lesbian and gay faculty and residents and the perceived impact of the latter on the program, the way in which the topics of homosexuality and lesbian and gay patient care are taught, and attitudes toward trainees’ disclosure of their homosexuality to psychotherapy patients. Also, the directors were asked in which course or teaching format and in which year instruction on gay and lesbian issues occurs. Survey items were constructed so that the respondent could circle a number from 1 through 5 on a Likert-type rating scale (for program stance, attitudes toward gay and lesbian residents, and residents’ disclosure to patients); for all other items, respondents were asked to indicate a “yes” or “no” answer. To facilitate comparisons, the survey was identical with that used with general psychiatry directors, except for changes necessitated by the different patient populations (e.g., questions about attitudes toward disclosing sexual orientation to children) and course work (e.g., questions about LGB-specific content in “Child and Adolescent Psychopathology”). Directors were not asked to elaborate on their responses. The questionnaire was mailed in 1994 to training directors of all 118 U.S. child and adolescent psychiatry programs listed in the 1993-1994 AMA Graduate Medical Education Directory. Each director was mailed as many as three copies of the survey, depending on whether he or she had responded to an earlier mailing. In the programs responding to the survey, the mean number of child psychiatry residents per year was 3.7. For purposes of analysis, programs with fewer than four residents per year were defined as “small,” while those with four or more were defined as ‘large.” Regional designation was assigned by convention ( The WorldAlmanac and Book ofFacts, 1982): North Central, Northeast, South, and West.
RESULTS
Responses were received from 78 (66.1%) of the 118 directors representing programs in 36 states and the District of Columbia. States with the most responses included New York (12), California (6), and Texas (5). Responses received by region were as follows: South, 2 3 programs (29.1%); West, 12 programs (15.2%); North Central, 20 programs (24.7%); and
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Northeast, 2 1 programs (25.9%). Eight programs were identified as free-standing (10.4%), two programs as military (2.6%), and 65 (86.7%) as university-affiliated. Most directors (49, or 65.3%) described their programs as “public,” fewer (26, or 34.7%) as “private.” The 40 nonresponding programs did not differ from respondents, either by class size (mean = 3.93 versus 3.53, p = .37), region = 5.53, df = 3, p = .14), private or public affiliation = 0.757, df = 1, p = .38), or whether university-affiliated, free-standing, or military = 0.236, df = 1, p = .31).
(x’
(x’
(x’
Curricular Emphasis
The great majority of directors (75, or 94.9%) reported that the topic of homosexuality was addressed in the child psychiatry residency curriculum, somewhat more often in the first year (82.7%) than in the second year of training (76.5%). Instructional methods used were as follows, in descending order of use: case conferences (78.2%), in a child development course (73.1%), in a child and adolescent psychopathology course (42.3%), in psychotherapy teaching (39.7%), in a lecture on depression or as a topic for journal club (30.8% each), in a lecture on suicide or in grand rounds (29.5% each), or in a consult-liaison course (28.2%). The 77 training directors reported the use of from one to nine of these identified methods (mean = 3.78, SD = 2.21). Somewhat more methods were used in the first year (mean = 2.81, SD = 2.35) than in the second year. Program Stance
A director’s view of programmatic stance toward homosexuality was assessed with a 5-point rating scale (from 1 = “pathological” to 3 = “neutral” to 5 = “normal”); five directors did not answer the question. Most directors reported “neutral” (55.4%), many reported “normal” or “somewhat normal” (43.3%), and one director (1.4%) reported “somewhat pathological.” The following nonsignificant trends were observed: As was true of general psychiatry training directors, directors of large child programs considered homosexuality normal more often than those in small programs (5 1.7% versus 37.8%). University-based programs were more likely than free-standing programs to view homosexuality as a normal condition (43.3% versus 37.5%). Public programs were also somewhat more likely than private ones to report homosexuality as normal (46.8% 765
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versus 34.7%). Finally, as in the earlier study, more directors from the West (54.5%) and Northeast (50.0%) reported homosexuality as normal. Directors reporting homosexuality as “somewhat normal” or “normal” were more likely to report that the topic of homosexuality was included in a lecture on suicide (x’= 7.58, df= 1 , p < . O l ) , in psychotherapy supervision (x’ = 2.65, df = 1 , p = .lo), or in a lecture on depression (x’ = 3.05, df = 1 , p = .08). In addition, they were more likely to report an awareness of lesbian and gay residents (x’ = 2.93, df = 1 , p = .09) and that these residents were an asset to their program (x’ = 17.70, 1 , p < .001).
df=
Awareness and Attitudes
Thirty-one directors (40.5% of 79) were aware of lesbian or gay faculty at their programs, and 32 (40.5% of 7 9 ) knew of LGB residents. Awareness of LGB faculty was lower in the North Central region (25.0%) than in the Northeast (42.9%), the West (46.7%), or the South (50.0%). Awareness of LGB residents was also lowest in the North Central region (35.0%), compared with the South (39.1%), the Northeast (42.9%) and the West (50.0%). Respondents from large programs were more likely to report an awareness of both LGB faculty (54.8% versus 29.8%, p < .05) and residents (61.3% versus 27.1%, p < .01). Of all respondents, more than one fourth (27.3%) reported the presence of faculty who considered homosexuality pathological. All respondents were also asked to assess the impact of LGB residents on their programs. Eight ( 1 1.1%) characterized them as “an asset,” while 1 1 ( 1 5.3%) considered them “somewhat of an asset.” Most (52, or 72.2%) reported “neutral,” and only one director (1.4%) said LGB residents were “somewhat of a detriment.” None said LGB residents were “a detriment.” Although not asked to elaborate on their responses, 1 1 directors (13.6%) reported in the margins of the survey that the sexual orientation of their residents was not an appropriate concern. Departmental assessment of residents was significantly associated with the department’s view of homosexuality: those who considered homosexuality other than a normal condition were less likely to consider LGB residents an asset (7.7% versus 53.3%) (x’ = 17.70, df = 1 , p < .001). Residents’ Disclosure to Patients
Most directors did not endorse the practice of disclosing homosexuality to psychotherapy patients. In fact,
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only one director (1.6%) regarded the practice as “favorable,” either to children, adolescents, parents of patients, or adult patients. More than half (32, or 50.8%) regarded disclosure to children as “unfavorable”; 14 (22.2%), as “somewhat unfavorable”; 14 (22.2%), as “neutral”; and 2 (3.2%), as “somewhat favorable.” Fewer (28, or 44.4%) regarded disclosure to adolescents as “unfavorable”; 17 (27.0%),as “somewhat unfavorable”; 15 (23.8%), as “neutral”; and 2 (3.2%), as “somewhat favorable.” Directors viewed disclosure to parents of patients or to adult patients similarly: 25 (39.7%) directors considered disclosure to either parents or adults as “unfavorable”; 16 (25.4%) viewed disclosure to parents as “somewhat unfavorable,” as did 14 (22.6%) to adult patients; 19 (30.2%) reported a “neutral” view of disclosure to parents, as did 18 (29.0%) to adult patients; and 2 directors (3.2%) reported disclosure to parents as “somewhat favorable,” as did 4 (6.5%) to adult patients. Comparison With Earlier Report by General Psychiatry Traininq Directors
The reported departmental attitudes about whether homosexuality represents a pathological condition were equivalent in child and general programs (child directors’ mean = 3.54, SD = 0.73; general directors’ mean = 3.68, SD = 0.84). Child and adolescent training directors were, however, less likely to regard disclosure of sexual orientation to patients favorably (child directors’ mean = 2.06, SD = 1.05; general directors’ mean = 2.39, SD = 0.98) ( t = 1.99, d f = 122.5, p < .05). In addition, directors of child programs were less likely to report LGB residents an asset to their departments (child directors’ mean = 3.36, SD = 077; general directors’ mean = 3.64, SD = 0.69) ( t = 2.64, df = 160.0, p < .Ol).[pa Child and adolescent directors were less likely to know of LGB faculty (39.7% versus 69.7%) (x’ = 18.13, df = 1 , p < .001) or residents (40.5% versus 68.9%) (x’ = 16.43, d f = 1, p < .001). These directors were somewhat less likely to know faculty who considered homosexuality pathological (28.0% versus 38.6%) (x’ = 2.38, df = 1 , p = .12). Significant differences were also observed regarding the courses in which the topic of homosexuality was taught. In child psychiatry training, homosexuality was more often discussed within a case conference (78.2% versus 62.7%) (x’ = 5.49, df = 1 , p < .05) or in a child development course (73.1% versus 53.7%) (x’ =
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GAY A N D LESBIAN ISSUES I N T R A I N I N G = 1, p < .OI), but in general psychiatry training, homosexuality was more often included as a grand rounds topic (48.5% versus 29.5%) (x’ = 7.35, df= 1, p < .O1).
7.75, df
DISCUSSION
The limitations of this study are similar to those of the previous survey of general psychiatry training directors. In both studies, the results are dependent on one person’s perception of departmental opinion on homosexuality. Any findings so derived must be viewed cautiously, since no person can have complete knowledge of his or her colleagues’ views. Although we consider our response rate good, a similar percentage of child and adolescent training directors-almost one third-did not return the survey. Also, the survey was kept to one page both to encourage a response and to replicate the format of the general director’s survey, necessarily limiting the scope of the information obtained. In addition, the 5-point scale we used to assess a department’s view on homosexuality is itself problematic, since it is unclear whether those who circled “neutral” were endorsing a middle ground between normal and pathological-our intention-or indicating “no opinion.” We nevertheless find it meaningful that most respondents chose not to indicate that homosexuality was considered normal at their programs, particularly since homosexuality per se has been absent from the DSM as a diagnosable condition for more than 20 years and is described as a normal variant in American Psychiatric Association materials (American Psychiatric Association, 1994). Moreover, directors rarely used “neutral” to describe their feelings toward the disclosure of a homosexual sexual orientation to patients, suggesting that they understood “neutral” to be an intermediate position. In addition, we consider it unlikely that directors who considered homosexuality a normal variant nevertheless chose “neutral” rather than “normal” to avoid associations with frequency, e.g., “normative” child development or the statistical mode; directors so inclined could have indicated “somewhat normal.” We did not ask directors the number of hours devoted to instruction on homosexuality, so quantitative comparisons are not possible. It appears, though, that the vast majority of training programs, whether
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general or child, discuss LGB issues in some way. Many child programs appear to be discussing the risk of suicide among LGB youths; perhaps more will follow if a consensus develops about their treatment. The fact that a “normal” departmental view of homosexuality correlated with the presence of lecture material on LGB adolescent depression and suicide suggests the likelihood that the content of these lectures emphasizes the relation between suicide and negative societal sanction of homosexuality, rather than the older view that homosexuality and depression result from a common psychosexual diathesis. In some ways it defies common sense to view training directors of general psychiatry programs as a separate population from those of child and adolescent programs. Many programs share a common physical plant, members of faculty, and even residents, as trainees progress from general residents to child and adolescent residents within the same department. Some of our findings are, therefore, surprising: why should child and adolescent directors, for example, be less aware of LGB faculty and residents? It may be that these residents and faculty are more circumspect about revealing sexual orientation, perhaps because of the long and erroneous association between homosexuality and child sexual abuse. Child psychiatrists have been thought to avoid such stigma by concealing their sexual orientation (Atkins and Townsend, 1996) when, in fact, the proportion of child psychiatrists who are LGB may equal if not exceed that of adult psychiatrists (Lesbian and Gay Child and Adolescent Psychiatric Association, personal communication, 1996). LGB child psychiatry residents may also be more likely to attend programs in cities with large LGB communities, to better achieve peer support, and thus may be less well-known to some training directors. Finally, many child programs, because they have smaller numbers of residents and faculty, may simply be less likely to contain LGB residents and faculty. Our intent in asking residency directors about the value of LGB trainees was to determine whether the presence of sexual minority residents was considered as important an aspect of residency diversity as the presence of racial or ethnic minority trainees. That several directors indicated their disapproval of our efforts to determine departmental opinion of LGB residents suggests the question may have been poorly phrased. In addition, we made no attempt to define
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what we meant by a “lesbian, gay, or bisexual” resident. Nevertheless, fewer child and adolescent directors reported that LGB residents were an asset to their programs. If this represents, for whatever reason, a more negative opinion about “open” homosexuality, it may help explain the more limited awareness of LGB colleagues. Finally, it appears that the overwhelming majority of child and adolescent training directors disapprove of disclosing sexual orientation to patients-even more so than general directors, who were also disinclined to endorse the practice. Self-disclosure is, of course, discouraged in many psychotherapeutic traditions (Strean, 1993), although some, mostly lesbian and gay therapists, have suggested that it is, at times, therapeutic (Hanley-Hackenbruck, 1993; Isay, 199 1). Psychotherapy supervisors may be unaware of the extent to which LGB residents are using self-disclosure in psychotherapy, if the 30% of residents in our survey who reported they self-disclose is any indication of actual prevalence. LGB residents may need encouragement to discuss these and other gay-specific issues with faculty, who must be prepared to offer appropriate guidance. If, in fact, LGB child residents are somehow discouraged from acknowledging their sexual orientation, supervision with these residents is made all the more difficult. In summary, psychiatry programs, general and child alike, have become diverse places, both with regard to the backgrounds of faculty and residents and to the variety of skills taught. Residency training programs must work to ensure that LGB issues are included in
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meaningful ways within that diversity. Although more research is needed to identify better the distinct needs of LGB patients, the variety of opinion reported in these surveys suggests that academic psychiatry must also come to a consensus about the clinical meaning of homosexuality itself. REFERENCES Alcohol, Drug, and Mental Health Administration (1989), Report of the Secretary? Task Force on Youth Suicide, Vol 1-3. Rockville, MD: US Department of Health and Human Services American Psychiatric Association (1994), Fact Sheet on Gay and Lesbian Issues. Washington, DC: American Psychiatric Association Atkins L, Townsend M H (1996), Issues for gay male, lesbian, and bisexual mental health trainees. In: Textbook ofHomosexualityandMenta1Health, Cabaj RP, Stein TS, eds. Washington, DC: American Psychiatric Press, pp 683-694 Farrow JA (1993), Youth alienation as an emerging pediatric health care issue. Am Dis Child 147:509 Hanley-Hackenbruck P (1993), Working with lesbians in psychotherapy. In: Review of Psychiatry, Vol 12, Oldham JM, Riba MB, Tasman A, eds. Washington, DC: American Psychiatric Press, pp 59-84 Isay RA (199l), The homosexual analyst: clinical considerations. Psychoanal Study Child 46: 199-2 16 Remafedi G , Farrow JA, Deisher RW (1991), Risk factors for attempted suicide in gay and bisexual youth. Pediaeics 87:869-875 Sanford N D (1989), Providing sensitive health care to gay and lesbian youth. Nurse Pract 14:30-47 Strean HS (1993), The middle phase continued: the therapist’s reactions to subtle resistances and the therapist’s subtle counterresistances. In: Resolving Counter-Resistances in Psychotherapy. New York: Brunnerl Mazel, pp 191-221 Townsend M H , Wallick MM, Cambre KM (1993), Gay and lesbian issues in residency training at US psychiatry programs. Academic Psychiatry 1767-72 Townsend M H , Wallick MM, Cambre KM (1995), Gay and lesbian issues in US psychiatric training as reported by residency training directors. Academic Psychiatry 19:2 13-2 18 The WorldAlmanacand Book ofFacts, 1982 (1981), New York: Newspaper Enterprise Association
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ABSTRACT Objective: Although increased evidence of disproportionate psychosocial risk and other health problems encountered by lesbian, gay male, and bisexual (LGB) youths has emerged, no study has described how the topic of homosexuality is addressed within child and adolescent residency psychiatry training. Method: Residency training directors in U.S. child and adolescent psychiatry programs were asked questions about instruction on the topic of homosexuality and the care of LGB patients, the department’s view of whether homosexuality represents a pathological condition, the director’s awareness of LGB colleagues and residents, and the director’s opinion of LGB residents’ disclosure of their homosexuality to their patients and patients’ families. Asking similar questions facilitated a comparison of sutvey results with those of an earlier study of general psychiatry training directors. Results: The reported departmental attitudes about whether homosexuality represents a pathological condition were essentially equivalent in general and child programs. Child and adolescent training directors were, however, less likely to have a favorable view of disclosure of sexual orientation to patients, less likely to know LGB residents or faculty, and less likely to report LGB residents an asset to their departments. Conclusions: The prediction that the majority of child and adolescent training programs would reflect a heightened awareness of the vulnerability of LGB youths was not confirmed. J. Am. Acad. ChildAdolesc. Psychiatry, 1997, 36(6):764-768.Key Words: gay, lesbian, adolescent, residency training.
During the past decade, increased evidence of disproportionate psychosocial risk (Farrow, 1993; Remafedi et al., 1991) and other health problems (R.R. Pleak and D. Anderson, unpublished, 1995; Sanford, 1989) encountered by lesbian, gay, and bisexual (LGB) youths has emerged. Health professionals have recognized that LGB youths are especially vulnerable to family rejection, diminished education, relief of emotional pain via substance abuse, unsafe sexual contact, and suicidal ideation and behavior (Alcohol, Drug, and Mental Health Administration, 1989). Even so, no study has described how the topic of homosexuality is addressed within U.S. child and Accepted November 6, 1996 Drs. Townsend and Wallick are with the Department of Psychiatry, and Mr. Cambre is with the Department of Computer Services, LSU School of Medicine-New Orleans. Dr. Pleak is with the Division of Child and Adolescent Psychiany, Long Island Jewish Medical Center, Albert Einstein College of Medicine, New York. Reprint requests to Dr. Townsend, LSU School of Medicine-New Orleans, Department of Psychiatv, I542 Tulane Avenue, New Orleans, LA 70112. 0890-8567/97/3606-0764$03.00/0@31997 by the American Academy of Child and Adolescent Psychiatry.
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adolescent psychiatry residency training. In a recent survey of general psychiatry residency training directors (Townsend et al., 1995), 97% reported the inclusion of gay and lesbian issues in the curriculum, most frequently in the third postgraduate training year. Like psychiatry residents in an earlier study (Townsend et al., 1993), almost half of the training directors (47.3%) reported that homosexuality was considered a normal condition. Regarding disclosure of residents’ homosexuality to patients, however, only 3% of faculty considered the practice favorably, compared with the 30% of residents who reported that they did disclose to psychotherapy patients. In this study, we surveyed residency training directors in U.S. child and adolescent psychiatry programs. In addition to instruction on the topic of homosexuality and the care of LGB patients, we were interested in the department’s view of whether homosexuality represents a pathological condition, the directors’ awareness of their programs’ LGB colleagues and residents, and the directors’ opinions of LGB residents’ disclosure of their homosexuality to their patients and
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patients’ families. Asking similar questions allowed for a comparison of survey results with those of the previous study of general psychiatry training directors (Townsend et al., 1995). Our prediction was that the child and adolescent training- curriculum would reflect a heightened awareness of the vulnerability of LGB youths. METHOD We revised a one-page questionnaire, previously used to elicit general psychiatry training directors’ views of gay and lesbian issues in their departments (Townsend et al., 1995), to include issues relevant to child and adolescent psychiatry training. Topics addressed within the survey included the following: programmatic stance toward homosexuality, knowledge concerning the presence of lesbian and gay faculty and residents and the perceived impact of the latter on the program, the way in which the topics of homosexuality and lesbian and gay patient care are taught, and attitudes toward trainees’ disclosure of their homosexuality to psychotherapy patients. Also, the directors were asked in which course or teaching format and in which year instruction on gay and lesbian issues occurs. Survey items were constructed so that the respondent could circle a number from 1 through 5 on a Likert-type rating scale (for program stance, attitudes toward gay and lesbian residents, and residents’ disclosure to patients); for all other items, respondents were asked to indicate a “yes” or “no” answer. To facilitate comparisons, the survey was identical with that used with general psychiatry directors, except for changes necessitated by the different patient populations (e.g., questions about attitudes toward disclosing sexual orientation to children) and course work (e.g., questions about LGB-specific content in “Child and Adolescent Psychopathology”). Directors were not asked to elaborate on their responses. The questionnaire was mailed in 1994 to training directors of all 118 U.S. child and adolescent psychiatry programs listed in the 1993-1994 AMA Graduate Medical Education Directory. Each director was mailed as many as three copies of the survey, depending on whether he or she had responded to an earlier mailing. In the programs responding to the survey, the mean number of child psychiatry residents per year was 3.7. For purposes of analysis, programs with fewer than four residents per year were defined as “small,” while those with four or more were defined as ‘large.” Regional designation was assigned by convention ( The WorldAlmanac and Book ofFacts, 1982): North Central, Northeast, South, and West.
RESULTS
Responses were received from 78 (66.1%) of the 118 directors representing programs in 36 states and the District of Columbia. States with the most responses included New York (12), California (6), and Texas (5). Responses received by region were as follows: South, 2 3 programs (29.1%); West, 12 programs (15.2%); North Central, 20 programs (24.7%); and
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Northeast, 2 1 programs (25.9%). Eight programs were identified as free-standing (10.4%), two programs as military (2.6%), and 65 (86.7%) as university-affiliated. Most directors (49, or 65.3%) described their programs as “public,” fewer (26, or 34.7%) as “private.” The 40 nonresponding programs did not differ from respondents, either by class size (mean = 3.93 versus 3.53, p = .37), region = 5.53, df = 3, p = .14), private or public affiliation = 0.757, df = 1, p = .38), or whether university-affiliated, free-standing, or military = 0.236, df = 1, p = .31).
(x’
(x’
(x’
Curricular Emphasis
The great majority of directors (75, or 94.9%) reported that the topic of homosexuality was addressed in the child psychiatry residency curriculum, somewhat more often in the first year (82.7%) than in the second year of training (76.5%). Instructional methods used were as follows, in descending order of use: case conferences (78.2%), in a child development course (73.1%), in a child and adolescent psychopathology course (42.3%), in psychotherapy teaching (39.7%), in a lecture on depression or as a topic for journal club (30.8% each), in a lecture on suicide or in grand rounds (29.5% each), or in a consult-liaison course (28.2%). The 77 training directors reported the use of from one to nine of these identified methods (mean = 3.78, SD = 2.21). Somewhat more methods were used in the first year (mean = 2.81, SD = 2.35) than in the second year. Program Stance
A director’s view of programmatic stance toward homosexuality was assessed with a 5-point rating scale (from 1 = “pathological” to 3 = “neutral” to 5 = “normal”); five directors did not answer the question. Most directors reported “neutral” (55.4%), many reported “normal” or “somewhat normal” (43.3%), and one director (1.4%) reported “somewhat pathological.” The following nonsignificant trends were observed: As was true of general psychiatry training directors, directors of large child programs considered homosexuality normal more often than those in small programs (5 1.7% versus 37.8%). University-based programs were more likely than free-standing programs to view homosexuality as a normal condition (43.3% versus 37.5%). Public programs were also somewhat more likely than private ones to report homosexuality as normal (46.8% 765
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versus 34.7%). Finally, as in the earlier study, more directors from the West (54.5%) and Northeast (50.0%) reported homosexuality as normal. Directors reporting homosexuality as “somewhat normal” or “normal” were more likely to report that the topic of homosexuality was included in a lecture on suicide (x’= 7.58, df= 1 , p < . O l ) , in psychotherapy supervision (x’ = 2.65, df = 1 , p = .lo), or in a lecture on depression (x’ = 3.05, df = 1 , p = .08). In addition, they were more likely to report an awareness of lesbian and gay residents (x’ = 2.93, df = 1 , p = .09) and that these residents were an asset to their program (x’ = 17.70, 1 , p < .001).
df=
Awareness and Attitudes
Thirty-one directors (40.5% of 79) were aware of lesbian or gay faculty at their programs, and 32 (40.5% of 7 9 ) knew of LGB residents. Awareness of LGB faculty was lower in the North Central region (25.0%) than in the Northeast (42.9%), the West (46.7%), or the South (50.0%). Awareness of LGB residents was also lowest in the North Central region (35.0%), compared with the South (39.1%), the Northeast (42.9%) and the West (50.0%). Respondents from large programs were more likely to report an awareness of both LGB faculty (54.8% versus 29.8%, p < .05) and residents (61.3% versus 27.1%, p < .01). Of all respondents, more than one fourth (27.3%) reported the presence of faculty who considered homosexuality pathological. All respondents were also asked to assess the impact of LGB residents on their programs. Eight ( 1 1.1%) characterized them as “an asset,” while 1 1 ( 1 5.3%) considered them “somewhat of an asset.” Most (52, or 72.2%) reported “neutral,” and only one director (1.4%) said LGB residents were “somewhat of a detriment.” None said LGB residents were “a detriment.” Although not asked to elaborate on their responses, 1 1 directors (13.6%) reported in the margins of the survey that the sexual orientation of their residents was not an appropriate concern. Departmental assessment of residents was significantly associated with the department’s view of homosexuality: those who considered homosexuality other than a normal condition were less likely to consider LGB residents an asset (7.7% versus 53.3%) (x’ = 17.70, df = 1 , p < .001). Residents’ Disclosure to Patients
Most directors did not endorse the practice of disclosing homosexuality to psychotherapy patients. In fact,
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only one director (1.6%) regarded the practice as “favorable,” either to children, adolescents, parents of patients, or adult patients. More than half (32, or 50.8%) regarded disclosure to children as “unfavorable”; 14 (22.2%), as “somewhat unfavorable”; 14 (22.2%), as “neutral”; and 2 (3.2%), as “somewhat favorable.” Fewer (28, or 44.4%) regarded disclosure to adolescents as “unfavorable”; 17 (27.0%),as “somewhat unfavorable”; 15 (23.8%), as “neutral”; and 2 (3.2%), as “somewhat favorable.” Directors viewed disclosure to parents of patients or to adult patients similarly: 25 (39.7%) directors considered disclosure to either parents or adults as “unfavorable”; 16 (25.4%) viewed disclosure to parents as “somewhat unfavorable,” as did 14 (22.6%) to adult patients; 19 (30.2%) reported a “neutral” view of disclosure to parents, as did 18 (29.0%) to adult patients; and 2 directors (3.2%) reported disclosure to parents as “somewhat favorable,” as did 4 (6.5%) to adult patients. Comparison With Earlier Report by General Psychiatry Traininq Directors
The reported departmental attitudes about whether homosexuality represents a pathological condition were equivalent in child and general programs (child directors’ mean = 3.54, SD = 0.73; general directors’ mean = 3.68, SD = 0.84). Child and adolescent training directors were, however, less likely to regard disclosure of sexual orientation to patients favorably (child directors’ mean = 2.06, SD = 1.05; general directors’ mean = 2.39, SD = 0.98) ( t = 1.99, d f = 122.5, p < .05). In addition, directors of child programs were less likely to report LGB residents an asset to their departments (child directors’ mean = 3.36, SD = 077; general directors’ mean = 3.64, SD = 0.69) ( t = 2.64, df = 160.0, p < .Ol).[pa Child and adolescent directors were less likely to know of LGB faculty (39.7% versus 69.7%) (x’ = 18.13, df = 1 , p < .001) or residents (40.5% versus 68.9%) (x’ = 16.43, d f = 1, p < .001). These directors were somewhat less likely to know faculty who considered homosexuality pathological (28.0% versus 38.6%) (x’ = 2.38, df = 1 , p = .12). Significant differences were also observed regarding the courses in which the topic of homosexuality was taught. In child psychiatry training, homosexuality was more often discussed within a case conference (78.2% versus 62.7%) (x’ = 5.49, df = 1 , p < .05) or in a child development course (73.1% versus 53.7%) (x’ =
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GAY A N D LESBIAN ISSUES I N T R A I N I N G = 1, p < .OI), but in general psychiatry training, homosexuality was more often included as a grand rounds topic (48.5% versus 29.5%) (x’ = 7.35, df= 1, p < .O1).
7.75, df
DISCUSSION
The limitations of this study are similar to those of the previous survey of general psychiatry training directors. In both studies, the results are dependent on one person’s perception of departmental opinion on homosexuality. Any findings so derived must be viewed cautiously, since no person can have complete knowledge of his or her colleagues’ views. Although we consider our response rate good, a similar percentage of child and adolescent training directors-almost one third-did not return the survey. Also, the survey was kept to one page both to encourage a response and to replicate the format of the general director’s survey, necessarily limiting the scope of the information obtained. In addition, the 5-point scale we used to assess a department’s view on homosexuality is itself problematic, since it is unclear whether those who circled “neutral” were endorsing a middle ground between normal and pathological-our intention-or indicating “no opinion.” We nevertheless find it meaningful that most respondents chose not to indicate that homosexuality was considered normal at their programs, particularly since homosexuality per se has been absent from the DSM as a diagnosable condition for more than 20 years and is described as a normal variant in American Psychiatric Association materials (American Psychiatric Association, 1994). Moreover, directors rarely used “neutral” to describe their feelings toward the disclosure of a homosexual sexual orientation to patients, suggesting that they understood “neutral” to be an intermediate position. In addition, we consider it unlikely that directors who considered homosexuality a normal variant nevertheless chose “neutral” rather than “normal” to avoid associations with frequency, e.g., “normative” child development or the statistical mode; directors so inclined could have indicated “somewhat normal.” We did not ask directors the number of hours devoted to instruction on homosexuality, so quantitative comparisons are not possible. It appears, though, that the vast majority of training programs, whether
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general or child, discuss LGB issues in some way. Many child programs appear to be discussing the risk of suicide among LGB youths; perhaps more will follow if a consensus develops about their treatment. The fact that a “normal” departmental view of homosexuality correlated with the presence of lecture material on LGB adolescent depression and suicide suggests the likelihood that the content of these lectures emphasizes the relation between suicide and negative societal sanction of homosexuality, rather than the older view that homosexuality and depression result from a common psychosexual diathesis. In some ways it defies common sense to view training directors of general psychiatry programs as a separate population from those of child and adolescent programs. Many programs share a common physical plant, members of faculty, and even residents, as trainees progress from general residents to child and adolescent residents within the same department. Some of our findings are, therefore, surprising: why should child and adolescent directors, for example, be less aware of LGB faculty and residents? It may be that these residents and faculty are more circumspect about revealing sexual orientation, perhaps because of the long and erroneous association between homosexuality and child sexual abuse. Child psychiatrists have been thought to avoid such stigma by concealing their sexual orientation (Atkins and Townsend, 1996) when, in fact, the proportion of child psychiatrists who are LGB may equal if not exceed that of adult psychiatrists (Lesbian and Gay Child and Adolescent Psychiatric Association, personal communication, 1996). LGB child psychiatry residents may also be more likely to attend programs in cities with large LGB communities, to better achieve peer support, and thus may be less well-known to some training directors. Finally, many child programs, because they have smaller numbers of residents and faculty, may simply be less likely to contain LGB residents and faculty. Our intent in asking residency directors about the value of LGB trainees was to determine whether the presence of sexual minority residents was considered as important an aspect of residency diversity as the presence of racial or ethnic minority trainees. That several directors indicated their disapproval of our efforts to determine departmental opinion of LGB residents suggests the question may have been poorly phrased. In addition, we made no attempt to define
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what we meant by a “lesbian, gay, or bisexual” resident. Nevertheless, fewer child and adolescent directors reported that LGB residents were an asset to their programs. If this represents, for whatever reason, a more negative opinion about “open” homosexuality, it may help explain the more limited awareness of LGB colleagues. Finally, it appears that the overwhelming majority of child and adolescent training directors disapprove of disclosing sexual orientation to patients-even more so than general directors, who were also disinclined to endorse the practice. Self-disclosure is, of course, discouraged in many psychotherapeutic traditions (Strean, 1993), although some, mostly lesbian and gay therapists, have suggested that it is, at times, therapeutic (Hanley-Hackenbruck, 1993; Isay, 199 1). Psychotherapy supervisors may be unaware of the extent to which LGB residents are using self-disclosure in psychotherapy, if the 30% of residents in our survey who reported they self-disclose is any indication of actual prevalence. LGB residents may need encouragement to discuss these and other gay-specific issues with faculty, who must be prepared to offer appropriate guidance. If, in fact, LGB child residents are somehow discouraged from acknowledging their sexual orientation, supervision with these residents is made all the more difficult. In summary, psychiatry programs, general and child alike, have become diverse places, both with regard to the backgrounds of faculty and residents and to the variety of skills taught. Residency training programs must work to ensure that LGB issues are included in
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meaningful ways within that diversity. Although more research is needed to identify better the distinct needs of LGB patients, the variety of opinion reported in these surveys suggests that academic psychiatry must also come to a consensus about the clinical meaning of homosexuality itself. REFERENCES Alcohol, Drug, and Mental Health Administration (1989), Report of the Secretary? Task Force on Youth Suicide, Vol 1-3. Rockville, MD: US Department of Health and Human Services American Psychiatric Association (1994), Fact Sheet on Gay and Lesbian Issues. Washington, DC: American Psychiatric Association Atkins L, Townsend M H (1996), Issues for gay male, lesbian, and bisexual mental health trainees. In: Textbook ofHomosexualityandMenta1Health, Cabaj RP, Stein TS, eds. Washington, DC: American Psychiatric Press, pp 683-694 Farrow JA (1993), Youth alienation as an emerging pediatric health care issue. Am Dis Child 147:509 Hanley-Hackenbruck P (1993), Working with lesbians in psychotherapy. In: Review of Psychiatry, Vol 12, Oldham JM, Riba MB, Tasman A, eds. Washington, DC: American Psychiatric Press, pp 59-84 Isay RA (199l), The homosexual analyst: clinical considerations. Psychoanal Study Child 46: 199-2 16 Remafedi G , Farrow JA, Deisher RW (1991), Risk factors for attempted suicide in gay and bisexual youth. Pediaeics 87:869-875 Sanford N D (1989), Providing sensitive health care to gay and lesbian youth. Nurse Pract 14:30-47 Strean HS (1993), The middle phase continued: the therapist’s reactions to subtle resistances and the therapist’s subtle counterresistances. In: Resolving Counter-Resistances in Psychotherapy. New York: Brunnerl Mazel, pp 191-221 Townsend M H , Wallick MM, Cambre KM (1993), Gay and lesbian issues in residency training at US psychiatry programs. Academic Psychiatry 1767-72 Townsend M H , Wallick MM, Cambre KM (1995), Gay and lesbian issues in US psychiatric training as reported by residency training directors. Academic Psychiatry 19:2 13-2 18 The WorldAlmanacand Book ofFacts, 1982 (1981), New York: Newspaper Enterprise Association
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