Gay and lesbian issues in pediatric health care

Gay and Lesbian Issues in Pediatric Health Care Ellen C. Perrin, MD,a Kenneth M. Cohen, PhD,b Melanie Gold, DO,c Caitlin Ryan, MSW, ACSW,d Ritch C. Savin-Williams, PhD,b and Cindy M. Schorzman, MDe

dolescents are questioning and coming to understand their sexuality, and recognizing and disclosing their sexual orientation, at increasingly younger ages. At the same time pediatricians have begun to care for teenagers through their adolescent years and even into their early 20s. Advances in reproductive and social possibilities have led to a rapid escalation in the number of children who have one or more homosexual parent(s). Thus, it is critical for clinicians who care for children and their families to have a solid base for understanding the development of sexual orientations, the concerns of gay and lesbian teenagers and their families and of gay and lesbian parents and their children, and to have access to the information and resources necessary to help everyone to maximize their developmental potential. We have attempted to present some of the highlights of the growing body of information that we believe are important for pediatricians and other health care professionals to know about with regard to homosexuality. Contributions from several professionals from various disciplines present their knowledge and opinions regarding the issues that pediatricians and other health care clinicians should know about homosexuality. First is a section regarding what is known about the origins of “homoeroticism.” Following this is a description of the phenomenon of very young children who manifest strong interests and preferences for

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playmates and activities that are not typical of their anatomical gender. Subsequent sections address the concerns of and about gay and lesbian teenagers, their families’ typical reactions to their recognition that their son or daughter is not heterosexual, and the current state of knowledge regarding the well-being of children whose parents are lesbian or gay. The next section is a review of some ways in which child health clinicians can improve their efforts on behalf of their patients and their families who are gay or lesbian. The final section provides a listing of some specific resources that can be posted and/or distributed as indicated.

Etiology of Homoeroticism —Kenneth M. Cohen, MD Historical Overview

Tufts University School of Medicine, The Floating Hospital for Children, Tufts-New England Medical Center, Boston, MA; bCornell University, Ithaca, NY; cUniversity of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, PA; dCollege of Ethnic Studies, César Chávez Institute, San Francisco State University, San Francisco, CA; and eOlympia Medical Center, Group Health Permanente, Olympia, WA. Curr Probl Pediatr Adolesc Health Care 2004;34:355-398 1538-5442/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.cppeds.2004.08.001

Homosexual behavior reflecting an orientation or an enduring trait was rarely acknowledged before the last century. Rather, it was viewed as an aberrant, if not temporary, situational behavior (eg, prison, boarding school, drunken state) toward which one could be seduced.1 Homosexuality as an individual characteristic was only recognized when it became apparent that some individuals consistently pursued exclusive homosexual behavior. This newly identified class of “homosexuals” was subsequently censured and treated as criminal, perverted, and amoral because of what their behavior implied about their character.2,3 One of the earliest attempts to challenge this view was undertaken by German sexologist Magnus Hirschfeld who wrote that homosexuality (or sexual inversion, as it was then referenced) was not a preference for moral debauchery or illicit activity but an essentially different, yet natural, condition from heterosexuality— one

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that resulted in men and women involuntarily assuming a position somewhere between typical males and females.3,4 The positive impact of Hirschfeld’s “third sex” view was not, however, long-lasting. The growing popularity of Freud and his psychoanalytic disciples’ teachings fortified the view that homosexuality was an unacceptable deviation from a preferred norm. Freud, who had several ideas about the genesis of (mostly male) homosexuality but no real systematic theory,5 never believed that it was an illness that should be criminalized. Despite these assertions, neo-Freudians, especially those in the United States,6,7 villainized homosexuality more than Freud ever intended. Although their views and several other popular theories have received little empirical validation,8,9 they remain popular in the public psyche. In terms of psychoanalytic theories, Freud proposed that male homosexuality is usually of preoedipal or oedipal origin. He wrote that during early childhood prehomosexual boys develop “an intense erotic attachment to a female person, as a rule their mother, provoked and fostered by the excessive tenderness of the mother” and “the recessiveness of the father.” Subsequently, “the boy represses his love for his mother by putting himself in her place, identifies himself with her, and takes his own person as a model in whose likeness he chooses his new love objects.” Having become “homosexual,” the child “has slid back into autoeroticism,” loving those who are “only substitute persons and renewals of his own childish person, boys whom he loves as his mother had loved him as a child.”10 Neo-Freudians expanded these views, maintaining that homosexuality results from, among other things, fixation at an early psychosexual stage of development that is characterized by same-sex attraction and narcissism. Consequently, “homosexuals” were regarded as emotionally immature, impulsive, deceptive, and unable to achieve genuine adult loving relationships. Some argued that homosexuality resulted from a family composed of a domineering mother and an absent or submissive father6,7 or asserted that it followed arrested psychosexual development after seduction by an older same-sex person.11 The related inadequate parenting theory proposes that parental discord, divorce, poor parenting, and improper samesex role models similarly generate early psychosexual fixations12 that result in arrested development and

excessive self-love, which are expressed through same-sex attractions. Sex segregation/heterosexual frustration theory posits that male homosexuality results from a scarcity of females or early negative experiences with females. Imprinting theory proposes that sexual attractions may be imprinted around the time of puberty and thus the individuals with whom one associates during this time may determine the sex on which the imprinting occurs. Imprinting refers to an unconscious process in which a strong emotional bond is fixated onto an individual or group of individuals. Some researchers (eg, Blanchard and Bogaert13) report that gay males experience puberty up to a year earlier than heterosexual males14,15 and thus are ripe for imprinting during a time when boys spend most of their time with same-sex peers.16 In contrast, later maturing heterosexual males become imprinted in a social context that is more inclusive of females. Thus, the former imprint on males, the latter on females. This mechanism does not appear, however, to operate among females; no empirical evidence suggests that compared with heterosexual females, lesbians experience an earlier pubertal onset. Sexual reinforcement theory maintains that homosexuality results from one or more early same-sex experiences that occur before sexual experience with opposite-sex persons. Because these are pleasurable and reinforcing, a homosexual behavioral pattern emerges. The more pleasurable the experiences, the greater the conditioning.12 Self-labeling theory claims that to the extent an individual behaves in a sex-atypical manner and is consequently labeled gay or lesbian by others, he or she will self-identify as gay or lesbian.9,12 Inappropriate sex role training theory suggests that males who are unable to fulfill societal demands of masculinity may seek escape in female sex roles. Others have proposed that inappropriate role models or sex role training may result in homosexuality.12 Bem’s17 exotic becomes erotic theory proposes that biological and psychological factors interact to produce both homosexuality and heterosexuality. Temperament, generated by biological factors, is expressed in behaviors such as activity level or aggression that predispose a child to prefer either sex-typical or sex-atypical activities and playmates. To the extent that a youth is gender-nonconforming, opposite-sex peers and activities will be sought and same-sex peers will be experienced as dissimilar and exotic. These feelings of differentness, compounded by same-sex

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By contrast, the past 15 years has witnessed the proliferation of biological research that has generated mounting support for biological theories. They suggest that for some individuals sexual orientation is the consequence of early biological events generated by genes and prenatal sex hormones, both of which impact brain morphology. The evidence is stronger for males than females, indicating that female sexual orientation may be multi-determined. Pedigree investigations estimate heritability by the incidence of homoerotic family members among homosexual and heterosexual individuals. Compared with heterosexual controls, gay males19 and lesbians20 have more homoerotic family members. Twin studies, in which one member of the dyad is gay, document a higher concordance rate for homosexuality among monozygotic than dizygotic twins, both of which are higher than the concordance rate among nontwin and adopted siblings.21,22 Technological advances facilitated identification of a genetic marker (Xq28) for homosexuality on the X chromosome among some gay males23; for failure to replicate.24 The mechanism by which genes initiate homoeroticism remains uncertain, though it is suspected that they direct the brain to develop in a sex-atypical manner. Uncharacteristic cerebral anatomy may also result from sex-atypical levels of sex hormones, par-

ticularly androgens—stimulated by genes and/or environment— during critical periods of prenatal development when the brain is being organized. The role of androgens is to masculinize and defeminize the brain. Underexposure in males results in inadequate cerebral masculinization and defeminization, whereas overexposure in females produces the opposite effect. In either case, sex-atypical behaviors and interests are generated, including sexual attractions.25 Such atypical cerebral anatomy is assumed from administration of neuropsychological tests in which documented sex differences exist. Although males typically outperform females on visual-spatial tasks, several studies report that the cognitive performance of gay males is more similar to heterosexual females than heterosexual males,26,27,28 indicating under-masculinized brains; lesbians display trends toward male-typical performance.28 Sex-atypical performance on verbal fluency tasks that are also sexually dimorphic have been noted among both gays and lesbians.29 Further evidence that homoeroticism is hardwired is derived from investigations of brain activity. During verbal and spatial tasks, brain wave patterns in gay males are more similar to heterosexual females than males, or they are intermediary.30,31 Male sexual orientation differences in the superior temporal gyrus were observed with magnetoencephalography32 and differences in hypothalamic glucose metabolism were detected with PET scans.33 Histological analysis of brain tissue revealed male sexual orientation group differences in the medial preoptic region (INAH 3) of the hypothalamus,34,35 the anterior commissure,36 and the suprachiasmatic nucleus.37 The first two are located in sexually dimorphic regions. Cerebral differences among females have not been investigated. Although not fully understood, numerous studies document a fraternal birth-order effect: a preponderance of older male siblings among gay males, with each additional older brother increasing the likelihood of homosexuality among later born males by 33%.38 Escalating maternal immunization “to Y-linked minor histocompatibility antigens (H-Y antigens) by each succeeding male fetus” (p. 105) is hypothesized to be the mechanism by which homoeroticism is generated. As maternal anti-H-Y antibodies enter the fetus brain they hinder cerebral sexual differentiation. Several additional sexual orientation differences in sexually dimorphic structures and behaviors are considered a likely consequence of sex-atypical levels of prenatal androgens. The dermatoglyphic profile (pat-

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peer ridicule and rejection, produce heightened autonomic nervous system arousal which is eventually transformed into erotic attractions. Bem’s theory has been criticized for overemphasizing the importance of peers; downplaying the roles of family and culture; and inadequately accounting for sex-atypical heterosexuality, female sexual development, and the directionality of the proposed cause– effect relationship.18 Bell and coworkers8 raised doubts about nonbiological theories. Their large-scale study of nearly 1000 lesbians and gays and 500 heterosexual women and men used path analysis to test several of these theories. They concluded that, Homosexuality is as deeply ingrained as heterosexuality, so that the differences in behaviors or social experiences of prehomosexual boys and girls and their preheterosexual counterparts reflect or express, rather than cause [italics added], their eventual homosexual preference. In short, theories that tie homosexuality to an isolated social experience cannot be expected to account well for such a basic part of one’s being as sexual preference appears to be. (pp. 190-191)

Biological Evidence

Given that homosexuality is likely of biological origin, it should not be surprising that mental health professionals have been unable to change sexual orientation. Thus far, medical interventions have been equally unsuccessful, though this may change with the application of gene therapy, prenatal hormone treatments, and other forms of prenatal selection. Despite various religious groups’ claims that they can “cure” homosexuality, there is little empirical evidence that this can be achieved through psychosocial interventions.51,52,53 Although a few ill-designed and largely discredited “investigations” report examples of changed sexual behavior and sexual identity, they do not demonstrate change in sexual orientation. To confound these domains mischaracterizes that which is obtainable and tenders false hope to those who are desperate for societal acceptance.

Nevertheless, the hostile treatment received by homoerotic individuals spurs some youth and their parents to seek alternatives to homosexuality, particularly when it is theoretically considered a choice that is subject to change. Indeed, it is common for homoerotic individuals to experience periods in which sexual “reorientation” is undertaken through denial, suppression, distraction, and prayer. Once the intractability of their sexual orientation is realized, these individuals may seek the medical advice of a trusted physician for assistance changing their sexuality. The pediatrician’s understanding of the etiology of homoeroticism inevitably determines the ways in which sexual orientation is understood and the accompanying dysphoria is treated. The American Psychological Association, in its policy “Resolution on appropriate therapeutic responses to sexual orientation,”54 acknowledged the enduring nature of sexual orientation. This document asserts that homosexuality is not a mental disorder and cautions against discriminatory practices and offering untrue or fallacious statements concerning scientific treatment claims. Other mental health associations (eg, National Association for Social Workers, American Counseling Association) embrace analogous policies toward reorientation treatments. As early as 1993, the American Academy of Pediatrics asserted that “Therapy directed specifically at changing sexual orientation is contraindicated, since it can provoke guilt and anxiety while having little or no potential for achieving changes in orientation”.55 It concluded that clinicians “who are unable to be objective because of religious or other personal convictions should refer patients to those who can”.55 Five years later, in a statement not unlike that of the American Medical Association, the American Psychiatric Association renounced “any psychiatric treatment, such as ‘reparative’ or ‘conversion’ therapy, that is based on the assumption that homosexuality per se is a mental disorder or is based on the a priori assumption that the patient should change his or her homosexual orientation” (p. 1131).51 Its ensuing recommendations accurately summarize the empirical literature: “Psychotherapeutic modalities purporting to convert or ‘repair’ homosexuality are based on developmental theories whose scientific validity is questionable. Furthermore, anecdotal reports of ‘cures’ are counterbalanced by anecdotal claims of psychological harm. In the last four decades, ‘reparative’ therapists have not produced any rigorous scientific research to substantiate their

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tern of fingerprint ridges) of gay males is similar to that of heterosexual females39 and the auditory (cochlear) responding40 and reflexive eye blink to loud noise41 of lesbians are similar to that of heterosexual males. Gay males and lesbians demonstrate sex-atypical finger length (2nd to 4th) ratio,42,43 bone morphology,44 and performance on some motor tasks.45 In contrast to heterosexuals, they are significantly more non-right-handed46 and display a dissimilar pattern of sleep-wake rhythmicity.47 Prenatal androgens are also implicated in the recurrent finding of childhood sex-atypical behavior and interests among homoerotic individuals. In prospective studies, most boys who were diagnosed with Gender Identity Disorder eventually reported samesex fantasies and behavior.48 Retrospective investigations consistently find that lesbian and gay adults recall greater childhood sex-atypical interests and behavior than heterosexual controls49—with bisexuals intermediate.26 A recent investigation50 documented the relationship between prenatal hormones and later behavior: blood testosterone levels of pregnant mothers positively correlated with subsequent masculinetypical gender behavior among 3.5-year-old girls. These environmental and biological theories have real-world implications for gay youth, parents, peers, and social institutions. Perhaps the most basic has been the consideration of whether homosexuality can be altered. Attempts to change homosexuality may well rest on one’s theoretical orientation about the origins of homoeroticism.

Can Homosexuality Be Changed?

claims of ‘cure.’ Until such research is available, APA recommends that ethical practitioners refrain from attempts to change individuals’ “sexual orientation.”56

Gender Identity Dilemmas —Ellen C. Perrin, MD. Expectations for the childhood behavior and adult aspirations of boys and of girls have changed less than one might have anticipated from the rigidity of 50 years ago. Nevertheless, important social changes have created somewhat more flexibility, acknowledging that the qualities labeled as typically masculine and feminine exist to some extent in people of both sexes. Gender variance is a behavioral pattern of intense, pervasive, and persistent interests and behaviors characterized as typical of the other gender. A striking similarity in interests and behaviors favored by these children is seen across different families with various cultural backgrounds. These gender-variant behaviors include play activities, toys and hobbies, clothing and external appearance, identification with role models, preference for other-gender playmates, and statements that indicate a wish to be of the other sex. This pattern is described in the DSM IV as “Gender Identity Disorder,” a diagnostic label that may no longer be appropriate based on current knowledge. Boys with gender variance may be consumed by an interest in Snow White or may want nothing for their birthday except a new Barbie doll. Their interests tend to be restricted to typically feminine ones, and generally they have observable discomfort with typically masculine pursuits and avoid rough-and-tumble play. Similarly, girls with marked gender variance typically show distinct discomfort with activities that are typically associated with girls, refuse to wear skirts and dresses, and often insist that they want to be a boy.

Natural History The onset of this pattern occurs typically before or during the preschool period. Longitudinal data suggest that the majority of boys with marked gender variance early in childhood later identified themselves as gay. A smaller percentage (about 6%57) identified themselves as transgender, and about a quarter identified themselves as heterosexual.58 It is not possible to predict which boys will take which course. Very little research has been done on girls.

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While gender variance exists in children of both sexes, health professionals see fewer girls than boys with this type of gender variance. This pattern may reflect a true difference in prevalence, but it is also impacted by the fact that the range of behavior that is considered acceptable in most modern societies is broader for girls than for boys.59

Significance of the Issue Children referred for so-called “gender identity disorder” are reported by their parents to have both internalizing and externalizing symptoms in greater number than their peers, most consistently after 6 years of age.58 Why? There is no intrinsic disadvantage caused to a boy by wearing dresses and make-up, nor to a girl with short hair competing in contact sports. Girls and boys with atypical play and playmate preferences confront stigma from peers and adults. They are isolated and teased. Their parents too face stigmatization and may feel embarrassed, conflicted, and insecure, which in turn may lead to critical and punitive responses. Emotional and behavioral symptoms are likely to be a reflection of this distress. While the adult sexual orientation of individual children with gender variance cannot be predicted, many of these children will most likely identify themselves as gay, lesbian, or transgender as adults. The serious risks gay, lesbian, and transgender adolescents typically face may be partly averted if children have the clear knowledge early in childhood that they are loved and accepted just as they are. Their parents and professional advisers have an opportunity to provide support for diversity in sexual orientation from early childhood onward. Although heterosexual parents may initially know little about and/or harbor negative views about homosexuality, many, if not most, will be able to modify their attitudes to become affirming, which in the long run will boost the child’s self-esteem and his/her ability to cope with social stigma. Parents who maintain persistently judgmental beliefs should be counseled about the potential risks of their attitudes to their child’s health and safety.

Pediatric Management When parents express concerns about their child’s gender-variant behaviors, pediatricians generally have offered reassurance, hoping that these behaviors are evidence of the child’s greater-than-average flexibil-

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TABLE 1. Suggestions for parents with a gender-atypical child

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Create an atmosphere of acceptance so your child feels safe within your family to express his or her interests. Identify and praise your child’s talents. Encourage your child to develop activities that help him/her to “fit-in” socially but still respect his or her interests and talents. Strengthen your child’s relationship with an adult role model of the same sex (eg, a parent, aunt/uncle, close friend) Help your child learn specific language and strategies to counteract criticism and stigma. Use gender-neutral language in discussing romantic attachments. Watch TV programs and movies together that include gay and lesbian adults and families. Read books about gay and lesbian heroes in history and in fiction. Discuss news stories about gay and lesbian issues with compassion and explicit acceptance. Highlight personal experiences and news stories of discrimination and negative stereotyping as inappropriate. Describe particular activities and interests concretely rather than labeling them as “girlish” or “boyish”. Educate others in your child’s life. Be sure to let your child’s siblings, your parents and siblings, neighbors, and friends know that you love and support your child unconditionally. Insist on classroom discussions about diversity and tolerance. Ensure that school and community libraries have reading materials (both fiction and nonfiction) that include evidence of the diversity of sexual orientations. Ask your primary care physician to provide reading materials and contact information for organizations of other parents and children with similar questions. If indicated arrange a referral to a psychotherapist with expertise in issues related to sexual orientation.

ity. This approach may not be in the best interest of the child and the family. Denial of the child’s differentness deprives families of an opportunity to develop a more authentic view of the child and to be actively affirming in case s/he is gay. It is important to acknowledge the considerable challenge of parenting a gender variant child. 60 Siblings, grandparents, aunts, and uncles also may need information, support, and guidance to come to a new understanding and acceptance of the gender-variant child. Parents of a child with GID, and the professionals to whom they look for advice, face considerable uncertainty with regard to helpful action. Some principles seem clear. It is legitimate (1) to help children feel more secure about their gender identity as boys or girls, perhaps preventing adult transgenderism; (2) to diminish as much as possible peer ostracism and social isolation; and (3) to treat evidence of associated behavioral/emotional distress. Attempts to alter the early developmental pathway toward a homosexual or a heterosexual orientation are neither ethical nor likely to be effective. The best advice for parents is what it always is—to support their children, to foster their strengths, and to model desired behavior. The positive and nurturing qualities of both parents, and their contentment with their own gender roles, should be made evident to their children. Families can help children learn techniques of recognizing and combating the damaging effects of stigma. For example, they can explain that particular behaviors are not typical of boys/girls of his/her age, that he/she may be unfairly criticized, and provide

strategies and language to help children resist teasing and criticism. Discussion with a pediatrician about their young child with atypical gender role behavior can provide a helpful opportunity for parents to consider how they might feel if their child were to be gay or lesbian. Most families can come to accept a homosexual son or daughter, especially if given adequate time and support to come to such acceptance. Physicians can be influential as a source of support, information, and guidance for all members of the family. Parent-toparent support may be invaluable, either locally or using electronic technology.61,62 Table 1 provides further suggestions for parents who are faced with the challenge of supporting a gender-variant child. Table 2 provides specific resources for parents. Most children will respond to their parents’ acceptance and encouragement. Referral to a mental health specialist is appropriate if the child is anxious, depressed, angry, exhibits self-destructive behavior, or if the child experiences significant social isolation, and these problems do not improve with short-term counseling.63 Therapists who are competent in dealing with other childhood issues do not necessarily have the competence to deal with gender variance. Parents may need clarification that psychotherapy does not change sexual orientation or gender identity.

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Summary Gender variance is not a common issue in primary care practice, but when it presents it should be taken seriously. Children are at risk for teasing, social

TABLE 2. Recommended resources

1. Books for Parents: Not Like Other Boys, Fanta-Shyer M and Shyer C. Houghton-Miffline, Boston 1996. Homosexuality: The Secret a Child Dare Not Tell, Cantwell MA. Rafael Press, Chicago 1998. Sissies and Tomboys: Gender Non-conformity and Homosexual Childhood, Rottnek, Matthew, ed., New York University Press, New York, 1999. Everything you never wanted your kids to know about sex (but were afraid they’d ask), Richardson J and Schuster MA, Random House, 2003. 2. A parent guide entitled “If you are concerned about your child’s gender behaviors” is available at www.Dcchildrens.com/gendervariance. Printed copies can be ordered at [email protected]. This website also provides information on how to access a discussion group for families of gender-variant children. 3. Movies/videos: Ma Vie en Rose (My Life in Pink) (Video). A film by Alain Berliner—Sony Picture Classics. For older children and adults. The Dress Code (video/DVD). A film by Shirley MacLaine-MGM/UA Studios (PG 13) Oliver Button is a Star (Video). Directed by John Scagliotti and Dan Hunt, with Tomie de Paola and others. http://www.oliverbuttonisastar.com. 4. Books for children: Oliver Button is a Sissy, 1979 Tomie de Paola. Voyager Books, Harcourt Brace and Company. Reading levels 4-8. The Sissy Duckling, 2002 Harvey Fierstein and Henry Cole (Illustrator), Simon & Schuster. Reading levels 4-8. It’s Perfectly Normal, Harris, Robie. Candlewick Press, 1994. (ages 10 and up). Changing Bodies, Changing Lives, Bell, Ruth et al., Random House, New York 1998 (teenagers).

The default assumption that everyone is heterosexual until proven otherwise (heterocentrism) leads to erroneous conclusions and insensitive remarks. Yet, unless a youth self-identifies as lesbian, gay, or bisexual and publicly declares this information, it may not be obvious which youth are not heterosexual. Despite stereotypes and considerable data demonstrating sex atypicality among gay-identified youth,64 many homoerotic youth do not appear “gay.” Furthermore, heterosexual youth also exhibit sex-atypical characteristics, including same-sex sexual behavior. Thus, health professionals must exercise caution when ascertaining who is and is not gay. This seemingly straightforward determination is quite complex and depends largely on the way in which “gay” is operationalized. One method is the adoption and the articulation to others by youth of a sexual identity label. An equally imprecise defini-

tion relies on whether same-sex behavior has occurred; in its absence, heterosexuality is assumed. However, research demonstrates that neither sexual identity nor sexual behavior necessarily implies sexual orientation.65 Some same-sex attracted youth engage in heterosexual sex but remain homosexual “virgins” and do not identify as gay. To effectively treat youth it is imperative to distinguish among three related but distinct domains of sexuality: sexual orientation, sexual behavior, and sexual identity. Sexual orientation refers to the predominance of erotic feelings, thoughts, and fantasies one has for members of a particular sex, multiple sexes, or no sex. Sexual orientation is likely to be established by birth or early childhood and is usually immutable, stable, resistant to conscious control, and internally consonant.66-68 Most preadults with a same-sex orientation do not identify as gay or report engaging in same-sex behavior during adolescence.69 Sexual behavior refers to the sexual activities in which individuals engage. Depending on cultural and individual factors (eg, religiosity, family values, race/ ethnicity, gender, and age), sexual partners may be consistent or inconsistent with a youth’s underlying sexual orientation.65 A recent example of domain incongruence is apparent among African-American males on the “down low”: individuals who engage in overt heterosexual and covert homosexual behavior within a context of a heterosexual identity.70 This highly masculine, secretive, gay identity-rejecting

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isolation, violence, and recurrent threats to their self esteem. Pediatricians have an opportunity to help parents create a family environment that nurtures their child and values his/her uniqueness and individuality, and to help them to recognize and counteract stigma in their wider social environment.

Growing Up with Same-Sex Attractions —Ritch C. Savin-Williams, PhD Who Is Gay?

Same-sex development does not proceed in an orderly, invariant, or universal manner. Even though most youth self-identify as gay before publicly disclosing this information and dating a same-sex partner,

some youth are “the last” to define themselves as gay— despite participating in a long-term same-sex romantic and sexual relationship. Indeed, an equal number of youth realize that they are gay before engaging in same-sex encounters as after.74 In terms of timing, youth may recall first same-sex attractions before pubertal onset, but it is not unusual for attractions to occur only late in high school. Thus, assumptions about what is “normal” or “typical” should be cautiously tendered. The cultural sexual revolution has deeply impacted the unfolding of gay development by lessening the stigma associated with homosexuality, especially among adolescents and young adults. The consequence of this destabilizing of traditional assumptions is that there is considerably more intragroup variability than at any previous time. This rapid change in developmental patterns across cohorts means also that recent research on gay youth development might, within a few years of publication, have limited generalizability to today’s same-sex attracted teens. The findings may serve better as guideposts than definitive maps. Gay development has been portrayed by two perspectives: sexual identity stage models and descriptions of developmental milestone acquisition. Sexual Identity Stage Models. All children and adolescents, regardless of attractions, have a basic, stable sexual orientation and may engage in sexual behavior. Generally only same-sex attracted preadults question the meaning of their sexual orientation and behavior and construct a sexual identity. Their sexualminority status creates a situation in which they are forced to reflect on the existence and meaning of their sexuality in a manner heterosexual adolescents seldom share. Because of this developmental uniqueness, gay-identified youth are often regarded by researchers and clinicians as constituting an exclusive type of adolescent with a particular developmental trajectory. Several dozen sexual identity stage models have been proposed to describe this hypothesized universal, gradual unfolding of gay development. The assumed developmental task is movement from awareness to acceptance of one’s sexuality. For example, one of the best known developmental models includes the stages identity confusion, identity comparison, identity tolerance, identity acceptance, identity pride, and identity synthesis.75 These intuitive and seemingly comprehensive models are generally accepted as accurate and necessary representations of individual gay evolution.

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population is consequently unreceptive to safer-sex messages directed toward gay and bisexual men and at high risk for contracting and transmitting HIV and other sexually transmitted infections (STI). Sexual identity is a socially recognized label that names sexual feelings, attractions, and behaviors and is symbolized by such statements as “I am gay” and “I am straight.” Sexual identity is a matter of personal selection, although choices are limited by the pool of potential, socially constructed identities given meaning by the culture and historic time in which one lives. An increasing number of (especially female) youth are rejecting sexual identity labels in favor of less confining and reductionistic descriptions, such as “unlabeled,” “I love Susan,” and “boidyke.”65,71 It is not that these youth are attempting to hide from their sexuality but that they feel that identity labels box them in, constrain their options, and buy into adult conceptions of sexuality. Instances of sexual domain inconsistency are abundant, particularly during early sexual development, suggesting that careful attention must be paid to the way in which sexuality is discussed. For example, whereas approximately 2 to 3% of college students in one study identified as lesbian and gay, 10 to 12% reported same-sex attractions.72 Among adolescents, just over 1% reported same-sex behavior or identified as gay/lesbian, whereas almost 5% acknowledged same-sex fantasies or had predominant same-sex attractions.73 Consider the girl who is attracted to both sexes (bisexual sexual orientation), chooses to have sex only with females (lesbian behavior), and identifies as heterosexual to ease parental concerns. An adolescent boy has primarily homoerotic longings (gay sexual orientation), sexual experiences with girls (heterosexual behavior), and a bisexual identity as a means of leaving future options open. Depending on the way in which these youth are asked about their sexuality, a different conclusion can be drawn about their sexual status. Thus, it behooves clinicians to eschew heterosexist assumptions (belief that heterosexuality is morally superior to homosexuality) and other preconceived sexual biases in favor of straightforward exploration of all three sexual domains.

Gay Youth Development

Failure to transverse the stages in a timely and coherent manner is said to result in negative outcomes, from minor delays in coming to terms with one’s sexuality to stunted psychological growth. Developmental Milestones: Differential Developmental Trajectories Perspective. The discerning clinician, however, is suspicious of universalistic representations of human behavior. The models can be faulted for necessarily reducing a complex, evolving process that varies by gender, cohort, ethnicity, and other factors.65 Youth who report same-sex activities, attractions, and/or identities do not constitute a unified type or pursue a singular pathway in their developing sexual consciousness, recognition, and practice. They are both similar and dissimilar to opposite-sex attracted youth and they vary among themselves in rather predictable ways. Indeed, youth of all sexualities are often more similar to those of their own gender, ethnicity, and class than they are to others of their sexual orientation. These principles are consistent with a differential developmental trajectories framework65,76—an alternative to traditional sexual identity stage models. This perspective emphasizes the variability of developmental milestones. Commonly experienced milestones are presented next that inform patient interests and needs and characterize the development of many, but certainly not all, homoerotic individuals. The clinician’s task is to both distinguish and de-emphasize sexuality factors, treating patients as simultaneously developmentally unique (homoerotic) and developmentally ordinary (adolescent). Although not a milestone per se, same-sex attracted youth frequently recall growing up feeling different from other children of their biological sex. This is not exclusively characteristic of gay youth; many nongay children feel different (eg, because of ethnicity, appearance, personality, or personal style) and many gay children do not (eg, because of gender conformity). It is further noteworthy that same-sex attracted preadults vary in the salience and meaning of their feelings of uniqueness. Some report that they always knew they were “not normal,” while others always felt that they fit in well with their peers. The primary source of differentness often noted by gay youth is their failure to manifest stereotypic characteristics of their sex— boys disliking sports and girls under-appreciating dolls. A secondary source involves expressions of characteristics of the other sex— girls loving mascu-

line team sports and boys enjoying feminine arts and crafts and drama. The first consistently reported milestone is the onset of same-sex attractions. The age range is wide, although currently the average is age 8 or 9. Since the 1960s, this milestone has witnessed a sharp decline in age, especially among girls. Girls are more likely to recall an emotional attachment or crush, and boys are more likely to recall a sexual thought, arousal, or behavior as the first sexual memory. Regardless of the actual content, most youth recount that as children they were not troubled by their homoeroticism because the attractions were considered a “natural” element of who they were, both pleasurable and mysterious.65 These attractions assume meaning as youth recognize that they might not be heterosexual. Some youth experience these attractions as having little significance at the time, believing that everyone has similar erotic fascinations. Other youth fear that their fantasies or arousals mean that they might be gay, that they are a little bit gay (bisexual), or that though their attractions are gay they are not themselves gay. This may trigger sexual questioning, which can last for a day or a lifetime and is not necessarily concluded with the self-designation of a sexual-minority identity label Diamond77 revealed in her longitudinal study that many sexual-minority young women transitioned among several identities; few consistently maintained the same identity label from childhood through young adulthood. The assumption of a nonheterosexual label rarely occurs among preteenagers but is more often a milestone achieved during adolescence proper. Among previous generations, labeling did not occur until the mid-20s and most same-sex-attracted individuals were never identified as gay. Contemporary teenagers are labeling their sexual identity at considerably younger ages, perhaps because of growing cultural and media visibility and acceptability of homoeroticism and same-sex-attracted individuals. Regardless, these labels are also undergoing metamorphosis, especially among young women, from traditional terms (gay) to the innovative (heteroflexible, omnisexual, transboi), hyphenated (half-dyke, bi-dyke), generic (queer), and resistant (unlabeled, questioning).71 For these reasons, precise descriptors of behavior, attraction, romance, and desire may be more revealing and informative than identity labels. Girls tend to attribute a romantic involvement, a fascination with other girls, or a facilitative event (movie, academic course, book) as precursors to identifying; boys attribute sexual

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thoughts, arousals, and sexual experiences as precursors to identifying.65 A first same-sex encounter may precede all milestones, co-occur, or arrive years later—if ever. That is, it is possible to acknowledge one’s homosexuality and identify as gay before having sex (“gay virgins”) and to have gay sex without ever identifying as gay. Not uncommonly, boys have their first sexual experience with a best male buddy during childhood or early adolescence. Some girls do as well, although the average age of their first sexual experience tends to be somewhat later (adolescence proper) and to occur following heterosexual activities. Nearly 80% of homoerotic girls and 50% of boys have an opposite-sex encounter. Among self-identified gay youth, claims of same-sex virginity are usually below 10% for boys and 20% for girls.65,76 Decisions concerning when, how, and to whom they should disclose their same-sex sexuality can generate great angst among youth. Coming out may occur immediately after self-disclosure or percolate for years or decades. The average time is 1 to 2 years for boys and somewhat less for girls. The first person told is usually a best friend and thus, despite many long nights of fretting, the first reaction is usually extremely positive. Rarely told first are parents, extended family members, or pediatricians.78 Romance is a highly desired milestone, though in the past most have postponed same-sex dating until they are safely away from their local high school and in college or the workplace. With increasing peer acceptance, the proliferation of visibly supportive community youth groups for gay and lesbian teens, schoolbased Gay–Straight Alliance organizations, and tolerance for bringing a same-sex date to high school proms, youth are beginning to date others of their gender while still in high school. Few of these first romantic relationships are long-lasting but they are of great personal and developmental significance, as they are to heterosexual youth. They promote social exploration, facilitate merging of emotional and sexual intimacy, and afford sources of enjoyment and support. They may facilitate the acquisition of a positive identity, a milestone that nearly all self-identified homoerotic youth achieve. In most samples, fewer than 10% of respondents state that they hate or do not want to be gay.65 A milestone deferred for many youth is the disclosure of their same-sex orientation or identity to their parents, although youth are increasingly disclosing to

a parent (usually mother first) while still living at home. They may be motivated by a growing commitment to a same-sex romantic relationship or an emerging comfort with their sexuality. Most, however, choose to disclose because they long to share this aspect of their life with their parents or because a parent, after being confronted with innumerable subtle and overt cues, eventually asks whether the youth is gay.78 Parents may respond initially with celebration or rejection, but most eventually come to accept what many have suspected for years. Given the variability and diversity among these developmental milestones, a clinician may obtain widely different information about a patient’s sexuality at various ages. What can be considered “normal” or “typical” is vast, including the time needed to process the milestones and their ordering within and between individuals. Thus, despite establishing a safe, gay friendly climate for discussions to take place, supportive pediatricians are likely to receive differing levels of disclosure from different adolescents about their sexuality. Health professionals need to assess how much discussion a teenager is prepared to tolerate and then pose questions in a sensitive, nonjudgmental manner. Inquiring about specific attractions, feelings, and behaviors is more likely to yield the needed or relevant information than requests for self-identity labels. Posing gender neutral questions (“Do you have a romantic or sexual partner?”) or bi-gender (“Are you dating any boys or girls?” “Are you attracted to girls, boys, or both?”) is an effective way to circumvent stereotype-driven queries and establish a nonjudgmental rapport. For example, if a pediatrician is assessing sexual diseases/infections, then he/she should inquire about sexual behavior; if a patient is experiencing difficulty feeling accepted by parents and peers, then sexual identity may be of greatest interest; and if a patient is pondering entering into a long-term relationship, then sexual orientation needs to be assessed. Generic questions such as, “Are you gay?” are likely to be counterproductive and may result in awkward, ambiguous, meaningless, or incongruent responses.

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Risk and Resilience Although most same-sex-attracted youth successfully navigate these milestones with grace and increasing confidence, some stumble momentarily or linger for protracted periods. Conventional wisdom has rested on stereotypes of “homosexuals” as typically mentally ill and poorly adjusted. Long after psycho-

analytically derived and empirically unsubstantiated biases were debunked, benevolent clinicians and researchers often continued to expect a poor outcome. Recent clinical research, sampling gay-identified youth in a variety of settings, documents the vulnerability of young gay men and women—the likely consequence of stress caused by society’s discriminatory practices. This is reflected in the media, which has shifted its coverage from portraying adult homosexuals as developmentally immature to portraying depression, suicidality, drug abuse, and other problematic behavior among gay youth as inevitable. Though these difficulties characterize some gay adolescents, such portrayals represent only a small minority of same-sex attracted youth. Thus, pediatricians are faced with the challenging task of remaining sensitive to the possibility of serious emotional problems among some gay youth while avoiding pathologizing the entire population. Recent methodologically sophisticated studies have surpassed earlier investigations that evaluated unrepresentative samples of vulnerable youth (eg, help seeking, early identifying, homeless) by distinguishing specific factors that place youth at risk for mental health problems. Familiarity with these nuances promises to aid assessment and treatment of this population. Minority Stress Model. Given the multitude of negative stereotypes about homosexuality, it is not surprising that some youth experience initial difficulty recognizing, naming, integrating, and accepting their nontraditional sexuality. The minority stress model proposes a conceptual framework for understanding elevated rates of mental and physical illness among these youth.79 The model asserts that sexual minorities, similar to other culturally marginalized groups, suffer negative life events perpetrated by the majority culture that generate stress reactions, which in turn lead to mental illness, such as depression and anxiety; problematic behavior, such as promiscuous sex and delinquency; and subsequently increased number of medical visits. It suggests that stress is initially generated from feelings of unacceptability and inferiority. Indeed, there are few life experiences as alienating as growing up believing that a most “natural” aspect of one’s self is deemed morally and socially deplorable, and knowing that one may become an outcast on its disclosure. From early childhood, youth are typically overtly or covertly instructed by persons and institutions they love and trust that homosexuals are corrupt, mentally ill, sinful, lonely, and doomed to die from AIDS.

According to the model, this presumed script is accepted by youth, resulting in internalized homophobia, a perceived need to conceal important aspects of self, and a fear of prejudicial events and rejection. Some learn that being gay would hurt or disappoint parents; others are directly warned by parents that they will be abused or thrown out of their home “if you ever tell me you’re a faggot.” Whereas other stigmatized youth who are teased because of physical traits, ethnicity, or religion are almost certain to receive support and guidance from family, community, and religious institutions, gay youth can feel isolated and alone with their “terrible secret.” Accepting cultural proscriptions against uttering words that would bring immediate and lasting shame to themselves and their families, they conceal their true selves while living with fear of eventual exposure and humiliation—if not outright verbal or physical abuse. At increasingly younger ages, children hurl the terms “gay” and “faggot” at those perceived to have transgressed group norms, from the most benign (eg, a silly comment) to the most egregious (eg, sex atypicality). Adult bystanders seldom intervene to halt this blatant prejudice. As these terms infiltrate the vernacular, they lose their sexual meaning to all but their gay and lesbian victims. As epitomized by the tragic experiences of Jamie Nabozny, the young gay man who successfully sued his high school principal, teachers, and school board for failing to protect him from repeated verbal and physical attacks by peers, antigay slurs and physical abuse are so normalized that they are expected (“boys will be boys”) and disregarded. Because gay youths’ sexuality is broadly stigmatized and punishable by socially sanctioned violence and discrimination, the minority stress model observes that they endure states of chronic arousal and hypervigilance. Additionally, they squander internal resources performing behavioral and psychological acrobatics (ie, defenses) to suppress, deny, or conceal their authentic selves from themselves and others. In the process, children learn to internalize society’s negative views of homosexuality and thus suffer distorted self-concept and deflated self-esteem, shame, and guilt. Although a youth’s failure to identify with a stigmatized group might provide shelter from internal shame and external discrimination, it does not necessarily afford protection as long as others believe the individual is a member of that group.79 To survive, youth may reject a sexuality that nevertheless grows stronger as puberty advances, or they

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may retreat into a private, secluded world of secrets and lies. Paradoxes and conflicts dominate their lives. They may feel safe as long as they remain closeted, but anxiety continually escalates as they fear discovery and as their sexual and socio-emotional development stagnates. To come out to themselves and/or others is to welcome social freedom, psychological integration, and personal authenticity— but also to invite rejection, hostility, and consequences of terrifying proportion. Until these psychic conflicts are resolved, youth may feel marginalized and isolated. Some youth externalize this stress by becoming hyperheterosexual, which can include vitriolic displays of aggression directed at those perceived to be gay, behavioral “proofs” of masculinity through promiscuous heterosexual sex, and antisocial or criminal acts. Youth also seek relief from stress by becoming asexual, by associating with other perceived social misfits such as “druggies,” or by overcompensating in other areas, including academics. Numbing the pain through alcohol and illicit drugs can be interpreted as an attempt to flee from unacceptable circumstances and to contain sadness and anxiety. Turning inward and becoming depressed or suicidal is another means of coping. Indeed, considerable research documents that compared with heterosexuals, gay youth report greater depression, anxiety, substance abuse, school-related problems, delinquency, and suicidality.79-81 The suicidality risk among gay youth has received the bulk of this research and media attention. Following the publication of a non-peer-reviewed paper on gay youth suicide,82 the media, researchers, and clinicians embraced and popularized the empirically unfounded statistic that gay youth comprise a third of all completed youth suicides. In reality, comparable rates for suicide completion are not available because the assessment of sexual identity among young suicide victims in postmortem studies is rarely conducted. By contrast, dozens of studies have documented that gay identified youth are 3 to 10 times more likely that heterosexual youth to report attempting suicide.81-86 Of greater significance is predicting which gay youth are at increased risk for negative developmental outcomes that can lead to suicidality. Perhaps not surprising to the pediatrician, the risk factors that predict suicidality among heterosexual youth are also the best predictors of suicide attempts among gay youth. These include the presence of on-going mental illness (eg, depression, hopelessness), loss (death of parent,

break-up of a romantic relationship), sexual abuse, prior suicide attempts among known others or oneself, victimization (peer harassment, dysfunctional family, community disorganization), substance use, and attenuated support and coping.83 In addition, factors that place same-sex-attracted youth at unique risk are important for pediatricians to assess. Perhaps the most distinct is youths’ growing awareness and inevitability of their nonheterosexuality, which often implies to them that they are “not normal.” Mental and physical health repercussions may be most severe among adolescents who recognize to self and others their same-sex attractions and fantasies at an early age, leading to possibly prolonged periods of adjustment at a time when they are most likely to have few internal and external resources for coping and support. Compared with middle and late adolescents, early adolescents are more physically and interpersonally dependent and thus are emotionally vulnerable at precisely the period of development (junior high school) during which peers are most judgmental and outwardly rejecting and parents are most disbelieving that their child is capable of making such an important life “decision.” For example, research reveals that loss of support, such as losing a friend subsequent to coming out, or feeling that no one cares, contribute to suicide attempts.87 Several methodological problems, however, affect the link between problematic behavior patterns and gay youth. For example, some initially-reported suicide attempts by gay youth were found on further questioning not to have actually occurred, raising questions about the validity and meaning of such accounts.69,83 These suicide attempt reports may be “cries for help” or represent a “suicidal script” presented to them in the culture about what it means to be young and gay. Reported suicide attempts generally reflect volunteers who are willing to disclose their same-sex attractions, behaviors, or identities to researchers. Even in studies involving representative samples of youth who were recruited from school settings, only a select subset of students acknowledge their same-sex sexuality. Thus, the high rate of reported suicide attempts may only exist within a biased group of homoerotic youth. Perhaps these are youth who were pushed out of the closet because of their gender nonconformity; alternatively, they may have encountered the kinds of experiences that place all youth at risk for suicidality, regardless of their sexu-

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ality. It is unlikely that this subgroup represents the typical homoerotic adolescent. Although the developmental unfolding of homoerotic sexuality is itself emotionally challenging, few events contribute more to adverse mental and physical health outcomes than peer harassment. For example, being the victim of a hate crime can result in posttraumatic stress disorder.88 Studies find that many lesbian, gay, and bisexual youth report sexual orientationrelated verbal, physical, and/or sexual abuse perpetrated by peers and relatives.79,89 A national sample of gay youth90 found that 9 of 10 respondents frequently overheard homophobic statements and almost a third described being physically harassed. Especially targeted for abuse are youth who appear vulnerable and demonstrate sex-atypical behavior and interests. Boys who fail to conform to gender expectations, and thus are presumed to be gay, become conspicuous targets for harassment among adolescents who notoriously demand gender conformity.91 The consequences of this burden are documented by research comparing gay and bisexual male suicide attempters from nonattempters, with the former expressing greater sex atypicality.92 Attempters report earlier first same-sex attractions, self-labeling, gay sex, heterosexual sex, and coming-out to others.87,92 Thus, although sexual development that is congruent with underlying sexual orientation can be a positive event for some youth, it can also place others at increased physical and mental health risk. Distinguishing negative from positive sexual development is central to maintaining an open and sensitive practice. It is critically important to avoid overpathologizing same-sex attractions by identifying variables other than sexuality that place youth at risk. Although in one study gay youth reported significantly more depression, hopelessness, and current and past suicidality than heterosexual youth, when elevated stress and deficits in social support, acceptance, and coping style were taken into account, the two groups were indistinguishable in all but past suicidality.84 Perhaps it is not same-sex attractions per se that are linked to health problems but support and coping mechanisms that cushion the unique environmental reactions (eg, harassment) associated with individuals who are gender nonconformists (“act gay”). A resiliency perspective65 maintains that despite environmental adversity, some individuals have the internal and external resources necessary to adapt and lead healthy lives. The vast majority of same-sex-

attracted youth, many of whom are presently not “out” to themselves or others and thus are under the radar screens of researchers and clinicians, may be better adjusted than youth who do acknowledge their homoeroticism in research. This is an empirical question that is difficult to test. Undetected youth may be closeted or tentatively “out,” unlabeled, or “label resistors.” The former, by virtue of passing as heterosexual, may be afforded greater protection from peer harassment, alienation, and diminished social support than that which is provided to “out” youth by social service agencies. Remaining closeted is facilitated by gender-conformity, which reduces the likelihood of hostile social reactions and secondary emotional difficulties. It is questionable, however, whether these short-term benefits outweigh possible long-term consequences of suppressing or minimizing one’s sexuality. What is certain is that a majority of youth who have same-sex attractions resist labeling their sexuality.65 Some feel greater comfort describing their personal sexual development rather than attaching themselves to negative societal stereotypes and images. These non-gay-identified but same-sex-attracted youth may be more common than once believed.

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Clinical Implications As the first medical professional with whom youth interact, pediatricians are afforded a unique opportunity to facilitate lasting trust in the health care system. Pediatricians express reservations about discussing sexual orientation with their patients because they fear offending them, are uncertain how to raise the issue, believe they do not know enough about their needs, and fear it would take too much time. These findings are not surprising because half report no formal training in the area. Consequently, the vast majority of pediatricians (68%) do not collect information about sexual orientation in their sexual histories.93 Gays, lesbians, and bisexuals frequently conceal their sexuality, sometimes subsequent to a negative encounter with medical personnel.94 Demonstrations of sensitivity and knowledge are essential to encourage patients to reveal personal information that they fear will invite hostility and compromise medical care. Indeed, fear of mistreatment and discrimination delays some from seeking medical treatment.95 Their misgivings are not unfounded; approximately 20% of physicians in small cities acknowledged homophobic attitudes as did almost 10% of pathologists, radiologists, ob/gyn physicians, and pediatricians.96 Buttressed by

both perceived and real discrimination, sexual minorities can be hypervigilant in searching for indications of heterosexism and homophobia. To counteract these trends and to lend support to homoerotic youth and their parents, planned interventions are required. These begin with office decorations, diverse staff, wording on s, and language used during oral history taking. Professional development is enhanced through continuing education, periodic staff training, and knowledge of community resources. Effective treatment is further achieved through enlistment of similarly compassionate and conversant medical specialists to whom youth are referred. Specific recommendations are offered below that should inspire comfort and trust among sexual-minority patients. Physical Environment. A pediatrician’s sensitivities are reflected in office decorations and staff. Appreciation for diversity is communicated by gay-affirming posters (same-sex couples, organizations) and symbols (pink triangle, rainbow flag), gay magazines, and information pamphlets (coming out, homophobia, safer sex, sexually transmitted diseases, HIV/AIDS) in the waiting room. The Gay and Lesbian Medical Association (GLMA) recommends posting a prominent nondiscrimination statement in which sexual orientation is included and designating bathrooms unisex to reduce discomfort among transgender patients.97 An office staffed by sexually and racially/ ethnically diverse employees suggests appreciation for diversity and may further engender patient comfort. The pediatrician’s office should include prominently displayed affirmative books on gay issues. Intake Form. Intake questionnaires for adolescents should avoid heterocentricism, which may be offputting. They should be gender-neutral or bi-gendered and sensitive to sexual-minority issues by assessing sexual orientation, identity, and behavior. Options for current and past sexual behavior should include with males, females, or both. Sexual identity should offer numerous options, including heterosexual, lesbian, gay, bisexual, questioning, uncertain, and other (space provided for elaboration). A question about safer sex might be included, eg: “Do you need any information about safer sex techniques? If yes, with: men, women, both.” An inquiry should also be made about sexual concerns: “Are you currently experiencing any sexual problems?”97 Clinical Interview. The clinical interview is the core of patient-physician interaction. Homoerotic patients

present to pediatricians for diverse reasons. Some may be comfortable with their sexuality and require little from the clinician beyond acceptance, respect, and perhaps information about safer sex practices and diseases. Others may only acknowledge same-sex behavior and will solely accept behavior-based interventions. Youth who both reject and suppress their homosexuality and are unable to experience adequate heterosexual functioning (difficulty achieving or maintaining erection, arousal, or orgasm) may request medical intervention for what they interpret to be a physiological problem. Other youth may disclose homoeroticism only under duress—following a relationship breakup, unrelenting peer harassment, or unyielding discomfort with their sexuality. If homoeroticism or sex-atypical behavior is discovered by intolerant relatives, youth may be brought by worried parents seeking advice or conversion. The pediatrician should avoid heterocentric assumptions and inquire about sexual behavior and relationships in broad terms. Consistent use of nonoppressive, nondiscriminatory language supports and validates homoerotic youth and educates heterosexual patients about diverse sexualities while modeling respect for sexual minorities. It also bolsters confidence and reduces isolation among friends and families of homoerotic youth. Although it may be helpful to ask about “significant others” or “partners,” these vague terms are sometimes disregarded by anxious youth who fear erroneously interpreting the question as an invitation to speak about same-sex involvements. Far better is to offer sexually affirming options that implicitly acknowledge that some youth engage in same-sex behavior: “Have you ever been sexually active with a boy or a girl, or both?” “Are you currently dating a girl or a boy or both?” Sexual behavior questions should be specific without assuming heterosexuality. For example, penile– vaginal intercourse should be distinguished from vaginal– object and anal intercourse. Youth who engage in same-sex activities but do not label themselves as gay may disregard safer sex messages directed at “homosexuals.” Thus, care should be taken to reflect a behavior-based language when discussing sexual protection. As discussed earlier, sexual attractions may not be reflected in behavior or sexual identity and thus all three sexual domains should be carefully assessed when educating patients about their interconnections. Pediatricians should avoid assuming that homosexuality is foremost about sex, that only one “gay lifestyle”

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exists, that same-sex relationships are not romantic, that bisexuality is a transitional state that will resolve in an eventual heterosexual identity, and that homosexuality is a psychological defense. Following these preliminary assessments and precautions, physicians can create opportunities for nonheterosexual youth to share concerns and request advice by conducting a more detailed history. This history should incorporate the timing and subjective experience of sexual developmental milestones, social support, parental reactions, family discord, harassment/violence, psycho-social stressors, mental health concerns, and coping strategies such as alcohol and drug use, social withdrawal, and eating disorders. In many cases, these factors contribute more to negative health outcomes than does sexual orientation per se. Given prevailing cultural attitudes, some youth will initially experience their homoeroticism as ego dystonic and thus desire to “change” sexual orientations. Youth should be informed that although sexual identity and behavior are subject to both choice and change, attractions are not, and that science has not demonstrated that therapy can alter sexual orientation.98 Rather, the pediatrician should focus on facilitating self-acceptance and diminishing loneliness and alienation. Education and reduced isolation can be achieved with helpful web sites; age appropriate videos; and books that bolster resilience by affirming a youth’s life experiences (see resources listed in the last section of this article).

Conclusion The minority stress model emphasizes that successful coping is the result of both individual personality variables and group resources. In the absence of group support, otherwise resourceful people often experience difficulty coping. Group identity and social support can attenuate the effects of prejudice and marginalization and generate resilience and mental health by providing acceptance, affiliation, and positive appraisal. Interactions with similar others afford opportunities for more appropriate self-comparison and unguarded authenticity, normalization, contextualization, and advice. Groups validate emotions and experiences considered deviant by the majority culture and model effective coping behavior and responses to discrimination. To bolster social support, pediatricians should become knowledgeable about community resources, such as LGB organizations, support groups, crisis centers, and hotlines. If available, teens should

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be referred to their high school’s Gay–Straight Alliance and young adults should be referred to their college’s LGB Resource Center. Youth who are experiencing mental health concerns may benefit from formal psychotherapy. They should only be referred to school-based counselors and/or community psychotherapists who are familiar with and sensitive to the intricacies of gay development.

Families of Lesbian, Gay, and Bisexual Adolescents* —Caitlin Ryan, MSW, ACSW Increasingly lesbian and gay youth are coming out during adolescence, while they are still living at home. Nevertheless, little attention has focused on their families and family adaptation after an adolescent self-identifies as lesbian, gay, or bisexual. Prior generations of lesbians and gay men were much more likely to self-identify as lesbian or gay during adulthood when they were independent and lived on their own. Coming out is very different for teens today who may become aware of same-sex attractions around ages 9 or 10, and who often identify as lesbian or gay during high school— on average, between ages 14 and 16.99-102 These youth are dealing with their sexual orientation at a time when they are dependent emotionally and financially on their families. In addition, peers and adults are more aware of homosexuality than were the families and friends of earlier generations of lesbian and gay adults. Coming out during adolescence and the response of family and friends affects an adolescent’s development and future life course, impacting risk and resiliency, help-seeking behaviors and self-care. This section will discuss family reactions to learning that an adolescent is lesbian, gay, or bisexual; parents’ needs for information and support; and the opportunity for family-inclusive care and anticipatory guidance for the families of LGB youth. This section is based on qualitative data from the first phase of the Family Acceptance Project (FAP), a study of the impact of family acceptance and rejection on health outcomes and development of white and Latino lesbian, gay, and bisexual (LGB) youth and

*This section reports on preliminary findings from the Family Acceptance Project, a community research and provider training initiative, funded by The California Endowment.

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transgender youth who identify as LGB conducted by Ryan and Díaz at San Francisco State University. The project includes in-depth individual interviews with youth and family members that explore child development and family life, sexual and gender identity, religious beliefs and practices, sexual orientation, ethnicity and culture, coming out, family response and adaptation over time, school-based experiences and victimization, resiliency, and sources of support. Participants include white and Latino youth ages 13 to 18 who identify as lesbian, gay, or bisexual, and their families, from a wide range of backgrounds and levels of acculturation who live in urban, suburban, and rural communities. This is the first major study of the families of LGB youth and includes out-of-home youth and youth in foster care. The study is ongoing and this section reports on preliminary findings from the first 40 families interviewed who live in a wide range of communities throughout California. Families were recruited statewide through schools (including students, teachers, counselors, and school nurses), youth service organizations [mainstream agencies and programs for lesbian, gay, bisexual, and transgender (LGBT) youth], health and mental health practitioners, foster care agencies and programs that serve out-of-home youth, and peer recruiters. Semistructured individual interviews were conducted in English and Spanish with youth and at least two family members, including siblings, grandparents, or extended family members, focusing on a wide range of issues and lasting from 2 to 4 hours. One in five families interviewed live in rural areas or on a farm, while the others were fairly evenly balanced between urban families and those living in suburban communities and smaller cities or towns. Slightly more than half are white. Nearly half are middle class, about 15% are upper middle class or high income, while the rest (about two-fifths) are low income or poor. Some families are extremely low income, living in a storefront or tenement, with up to 15 children. Nearly two-thirds of the Latino families interviewed are immigrants; some were newly arrived while some had lived in the U.S. for long periods of time. Most came from Mexico, while others emigrated from various countries in Central or Latin America, some making arduous journeys, walking across Mexico and crossing undocumented into the U.S. Immigrant families were fragmented by the separation from important family members, such as grandparents and sib-

lings, who had been left behind. This has resulted in a loss of confidants, child care providers, and emotional and financial support, which has made it more challenging for immigrant parents to respond to their child’s emerging sexual or gender identity in a new and different cultural environment. A majority of all families were divorced or blended. About one in four adolescents had been removed or ejected from their homes. They lived in foster care or residential programs and several had been homeless.

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Coming Out: Family Responses and Adaptation In the past, even youth who self-identified as lesbian or gay during adolescence generally waited until they had separated from their parents and moved out on their own to come out to them. Increasingly, adolescents who identify themselves as LGB disclose their sexual identity to their parents sooner—within a few years of coming out to themselves. Many youth want to share their lives with their parents and find that hiding their sexual identity, outside activities, and relationships further separates them from their families and undermines the integration they are struggling to achieve in trying to consolidate multiple identities. Others find it difficult to pretend to be straight. Youth living with their families in close quarters may find it difficult to hide their sexual orientation from siblings and parents. Regardless of their motivation, adolescents are more likely to come out to family members and peers at earlier ages than prior generations of lesbians and gay men, prompting a need for informed health care practitioners and for education and support for both adolescents and their families. Most youth we interviewed came out to their friends and siblings before disclosing their sexual identity to parents, and most came out to their mothers before their fathers. Although many parents interviewed in the current study report gender nonconforming behavior when their children were younger, they did not necessarily equate this with having a lesbian or gay child. Not surprisingly, many parents reacted to learning about their child’s lesbian or gay identity with a great deal of ambivalence. Few were initially accepting and some were openly rejecting and even reacted with violence and hostility. Some youth were ejected from their homes after their parents learned about their sexual orientation. It was not unusual for spouses to have had different reactions; for example, one parent

Some parents were accepting immediately when their children came out, especially if they anticipated that their children might be gay, based on gender nonconforming behavior at an early age. Some of these parents reported being uncertain of how best to introduce the topic of their child’s sexual identity— should they ask their children directly or wait until their child told them? When asked about this, adolescents had a variety of responses: some wanted the opportunity to tell their parents in their own time and resented having their disclosure preempted by a parental intervention, while others hoped their parents

would figure it out by clues they left around the house, such as gay-related literature in their room or web pages bookmarked on the family computer. Even youth from families that were accepting reported substantial anxiety and stress before coming out to their parents. Some reported depression that required medication and suicidal ideation as they struggled to understand their emerging sexual identity. In most cases, parents observed depression, withdrawal, or moodiness before they were aware that their children were dealing with issues related to their sexual identity. Other youth from accepting families reported a smooth transition from self-identifying as LGB to coming out to siblings and parents, grandparents, and other family members. Accepting parents had a range of reactions, primarily concern for their child’s future in a homophobic society. These parents, as well as many parents who were ambivalent about their child’s sexual orientation, responded to their child’s disclosure by telling them they loved them and often giving them a hug—a very important response for both parents and youth. Parents who were accepting of their child’s sexual orientation were more likely to have broader knowledge of lesbian and gay issues, to have gay friends or other gay family members, and to report good communication with their children and spouse. Accepting families were generally more open and knowledgeable about LGB youth, their child’s friends, and related school and community activities than ambivalent or rejecting families. Families that accepted their LGB children were interested in all aspects of their child’s development, including how their sexual identity would be addressed at home, at school, and in the community. These families welcomed their child’s LGB friends and were one of the few places where these youth were invited to socialize. These parents also understood that their homes provided a safe place for LGB youth to socialize, away from the streets or unsupervised events where they would be at risk for violence or exploitation. Youth from accepting families reported that their parents were especially supportive of their LGBT friends whose parents were ambivalent or rejecting. Their parents sometimes provided counseling, guidance, and a place to stay when their children’s friends had problems at home. Accepting families were also more likely to support their child’s same-sex romantic relationships, driving them to dates or supervised activities and participating in LGBT community and school events such as Gay

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may have been accepting while the other was rejecting or ambivalent. It is important for family members to be allowed to grieve the loss of their child’s heterosexual identity and to reframe longstanding dreams for the child’s future in terms of having successful employment or career, having a committed primary relationship, and having grandchildren. Increased awareness of homosexuality in the media and popular culture seems to have mediated the initial shock for parents of learning about their child’s sexual orientation. Many parents in this study nevertheless still reacted in familiar ways— by denying that their child was gay, or maintaining that they were too young to “foreclose” their sexual identity and should wait until they were older and had more experience. Equating sexual experience with sexual orientation, parents commonly encouraged their child to wait until they became sexually active to “decide” about their sexual orientation. While these parents may not have intended to promote sexual activity, this reaction may have the effect of prompting their child’s sexual debut. Some parents became more negative and some more accepting as they adapted to the reality of having a nonheterosexual child. It was helpful if parents knew successful gay or lesbian role models who could help to dispel negative stereotypes and provide models of successful adulthood. Although a number of youth in our study had older gay family members, such as older siblings, uncles, or aunts, few were openly accepted and several had died of AIDS, so their parents had little knowledge of how families accept and integrate gay family members into routine family life. Family members—including siblings, aunts and uncles, parents and grandparents—rarely spoke of their gay family members’ homosexuality, and their life partners rarely participated in family events.

Accepting Families

Pride or Gay Straight Alliance (GSA) activities. These parents spoke about their child’s accomplishments with pride, such as organizing GSAs in their schools or working as advocates for LGBT youth in their communities. One father of a 15-year-old lesbian youth who was active in helping her rural school comply with a state law that prohibits discrimination based on sexual orientation said simply: “My daughter is my hero.” Youth from accepting families had closer relationships with their parents and siblings, appeared better adjusted, and reported high levels of self-worth. These youth appeared more confident, were able to talk freely with their parents about their concerns, had a well-developed sense of their future, and were more hopeful about their lives and options.

Ambivalent Families Most families were ambivalent when their child came out to them. Many had never thought about having an LGB child so they were unprepared to respond when their child came out. Ambivalence was expressed after disclosure by mixed reactions, notably reluctance to tell other family members or close friends that their child was gay, concern about their child’s religious well-being, and anger or disappointment. Ambivalent and rejecting families were likely to blame their child for negative experiences such as antigay victimization, while accepting families blamed a largely hostile society for negative events their LGB children experienced. Some ambivalent families had difficulty resolving their religious beliefs with having an openly gay child. Unlike rejecting families, however, ambivalent families were able to make adjustments and compromises that helped keep their child in the home, such as making an effort to learn about homosexuality or deciding to attend a church that is more tolerant of gay members. Ambivalent families typically reported mixed reactions from parents, siblings, and grandparents that provided both subtle and direct messages to youth regarding behavior that is considered acceptable. Parents who were ambivalent about their child’s sexual orientation needed time to adjust to their new status and to get access to accurate information about homosexuality. Although these parents would benefit from an opportunity to talk with other parents of LGB youth, many were reluctant to disclose that their child was gay, even with other family members and close confidants with whom they generally share key aspects of their lives. Some were even more reluctant to

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approach a group of other parents, eg, through PFLAG. Many parents felt very isolated when their peers talked about their own children’s normative experiences such as dating, and hopes for their children’s future. It is important for these families to find support and to be encouraged to talk about their experiences with an informed practitioner.

Rejecting Families Some parents rejected their children when they learned that they were not heterosexual, at times reacting violently and forcing their child to leave home after a fight. Rejecting parents may have deep philosophical or religious beliefs that make it difficult to reconcile love for their child with his or her LGB identity. These parents in the study generally lacked the flexibility or coping skills to figure out how to adapt their belief systems to incorporate their child’s sexual orientation. Rejecting families were also the most isolated, with little access to accurate information about sexual orientation. These families were also much more likely to be dysfunctional and to include addicted or mentally ill parents. Youth from rejecting families were much more likely to become homeless or to live in foster care or residential programs for out-of-home youth than youth from families with other types of reactions. At the same time, however, some parents were able to adapt when they understood the serious risks their child would face without family support, including risk for homelessness, violence, and suicide. More than half of out-of-home youth in the study maintained some family involvement, and these families had the potential to strengthen these relationships—an important outcome for both adolescents and their families.

Impact on Siblings and Other Family Members Siblings have often been overlooked as parents struggle to figure out how to respond to a gay child’s coming out. In this study some reported being harassed or ridiculed in school after their sister or brother came out, and having to figure out how to deal with bullies. Siblings of youth who have been victimized in schools may become secondary victims through harassment in school and lack of attention at home once parents become aware of the severity of victimization targeting their LGB sister or brother.

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Siblings in accepting and ambivalent families experienced a range of reactions to their sister’s or brother’s coming out. Some were immediately supportive and were often the first person in the family who knew about their sibling’s LGB identity. In some accepting families, older siblings helped their younger sister or brother come out, by sounding out how their parents might react or letting them know the best time to tell their parents. Siblings in ambivalent families were more likely to report mixed reactions. While they loved their LGB sister or brother, many were uncomfortable being seen with siblings who were gender atypical, while at the same time fearing for their sibling’s safety in unsafe neighborhoods and communities. Younger siblings, who generally had little information about homosexuality, needed time to process their feelings, information about homosexuality, and support to think about how this new information would affect them. Family counseling can be especially valuable in helping families adjust after a young person comes out, and in dealing with the secondary stigma about homosexuality that affects the entire family.

lesbian, gay, or bisexual. Health care practitioners may be able to help youth and parents to expand their immediate support network by including members of their extended family.

Gender Non-Conforming Youth

Many LGB adolescents were open with their grandparents, uncles, aunts, and cousins. Adolescents from accepting families were more likely to be open with other family members than other youth. Historically, lesbians and gay men have often regretted the lack of intimacy with family members that resulted from their inability to be honest with them about the reality of their lives. Adolescents who are open with grandparents and other family members about their sexual identity, community involvement, and relationships with same-sex partners are able to deepen those relationships and increase intimacy, enriching family life over time. In the context of a supportive family, these relationships have the potential to mediate risks for LGB youth who are exposed to negative life experiences from society at large. Grandparents, aunts, and uncles can help buffer difficulties in relationships between parents and their children. Several grandparents participated in the FAP study hoping to learn how best to provide support for their LGB grandchildren. This includes families in which youth had not explicitly talked with their grandparents about their sexual orientation, but in which grandparents were aware that the youth were

For most parents in the FAP study, dealing with gender nonconformity in their child’s dress, mannerisms, and behaviors was particularly challenging, especially during adolescence. For parents of girls, concerns with gender atypical presentation and dress increased with age, becoming a concern when girls entered high school and were expected to take an interest in their appearance and dating boys. Tension between gender nonconforming girls and mothers and grandmothers from ambivalent and rejecting families provided a persistent source of conflict and stress. Gender nonconformity often caused distress among siblings, eg, a brother who is involved with sports and interested in girls may be embarrassed by having an effeminate, artistic brother. Family members’ discomfort and disapproval with gender atypical behavior also affected interaction with the extended family and participation in community cultural events, including, for example, family visits to Latin America. Fathers were often less concerned with their son’s interest in art or sewing, and more concerned with how peers would perceive their son’s hobbies. They feared potential ridicule or humiliation for their son, in addition to experiencing distress themselves. Parents of transgender youth felt especially distressed since they had very little information about normative development and how best to provide support for their child. They also had great difficulty finding practitioners or resources to help them understand and address their child’s needs and concerns, and lacked peer support from other parents. Some found themselves wishing their child were lesbian or gay since they found this possibility less stigmatizing and easier to explain to other family members and friends. Fear of Anti-Gay Violence. Regardless of their socioeconomic status, educational background, or level of acceptance, all parents interviewed feared antigay violence. Many parents were deeply affected by Matthew Shepard’s murder and the injuries or deaths of local gay or transgender youth from hatemotivated crimes. They feared for their child’s safety from society, in general, and in poor families, from the gang activity and street violence that pervades their

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Extended Family Members

Parents are often eager to find resources to connect them with other parents of gay or transgender youth, to seek information and guidance on dealing with everything from dating to school safety. Access to resources is especially important since family members may not readily talk even to each other about their child’s sexual orientation.

neighborhoods. Many parents had discussed these concerns with their children but their lack of awareness of gay-related groups and activities made it difficult for them to provide specific guidance on how to help their children protect themselves. School Victimization. Antigay harassment starts early, generally in elementary and middle school, and escalates in high school. Negative school experiences were widespread among youth in the study, ranging from teasing to assault. Some youth who participated in the FAP study reported experiencing years of victimization that negatively affected their health and mental health and culminated in posttraumatic stress disorder. Parents were generally unaware of school victimization until it had escalated, sometimes years after it began. Several parents and youth reported that somatic complaints were early indicators of school victimization that had been misidentified by parents and practitioners. Had these complaints been correctly identified as being related to antigay victimization, parents might have been able to intervene earlier, preventing negative health outcomes and severe emotional and psychological distress related to school victimization. Regardless of their families’ socioeconomic background or access to resources, few parents understood their advocacy role. As a group, they were quite uninformed about their child’s rights, state law, or how to intervene. Latino families, especially immigrants, had difficulty advocating for their child in dealing with school victimization since confronting authority is culturally incongruent and many did not understand how to negotiate the school system or feared making the situation worse by calling attention to their child. Isolation and Need for Support. A surprising finding of the FAP study was that all families, regardless of their socioeconomic background, felt isolated and unsupported in dealing with their child’s sexual orientation. Few resources are available for families of LGB youth that meet their specific needs for access to accurate information about their child’s health, development, and safety issues. Even programs that target LGBT youth, generally do not provide services for their families. PFLAG (a national support and advocacy organization for Parents, Families, and Friends of Lesbians and Gay Men) with chapters throughout the U.S. provides education and support for families and a range of referrals to supportive practitioners, counselors, and LGBT youth service organizations.

Coming out is a key developmental milestone for LGB youth, particularly since youth increasingly selfidentify as LGB and come out to family members and peers when their social and financial resources are still defined by their families. Clinicians have typically been advised to caution youth about coming out to their parents impulsively without thinking about the consequences. Instead, adolescents should take time to think through how their parents or guardians might react, to obtain information and advice (eg, from PFLAG) and information on community resources to help families of LGBT youth. If a practitioner has been told by a teenager that s/he is gay or lesbian, s/he should ask who else knows about his/her sexual identity in the family and peer network and how these individuals have responded. Many youth are open about their sexual identity only with a friend or sibling. Yet they may also have a close relationship with a specific family member, such as a grandparent, with whom they would like to share their sexual orientation, who can provide guidance and support to negotiate these issues within the family. Clinicians should help youth determine their motives for coming out to their families. Some are unclear about why they should do so and are prompted largely by what they hear from other youth. For example, some may think that coming out to their family is an expectation of participating in an LGBT youth group. Others may feel that keeping a secret from their parents or siblings is causing distress and restricting those relationships. For some youth, waiting until they leave home to tell parents or other family members is the most prudent decision. Youth from families that have very negative beliefs about homosexuality, including negative religious beliefs, are at greater risk of being ejected from their homes and becoming homeless. Youth who decide to tell a parent, sibling, or other family members should find a time when they will not

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Coming Out—An Opportunity for Health Professionals

be interrupted and can talk openly with that person. They should think carefully about what they want to say and what words to use. Some parents will not be surprised, but others will have many questions and will need time to process their feelings. Some PFLAG chapters help adolescents role-play coming out to parents or other family members. For parents, it is important to hear that youth want to be honest with them and do not want to hide this important aspect of their lives. Expressing affection and letting family members know how important they are to the adolescent helps reinforce the reason for coming out and why this new information can ultimately help strengthen their relationship. Some parents, particularly of younger adolescents, may perceive their child’s LGB identity as a phase that will eventually resolve itself. Some parents still think that homosexuality can be “cured” and seek counseling from mental health practitioners in an effort to change their child’s sexual orientation and should be told that this effort is disavowed by professional associations as ineffective and potentially harmful. In many cases clinicians may be the only resource to help parents dispel myths, clarify concerns, and identify the best way to help their child. For a variety of reasons, many parents are reluctant to reach out to community programs and are more comfortable talking with a clinician. Providing resources and referrals to a knowledgeable practitioner or family support group such as PFLAG can create a way to help parents sort out their feelings. It is helpful to reassure parents and other family members about their child’s potential for having a rewarding career and a committed relationship. Many parents are encouraged by information about the increasing opportunities for lesbians and gay men to have children. Parents should understand that expressing their love and acceptance to their child and finding ways to show their support are especially important when the youth is struggling to define his or her identity and may be dealing with rejection from others. Support is essential to build self-esteem and promote self-care, as well as to decrease risk behaviors. Among adult gay men, for example, family acceptance has been found to reduce risk for HIV infection and to foster resiliency in adulthood.103 Parents who are having a hard time accepting the reality that their child is gay or lesbian should be encouraged to seek support and guidance through pastoral and family counseling. Youth who are rejected by

their families are likely to end up on the street where they are at high risk for exploitation and serious health and mental health problems. Homeless youth, in general, are at high risk for victimization, STDs, HIV, alcohol and drug abuse, suicide, and mental disorders, but LGBT youth who are homeless are even more vulnerable.104 In a random sample of street youth in San Francisco— nearly two-thirds of whom had been ejected from their homes—youth who reported that they could not go home were at highest risk for intravenous drug use, sexual coercion, and unprotected sex.105 Pediatricians and other child health professionals can help by alerting families to these risks, and by providing referrals to knowledgeable and supportive family therapists and pastoral counselors to help families mediate their differences.106

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Gay and Lesbian Parenting —Cindy M. Schorzman, MD and Melanie Gold, DO Introduction As more gay and lesbian individuals and couples are expanding their families to include children, gay and lesbian parenting has become an increasingly prominent topic in the literature. Recent estimates of children in the United States living with at least one gay or lesbian parent range from 1 to 9 million.107 These estimates are limited by barriers to obtaining accurate numbers because many gay and lesbian parents often fear discrimination, and thus conceal their sexual orientation. Specific concerns include loss of child custody and fear that their children will face stigmatization and discrimination.108 Much of the early professional literature was driven by legal dilemmas, such as the rights of lesbians and gay men to be parents, and addressed concerns such as the perceived mental instability and parental fitness of gay men and lesbians.109 These early studies were almost all focused on children born into heterosexual environments and subsequently raised by lesbian mothers; they represented children coming from a background of separation or divorce, not children born or adopted into a stable, established same-gender family. More recently, as the legal debates have shifted, so has the emphasis of research. Recent studies have focused on more complex medicolegal issues, particularly focused on lesbians who have come out before having children. These more recent investigations

address children born after alternative insemination or surrogate pregnancy, or who have been adopted or are in foster care.110 As gay and lesbian parenting has become more accepted, the professional literature has evolved to be driven by clinical concerns. Since the existing body of knowledge does not describe any significant differences in outcomes regarding child development, the focus of attention has shifted to potential differences in the experiences of gay and lesbian parents and of their children. Recent research has highlighted such topics as coparenting roles, impact on work and career, coming out to children, and relationships with the children’s schools.111 These issues have ramifications for clinicians and for counselors, related to providing anticipatory guidance and therapy. Specific research on issues surrounding gay and lesbian parenting is a relatively recent development. Before 1973, homosexuality was classified as a mental disorder (DSM II–1968); research conducted before the revision of this classification in the DSM III generally reflected this perspective. After homosexuality was no longer considered a mental disorder by the major professional organizations (the American Psychiatric Association in 1973 and the American Psychological Association in 1975), the bias evident in professional research decreased somewhat, although relatively few articles relating to lesbian and gay men’s issues appeared in major professional journals until 1989.112

Most research on gay and lesbian parenting conducted before 1989 focused on the biological children of lesbian mothers from previous heterosexual relationships and described the subsequent legal and custodial issues they faced. These studies focused on the fitness of the mother to remain a legal custodian. They compared children raised by homosexual and heterosexual mothers after divorce to discern any negative impact from having a lesbian mother. Consistently, these earlier studies reported no higher rates of psychological problems, no confusion with regard to gender identity, and no differences in sex role behaviors among children whose mothers were lesbian as compared with children whose mothers were heterosexual.59,108 For example, Huggins examined selfesteem in a comparison study of 18 adolescent children (ages 12 to 19) of divorced lesbian mothers with a matched group of children of divorced heterosexual

mothers. She found no differences in the self-esteem of adolescents raised by lesbians and those raised by heterosexual parents.113 Golombok and colleagues published a longitudinal study of 25 sons and daughters of lesbian mothers, comparing them with 21 children of heterosexual single mothers; again they demonstrated no differences in emotional functioning or behavioral adjustment among children raised in homosexual and heterosexual environments. Further, this study showed that the young men and women with lesbian mothers continued to function well in adulthood with regard to emotional well-being and intimate relationships, and that they maintained positive relationships with both their mothers and their mothers’ partners.114 Patterson, in her review of this body of literature, concluded that “there is no evidence to suggest that psychosocial development among children of gay men or lesbians is compromised in any respect relative to that among offspring of heterosexual parents.”108 Allen and Burrell, in a meta-analysis of this earlier literature, similarly concluded that no differences were demonstrated on any measures between the heterosexual and homosexual parents regarding parental styles, emotional adjustment, and sexual orientation of the children.109 More recently, studies have focused on such issues as whether lesbian and gay individuals should have access to donor insemination and other assisted reproduction procedures. These studies tended to be more directed toward children raised in nonheterosexual environments (most often by lesbian mothers) from the start. These studies, representative samplings of which are cited below, also have shown no consistent differences in the psychological profiles of children raised by gay and lesbian parents. Flaks and colleagues compared a group of 15 lesbian couples living together with their 3- to 9-year-old children (born to them through alternative insemination) and a matched sample of heterosexual parents and their children. In this study, a variety of assessment measures showed no significant differences in cognitive or emotional functioning between those children raised by lesbian couples and those raised in matched, heterosexual parented families.115 Green and colleagues compared 56 children of 50 divorced lesbian mothers to 48 children of 40 divorced heterosexual mothers; they similarly found no group differences in either emotional functioning or cognitive functioning.116 Chan et al. reported a careful assessment of

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Emotional and Cognitive Development

heterosexual and lesbian parents and their children which also included reports by teachers, and concluded that “children’s well-being is more a function of parenting and relationship processes within the family than it is a function of household composition or demographic factors.”117

Psychosexual Development Sexual orientation, gender identity, and gender role behavior have been areas of particular concern for critics of lesbian and gay parenting. The gender identity and gender role behavior of children raised by lesbian mothers appears in many studies to be consistent with their biologic sex. In a recent review, Anderssen and colleagues found no consistent differences in sexual orientation among the children of gay or lesbian parents.118 In one of the largest published studies to date of adult sons of gay men, 55 gay or bisexual men reported on 82 adult sons. Sixty-eight of 75, more than 90% of the sons whose sexual orientations were reported, were heterosexual. Further, environmental factors such as length of time living with their fathers did not appear to contribute to the sexual orientation of the adult sons.119 There is some evidence that children raised by a lesbian mother are more likely to report that they would consider a nonheterosexual relationship, which is not surprising since they are familiar with and likely to be accepting of nontraditional relationships. These young adults were no more likely to identify themselves as gay or lesbian than children brought up by heterosexual mothers.120 Among more than 300 children between 3 and 11 years of age that have been studied, none has shown any deviation from typical patterns of gender role development.121 In a large community-wide sample including both lesbian and heterosexual mothers and their children, no difference in gender role behavior was found based on whether a father was present in the home.122

on local and national contexts. Haack-Moller and Mohl interviewed 13 offspring of lesbian mothers in Denmark and summarized their comments like this “relationships to friends have in many instances been problematic, there have often been direct negative reactions toward the children because of their lesbian mother”.123 This study noted that ages 10 to 11 were most problematic with regards to these “negative reactions.” In contrast, Golombok found no higher prevalence of peer group hostility in her British sample, since it appeared that many children at this age were teased about various characteristics. She noted that more of the boys of lesbian mothers were teased regarding themselves “being gay” and regarding their mother(s) being lesbian. It is not clear from these reports whether more teasing actually occurred, or whether these children were more sensitive to or more likely to report these sorts of taunts.114 One study, that included eleven 16- to 23-year-old children of lesbian divorced mothers, reported that several of these children experienced shame because of the conflict between their loyalty to their parent and the perceived need to conceal their parents’ sexual orientation for self-preservation.124

Lack of Consensus

The psychological phenomenon of most concern for children raised in homosexual environments has been the threat of stigmatization and resulting difficulties with peer relationships. The empirical data have been inconsistent on this point, but some studies do suggest that children of nonheterosexual couples are more likely to be teased and to be concerned about being harassed. There appear to be important differences in children’s reports of teasing and discrimination based

Our overall interpretation that the collective body of research demonstrates no discernable difference in parenting or in child outcomes based on parents’ sexual orientation is not universally accepted. Outspoken critics of the literature, such as Cameron and colleagues125 and Lerner and Nagai,126 have highlighted the limitations of these studies. Important limitations included small sample size (these studies may be more likely to conclude there are no differences when some differences do indeed exist), lack of generalizability (participants were mostly lesbian, white, well-educated, urban and middle class), lack of randomization of study populations, and lack of appropriate comparison groups. Descriptions of research design and statistical analyses were also poorly described in some of the studies. The studies were often quite diverse in the context in which the children were born and raised, with parameters such as divorce, single versus two-person parenting, stage of parenting at which the parents came out, and the presence of other male and female adult role models other than parents. Conversely, there have been no published studies without these same flaws that demonstrate any evi-

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Stigma and Peer Relationships

To avoid some of the limitations of earlier studies (such as small sample size and convenience-sample or volunteer populations), Golombok analyzed the data set from the Avon Longitudinal Study of Parents and Children (ALSPAC) that follows 14,000 mothers and their children who were born in a single county in England. From this data set, extensive background information was obtained beginning in pregnancy. Matched groups were identified of two-parent heterosexual families, single heterosexual mother families, single-parent and two-parent lesbian families.125 Snowball sampling was used to make the sample sizes comparable. Nonsignificant trends were reported (as well as statistically significant effects) to answer criticisms of the existing literature that research has underreported the differences between children of gay and heterosexual parents. Children were evaluated by parents, teachers, and psychologists when the children were 7 years old. Overall, the findings in this study were comparable to those of earlier, smaller studies. Few significant differences were found between children in lesbianparented families and children in heterosexual families. After multiple regression analyses, the mother’s sexual orientation was found to be unrelated to the children’s psychological adjustment. No differences were found in the proportion of children identified as having a psychiatric disorder. Further, there were no significant effects for gender development based on sexual orientation of the parents. No significant differences were found for peer relationships based on the sexual orientation of the parents, though there was a nonsignificant trend for lesbian mothers to report that their children had more difficulty with peer relationships. Teachers’ reports, on the other hand, did not show any differences between children from heterosexual and lesbian-parented families in peer relation-

ships. In contrast, significant differences were found between children in single-parent and those in twoparent homes, regardless of sexual orientation. For example, this analysis revealed that a significantly higher proportion of children living in single-heterosexual-parent homes were reported by their teachers to have conduct problems, compared with children living in two-parent homes.127 While the majority of the existing research in this field is focused on the impact on the children, this longitudinal study also assessed the impact of parenting on the gay and lesbian parents. Golombok found a greater level of enjoyment of motherhood in twoparent families (independent of sexual orientation), no difference in relationship satisfaction between lesbian and heterosexual mothers, and no differences in child supervision based on sexual orientation. Lesbian mothers were found to engage in more imaginative play with their children than heterosexual mothers. Differences were again found when comparing singleparent versus two-parent households, independent of sexual orientation, with more severe disputes between parents and children reported by single mothers. With regard to a comparison of co-mothers versus fathers in two parent households, there was no difference in overall parenting quality of expressed warmth; a greater number of fathers were found to have raised levels of emotional involvement with their children, and fathers used corporal punishment with their children more frequently, compared with co-mothers.125 In summary, the results of this larger, communitybased study support the majority of earlier studies that indicated positive mother– child relationships and well-adjusted children of lesbian mothers. No significant differences between lesbian mothers and heterosexual mothers were noted for most of the parenting variables, except that lesbian mothers reported using corporal punishment less often when disciplining their children and engaged more frequently in imaginative play with their children than did heterosexual mothers. Regarding the children, no significant differences in psychiatric disorders were identified by a child psychologist blinded to family type, or by the mothers or the children’s teachers. Although there was a nonsignificant trend toward greater peer problems among children in lesbian-parented families as rated by mothers, neither the children nor their teachers reported greater problems with peers. There were no differences in gender-typed behaviors among the children, for either boys or girls. Further, the presence of two

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dence that gay and lesbian parenting causes significant deleterious effects to children. Taken together, the overwhelming number of studies (despite the limitations of each individually) that demonstrate no important differences in children’s development based on the sexual orientation of their parent(s) provides a consensus. Research in this area is hampered by fear of discrimination and reluctance to seek medical care on the part of potential participants, vast diversity in the family arrangements to be studied, and strongly held moral and religious beliefs of the investigators.

Community-Based Sample

parents, irrespective of their gender or sexual orientation, was associated with more positive outcomes for the children’s psychological well-being.

The latest strand in this line of research seeks to define differences in terms of potential benefits and resiliencies of homosexual parenting, rather than attempting to defend gay and lesbian parenting from its critics. Some studies have described increased tolerance for diversity among children whose parents are gay or lesbian, and a more nurturing and less aggressive style. In that most of these findings were generated from families in which the parents are both women, some have questioned whether they are related more to gender of parents than to their sexual orientation.59 Since no significant differences have been found in developmental outcomes, there has been less focus on the justification of gay and lesbian parenting, and more focus on helping to address the unique needs of gay and lesbian families. Such issues include coparenting roles, impact on work and career, coming out to children, and relationships with the children’s schools. In a recent qualitative study, McNair and colleagues interviewed lesbian parents regarding their views on the positive and negative aspects of homosexual parenting compared with heterosexual parenting. These mothers noted numerous potential benefits to nonheterosexual parenting including exposing children to greater experience, appreciation, and tolerance for diversity; having opportunities to be politically active in support of alternative family structures, and taking action in the face of prejudice. Enhanced self-esteem and resilience for children and a sense of strength and self-worth for parents were attributed to success in meeting the challenges presented by living in homophobic cultural contexts. These parents also saw positive implications in the fact that their parenting was carefully planned, and that the difficulties and constraints involved in organizing conception/adoption increased the likelihood that the children would feel wanted, loved, and respected.128 One of the key strengths documented in the literature about lesbian parent families is the prevalence of supportive and egalitarian coparenting relationships.129 Gartrell and colleagues, in their

longitudinal study of 84 lesbian mothers who had children through donor insemination, found that 75% of lesbian parents shared parenting responsibilities equally, and 68% of the mothers of the children at 5 years of age felt that the child was equally bonded to both mothers (among families who had not separated or divorced).130-132 Participants in McNair’s study contrasted their own arrangements to those among heterosexual couples, citing they had more equitable arrangements with shared household tasks and responsibilities, childrearing and financial arrangements, and shared experiences of pregnancy and delivery when both parents had experienced birth.128 Just as heterosexual families are not uniform in nature, neither would it be appropriate to assume homogeneity among families headed by gay or lesbian parents. In their work, Ciano-Boyce and Shelley-Sireci focused on parenting styles and relationships among lesbian parents.134 They compared lesbian birth, lesbian adoptive, and heterosexual adoptive couples, finding overall that the three types of families were more similar than different. Contrary to earlier studies, this study found that lesbian parents in the sample were less egalitarian in their division of child care tasks and suggested that the concept of primary and secondary caregivers does exist. These investigators found that lesbian families that had given birth to their child divided tasks such that the birth mother provided more childcare and was more satisfied with that role. Lesbian adoptive parents, while egalitarian in their childcare practices, tended to have more dissatisfaction with their division of child-care tasks. Further, they found that those lesbian adoptive parents were significantly more likely to report that their child’s preference for one parent over another was occasionally a source of conflict. This study identified a parental role ambiguity that could become a source of tension in lesbian-parented families and suggested that health care providers take the opportunity to discuss this topic when counseling lesbianparented families about parenting issues. Other recent studies also have emphasized the extent and variety of biological and social kinships, with diverse perspectives reported by lesbian parents highlighting the wide range of experiences in nonmainstream parenting. Many of these potential differences have not yet been fully explored and

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Potential Strengths

pose further questions for the next generation of research regarding gay and lesbian parenting.

The increasing prevalence of children whose parents are gay or lesbian has led to the recognition that pediatricians could take an important role in helping these families via both clinical and advocacy activities. As a result, the American Academy of Pediatrics (AAP), through its Committee on Psychosocial Aspects of Child and Family Health, reviewed the available knowledge about these children and families. Based on this review, the AAP published a technical report to support its Policy Statement supporting coparent or second-parent adoption by same sex parents. Their conclusion was that “a growing body of scientific literature demonstrates that children who grow up with one or two gay and/or lesbian parents fare as well in emotional, cognitive, social, and sexual functioning as do children whose parents are heterosexual,” and that “children’s optimal development seems to be influenced more by the nature of the relationships and interactions within the family unit than by the particular structural form it takes.” Despite some reserve based on the limitations of the studies, as noted above, the Committee believed that the weight of the available evidence was strong enough to demonstrate “that there is no systematic difference between gay and nongay parents in emotional health, parenting skills, and attitudes toward parenting.”135 With this recognition come some specific challenges for clinicians in dealing with gay and lesbian families. While the literature focuses on population-based studies and theoretical risks/benefits of gay and lesbian parenting, the challenge for clinicians lies in addressing the very practical concerns faced by individual families. Meeting the needs of children of gay and lesbian parents means addressing the needs of the children themselves, as well as understanding those issues within the context of their family as a whole. The primary challenge for the clinician lies in creating an open and accepting environment in which these individuals feel comfortable enough to disclose and discuss their sexual orientation and family constellation. Health care professionals have traditionally had little or no training about homosexuality.135,136 In fact, there is a large body of evidence to suggest that gay and lesbian adults find the health care system to be

unresponsive and sometimes antagonistic to their unique needs and concerns.137 To help identify the specific barriers to providing pediatric care to children whose parents are gay men or lesbians, Perrin conducted a study focused on those parents who selfidentified as gay or lesbian.138 The study found that overall most gay and lesbian parents perceived their children as receiving pediatric care that was affirming, supportive, and satisfactory. However, there were many specific deficiencies noted, such as heterosexist assumptions on office forms, exclusion of the nonbiological parent from the evaluation and treatment process, and explicit insensitivity to particular family involvements. In addition, those parents who had not disclosed their sexual orientation to their child’s pediatrician had concerns that such disclosure might compromise their child’s care, result in negative judgments about their parenting, and infringe on their confidentiality. They described a number of concerns regarding health care providers such as prejudice against their children, providing disparate care, lack of communication about the child’s health with the nonbiologic parent, and blaming parental sexual orientation as the cause of any child physical or behavioral problems. Establishing a supportive health care environment requires, first and foremost, that clinicians examine their own attitudes toward gay and lesbian parenting. Health care professionals “who cannot reconcile their personal beliefs with their professional obligation to provide supportive, understanding, and respectful care to gay and lesbian families should recognize this limitation and refer these families to a [clinician] who can better meet their needs.”137 Once the clinician has addressed these issues personally, then health care staff attitudes should be similarly addressed with interventions such as diversity training and strict guidelines regarding confidentiality. Hospital and office policies regarding the use of gender-neutral language and the inclusion of nonbiological parents during the child’s office visits should be discussed and enforced. The office environment should reflect a supportive, safe environment for children of diverse families. Perrin has identified several changes in the office or hospital environment that demonstrate support for a diversity of family structures. These include displaying posters, magazines, books, and pamphlets that portray a wide range of family constructs. A nondiscrimination policy, prominently displayed in the waiting area, can do much to assure both gay and lesbian

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The Role of Health Care Clinicians

parents and adolescents that the office is a safe environment for disclosure of sensitive issues. Standard office forms should be modified to include gender-neutral terms, such as “parent,” “caregiver,” and “family member.”59 Other resources should be available in the office, such as books about gay and lesbian parenting, information regarding community and national resources (see Table 3), and standard medical forms such as medical power of attorney designation. Meeting the needs of the children of gay and lesbian families often starts before conception, involving family practice and obstetric providers as well as pediatricians. Preconception issues include routine anticipatory medical care (such as blood work, immunizations, adequate treatment of chronic medical conditions) as well as items that may be more specific to gay and lesbian individuals. Specific challenges for potential parents may include deciding whether to adopt or to conceive a child, obtaining donor sperm or arranging for a surrogate mother, finding an accepting adoption agency, making legally binding arrangements regarding parental relationships, and creating a substantive role for the nonbiologic or nonadoptive parent.59 Often issues previously addressed, such as coming out to friends and family, take on a new dimension that requires continual reexamination within the new framework of expanding their family. Gay and lesbian individuals must also learn to cope with actual and feared discrimination and stigmatization, and the implications of raising a child with regard to their own ongoing coming-out process. As the child grows and develops, in addition to standard anticipatory guidance issues, particular issues tend to surface regarding different developmental stages. In the preschool period, common concerns include how to explain the construct of their own family and the methods of reproduction.59 Gold and colleagues suggest that early childhood “is a good time to initiate explanations to the child about his or her own origin and to introduce concepts of the variety of loving relationships.”137 Clinicians can help parents empower their children to deal with these issues by encouraging them to allow the child to control the information they disclose to friends or teachers; parents should simultaneously help them prepare for the possible negative consequences of disclosure. Parents should be encouraged to help their children come up with their own creative ways to describe their

family in positive terms.139 A gay or lesbian couple might celebrate their essential roles as two loving, supportive parents while additionally recognizing the other important adult role models and caretakers who help comprise that child’s extended family. For a lesbian couple, for example, one approach to Father’s Day might be to redefine it as a celebration of that child’s male role models, such as writing cards to an uncle or close male family friend. The transition to school years poses particular challenges for children from a nontraditional family background.138 For parents and children alike, this involves whether to disclose their nontraditional family status to teachers and the families of the child’s friends. It is at this time that peer acceptance and teasing often become concerns. Empathic listening, role playing about how to respond to teasing, and providing information to parents and their children through support groups can assist both parents and children in coping with stigma and discrimination.59,138 During adolescence, issues of sexuality tend to come to the forefront regardless of family structure; teenagers in households with lesbian and gay parents are certainly no exception, and they may have their own special challenges. Early adolescents may feel marginalized and stigmatized by being seen as part of a nontraditional family.140 Teenagers may feel guilty, torn between their loyalty to their family and pride in their family structure, and their intense desire to form and maintain relationships and fit in with their peers.124 Health care providers can help adolescents and their parents by listening in a nonjudgmental fashion, and by offering lists of resources and support groups.59 Although individual situations vary, there is some evidence to support encouraging adolescents to disclose their nontraditional family status to their friends. Gershon and colleagues found that adolescents who disclosed their mother’s lesbianism to their friends reported closer friendships and higher selfesteem than those who did not.140 To meet the ever-changing needs of their patients and their families, health care providers should have available a list of local and national support groups and community resources. They should also take a proactive approach in their patient’s lives by not only providing a safe, nurturing office environment, but also by taking steps in the community to help counteract the generalized homophobia that children of gay and lesbian parents continually face.

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TABLE 3. Resources for gay and lesbian parents and their children

COLAGE: Children of Lesbians and Gays Everywhere 3543 18th ST #1 San Francisco, CA 94110 (415) 861-KIDS (5437) Website: www.colage.org Family Pride Coalition (formerly Gay and Lesbian Parents Coalition International (GLPCI)) P.O. Box 65327 Washington, DC 20035-5327 (202) 331-5015 Website: www.familypride.org Human Rights Campaign 1640 Rhode Island Ave., N.W. Washington, D.C. 20036-3278 (202) 628-4160 Website: www.hrc.org/familynet Selected Books: Stories of GLBT families: J. Drucker. Families of Value. Plenum Press, NY (1998). A collection of stories depicting gay, lesbian, transgendered and bisexual parents and their children. P. Gillespie, editor. G. Kaeser, photographer. Love Makes a Family: Portraits of Lesbian, Gay, Bisexual, and Transgender Parents and Their Families. U. of Massachusetts Press, Amherst (1999). Combines interviews and photographs to document the experiences of LGBT parents and their children. D. Herrera. B. Seyda, photographer. Women in Love: Portraits of Lesbian Mothers and Their Families. Bulfinch Press. Boston (1998). Collection of photographs and stories of lesbian mothers and their families. C. Rizzo, J. Schneiderman, L. Schweig, J. Shafer and J. Stein, editors. All The Ways Home. New Victoria Publishers, Norwich (1995). A collection of stories written for and by lesbian and gay parents exploring what it means to be a parent in the queer community. D. Strah et al. Gay Dads: A Celebration of Fatherhood. JP Tarcher, Putnam (2003). The stories of 24 families, including family-building resources for gay men. J. Wells, editor. Lesbians Raising Sons. Alyson Publications, New York (1997). A collection of essays on what it means to be a lesbian raising a son, which addresses such issues as feminism, coping with homophobia, and male role models. Coming out: L. MacPike. There’s Something I’ve Been Meaning to Tell You. Naiad Press, Tallahassee (1989). True life stories from 25 lesbians and gay parents who have come out to their children. Legal issues: H. Curry and D. Clifford. A Legal Guide For Lesbian and Gay Couples, 10th Edition. Nolo Press, Berkeley (1999). An excellent resource for all lesbian and gay couples: includes information on custody, parental rights, and domestic partner benefits. Parenting resources: L. Davis and J. Keyser. Becoming The Parent You Want To Be. Broadway Books, New York (1997). A guide to parenting that addresses multiple issues including toilet training, punishment, parenting with a partner, and gender roles. A. Gelnaw. Opening Doors: Lesbian and Gay Parents and Schools. Family Pride Coalition, San Diego (1999). A handbook for parents that explores the relationship between parents, their children, child care and school personnel to create a more inclusive educational environment for children of LGBT parents. A. Martin. Lesbian and Gay Parenting Handbook. Harper Collins, New York (1993). A guide to parenting, with many examples of gay and lesbian parents and their children. Academic interest: S. Golombok and F. Tasker. Growing Up in a Lesbian Family. Guilford Press, New York (1997). An academic look at children raised by lesbians, with comparisons with children raised in heterosexual environments. L. Benkov. Reinventing the Family. Crown Publishers, New York, 1994 Perrin EC. Sexual Orientation in Child and Adolescent Health Care (chapter 5). New York: Plenum Publishers; 2002. Other Publications of Interest: Just For Us. Specifically designed for children of GLBT parents. 3543 18th St. #17 San Francisco, CA 94110 Proudparenting.com. Online publication. P.O. Box 8272 Van Nuys, CA 91409-8272 Website: www.proudparenting.com Gay Parent Magazine. Features the personal stories of lesbian, gay, bisexual, and transgender (LGBT) parents from across the United States. [email protected] P.O. Box 750852, Forest Hills, New York, 11375-0852 Website: www.gayparentmag.com/index.html

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Conclusion While there are no data to suggest that children with gay or lesbian parents are different from other children with regard to their cognitive, psychosocial, and sexual development, these children and their families do face social challenges that their health care providers have a unique opportunity to help them address. These challenges must be addressed within the context of the child’s life as a whole, and the routine medical care of children and adolescents should not be overshadowed by their nontraditional family status. The diversity of the family structures within the gay and lesbian community (that has only minimally been addressed by researchers to date) should be recognized and assessed over time, and anticipatory

guidance and care should be tailored to individual needs.

Diverse Roles for Child Health Clinicians —Ellen C. Perrin, MD Pediatricians can work to improve the lives of gay and lesbian individuals of all ages as community and political leaders, as advocates for change in their office and hospital settings, in the context of the clinical care they provide, and as members of professional educational institutions (Table 4). Tremendous potential has been created by recently increased focus on gay and lesbian issues within all

TABLE 4. Roles for health care professionals on behalf of gay and lesbian youth

Community Advocacy  Help to raise awareness and acceptance among school and community leaders of issues relevant to non-heterosexual individuals and families.  Support the inclusion of materials about gay and lesbian issues in school curricula and in school and community libraries.  Support the development and maintenance of school-based and community-based support groups for gay/lesbian students, their friends, and their parents.  Initiate and support AIDS prevention/education efforts.  Develop and/or request continuing education opportunities for health-care personnel related to issues of non-heterosexual youth and families. Safe and Supportive Health-Care Environments  Assure confidentiality.  Implement policies against homophobic jokes and remarks.  Be sure that informational forms use gender-neutral language and are free of heterosexist bias.  Display posters, brochures, and information on bulletin boards that demonstrate support of issues important to gay and lesbian youth, parents, and their families.  Provide information about support groups and other resources for non-heterosexual teens and their friends and families. Comprehensive Health Care  Be aware of the special issues surrounding the development of the range of mature sexual orientations.  Assure confidentiality.  Discuss emerging sexuality with all adolescents.  Discuss family constellation and sharing of child care responsibilities with all parents.  Use gender-neutral language in discussing sexuality.  Give evidence of support and acceptance to adolescents questioning their sexual orientation.  Provide information and resources regarding lesbian and gay issues to all interested adolescents.  Provide information and resources to gay/lesbian parents and their children.  Offer support for adolescents faced with or anticipating conflicts with families and/or friends.  Provide “safer sex” guidelines to all adolescents.  Provide further screening and education as indicated for each adolescent’s sexual activity.  Ensure that referral and consulting colleagues are respectful of the range of adolescents’ sexual orientations.  Encourage lesbian/gay parents to help their child(ren) recognize and resist stigmatization and criticism.  Initiate opportunities for discussions of concerns about sexual orientation in regular health supervision encounters. Medical Education  Increase curricular attention to GLB issues.  Speak about experiences of stigma and marginalization.  Develop systems to support GLB students, staff, faculty.  Advocate for inclusion of homosexuality in affirmative action programs.  Improve access to and visibility of appropriate health care options.  Develop research programs that focus on issues of concern to GLB patients/families.

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Physicians can help to raise awareness and acceptance of issues related to nonheterosexuality among school and community leaders. They may serve as a consultant or adviser to a community youth group or to a middle or high school’s extracurricular activity group. National organizations and their local chapters that support gay and lesbian teenagers, parents, and their families generally welcome the participation of child health professionals in their activities. A growing collection of fiction may help children of all ages and young adults to understand the diversity of sexual orientation and family constellations. Several collections of essays and explicit guide books provide resources for teenagers and their families, and for gay and lesbian adults interested in planning for parenthood and coping with the associated decisions and concerns. Physicians

should encourage their local school and community libraries to have a wide variety of these books available. An annotated list of recommended books is provided in the resource section of this article. Pediatricians and other child health professionals may serve also as advisers to schools. Curricular materials should be available for every age level that present the diversity of family structures and address issues related to sexuality and sexual orientation. Children who live with only one parent or whose parents live separately, children whose parents have created their families through adoption, interracial and international families, children whose parents are gay and/or lesbian, and blended families all are present in many classrooms. Children can be helped to see that a variety of acceptable family arrangements all share the primary function of providing nurturing and care of their members. Traditionally homosexuality is severely stigmatized, and slang expressions for homosexuality abound in children’s teasing, criticism, and derision of each other. Classroom materials and programs should present information about people with various sexual orientations and family structures and help all children to understand the value of this diversity. Classroom presentations by physicians, and their participation in extracurricular activities, committees, or on school boards help to support efforts at increasing appreciation for diversity. At the high school level, child health professionals can serve as advisers to “gay–straight alliances” and other extracurricular activities and can be available to speak to selected assembly programs or make presentations as part of classroom curricula. In this role, they have the opportunity to teach about and encourage safe and responsible sexual behavior, including various forms of sexual expression, to initiate and support AIDS prevention education efforts, and to advocate for educational and support programs in schools. Child health care professionals can be effective also in national and local politics. Their support for laws and statutes that forbid discrimination based on sexual orientation, their outspoken opposition to discriminatory policies and habits, and their participation in political initiatives on behalf of gay and lesbian rights all are effective advocacy roles. Professional associations provide yet another context for effective advocacy. All health care fields would benefit from increased teaching about, visibility, and acceptance of nonheterosexual students and col-

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settings where health care for children and adolescents is provided. Health care clinicians can be resources to all children and adolescents for advice and information regarding sexual behavior, its risks, and their sexual orientation. They may be a valuable source of support and advice for adolescents who are preparing to disclose their homosexuality to parents, peers, and teachers, and if the adolescent anticipates or encounters rejection after such disclosure. Information about their prospects for future intimate relationships and opportunities for parenthood may be beneficial to these teenagers and to their parents. Parents of gay and lesbian teenagers also will appreciate any information, support, and advice their child’s physician can provide, as well as her/his support for the adolescent her/himself. Lesbian and gay couples considering parenthood may consult a child health professional for advice in making decisions regarding sperm donation, adoption, and surrogacy options. Lesbian and gay parents may have questions about how to help their children understand their parents’ sexual orientation, their family’s development and constellation, and may appreciate advice regarding coping with possible criticisms. Sensitivity, information, and access to appropriate care are important for transgender individuals as well.141,142 The American Academy of Pediatrics has recently reaffirmed the importance of pediatricians to gay and lesbian youth and their families.143

Community Advocacy

leagues, and from expanded continuing education opportunities related to homosexuality.144

The Health Care Environment A safe and supportive setting is a prerequisite for all health care activities. Health care professionals must assure all patients and their families that they respect the need for confidentiality and honor the trust implied in their clinical encounters. People who have been subjected to discrimination and negative stereotyping may need special reassurance before they disclose their concerns and worries. Physicians should post prominently their policies about confidentiality and its limits; all staff members must be informed of the gravity of such policies, which must be scrupulously enforced. Strict policies against homophobic and other stigmatizing remarks, jokes, and slurs must be publicly announced and rigorously enforced in all health care contexts. Recurrent experiences of stigma and discrimination make questions about or disclosure of homosexuality difficult and risky. A paper-and-pencil or computerized checklist administered in advance of the office encounter makes initiation of discussion about this and other potentially difficult topics easier.145 Once an adolescent or a parent has indicated a concern, it is the clinician’s responsibility to initiate the relevant discussion. It may be appropriate to use an internal code to document information about sexual orientation in the charts of adolescents or of children whose parent(s) is(are) gay or lesbian so that this information will not become public without the patient’s and parents’ explicit consent. It is easy and helpful to let patients and their families know indirectly of the office’s acceptance of nonheterosexuality. Posting relevant informational materials on bulletin boards in waiting areas makes a powerful statement, as does the presence of posters, books, magazines, and newspapers that describe and discuss issues of particular interest to gay and lesbian clients. Even the minimal symbol of a pink triangle or rainbow sticker posted in the waiting room or in examination rooms can serve as an indication of the office’s acceptance of sexual minorities. Many hospital, clinic, and office informational forms and reading materials, as well as commercially available educational and health promotional brochures, assume heterosexuality. These materials should be replaced or rewritten using gender-neutral language. Brochures about adolescent sexuality should present

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information about the broad range of sexual orientation rather than assuming heterosexuality. A brochure directed specifically at gay and lesbian youth and their families has been produced recently by the American Academy of Pediatrics (AAP). The AAP is currently preparing a brochure specifically focused on gay and lesbian parenting. Many of the recommendations made above regarding office environments apply to hospitals as well. Policies that assure confidentiality and that forbid stigmatizing jokes and slurs must be clearly posted and enforced by all staff. Heterosexist assumptions that may be implied in forms and written materials should be noted and corrected. Both general indications of acceptance of sexual minorities and specific information relevant to clients of diverse sexual orientation should be visible and available. Recording of patients’ sexual orientation in charts and on hospital wards should be done with care and sensitivity. Hospital policies must be flexible enough to allow gay partners to participate in one another’s care. If a child has coparents of the same sex, both should be kept informed and both should be invited to be present with the child during procedures or overnight in the hospital.

Compassionate and Comprehensive Health Care Pediatricians and family physicians have an opportunity in the context of their care for young children and adolescents to model acceptance of a variety of patterns of sexual attraction and sexual behavior. In the questions they ask they can encourage parents to ask and talk about the development of sexuality in their small children, as well as invite questions and discussion about a range of sexual behavior as children grow. The goal for primary care physicians caring for children is not merely to identify those adolescents and those parents of their patients who are gay or lesbian or who are struggling to understand or to acknowledge their sexual orientation. Most adolescents will have some experience with and thoughts about homosexuality: they may have a parent, a sibling, an aunt or uncle, a peer, a teacher, or another contact who they know is or suspect may be gay; or they may have encountered homosexuality only through literature or the media. With increasing visibility of gay and lesbian leaders in political, academic, and social cir-

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cles, adolescents’ curiosity about the range of sexual orientation is likely to increase.146 Adolescent Health Supervision. Gay and lesbian youth have general medical needs and problems that are substantially similar to those of their heterosexual peers. Nevertheless some special attention to the process and content of health supervision efforts is warranted. The stigmatization and ensuing social isolation that they frequently encounter creates special vulnerabilities. Gay and lesbian adolescents may face additional health risks as a result of the nature of some of their sexual and social behavior, as well as considerable uncertainty regarding the level of support they can count on from their family, friends, and teachers. Nonjudgmental discussions of sexuality should be routine in the course of all adolescents’ health care. Physicians can create a context within which teenagers can discuss their sexual concerns and avoid or alleviate any associated shame or confusion. A previsit questionnaire (Table 5) provides an efficient mechanism for adolescents to indicate the topics about which they would appreciate discussion. An especially urgent need is that all teenagers have a thorough understanding of HIV/AIDS and its prevention. “Safer sex” practices, including how to obtain and use condoms, should be discussed with and taught to all adolescents regardless of their current sexual behavior or identified sexual orientation. Counseling should emphasize education about transmission and prevention of HIV and stress the wisdom of limiting the number of sexual partners, avoiding the exchange of body fluids, and the regular use of condoms during all forms of sexual intercourse.

Adolescents should be assured that monitoring of sexual development is an important and routine part of all adolescents’ health supervision and reminded that the information they provide will remain confidential. Using gender-neutral language, a nonjudgmental, accepting manner, and some initiative on the part of the clinician can help patients to discuss these issues. It is very important that clinicians become comfortable with a manner of asking questions about sexuality that does not assume heterosexuality. Asking, “Are you involved in a relationship with a particular boy or girl?”, provides a wider range of opportunities for response than “Do you have a girlfriend?” (Table 6). Whatever teenagers’ responses may be to these questions, the act of asking them in itself is an important invitation to raise questions regarding their own or someone else’s sexual behavior and sexual orientation. It is important to remember that sexual behaviors do not necessarily reflect sexual orientation. Many teenagers explore both homosexual and heterosexual relationships and activities. Whatever their sexual orientation may turn out to be, they may be at risk for pregnancy and other risks of adolescent sexuality. Medical management generally should be guided by the adolescent’s sexual behaviors, not his/her sexual orientation. Homosexually active young men should be tested for all classical sexually transmitted diseases, such as syphilis and oral, anal, or urethral gonorrhea at intervals suggested by their sexual history. All sexually active young people should be immunized against hepatitis B, regardless of the sex of their partners. Lesbian adolescents, if neither they nor their sexual partners have been heterosexually active, are unlikely to develop sexually transmitted diseases. However, because many adolescents are actually sexually active with both men and women, discussions about sexually transmitted diseases and contraceptive counseling may be appropriate. Each adolescent’s particular risks that result from his/her pattern of sexual behavior will suggest indications for further screening and education.59,147 The revelation of an adolescent’s homosexuality may precipitate intense family discord. In some families, “coming out” may lead to physical and/or emotional abuse or even expulsion from the home. Adolescents’ worries about their parents’ possible responses must be taken seriously. Health professionals are in a good position to help adolescents get advice about how to disclose their homosexuality and

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TABLE 5. Teenagers’ concerns

Teenagers usually have many things on their minds. In this office we hope to be able to help you cope with anything you are worried about. Remember, anything we talk about will be private and will not be disclosed to your parents, teachers, or anyone else without your permission (unless it involves your safety or someone else’s safety). Please indicate which of the following topics you would like to discuss: your skin your weight or appetite your parents alcohol use smoking sexual activity using drugs birth control sexual orientation

your friends your school or teachers your brothers or sisters driving aches or pains violence feeling sad or worried anything else

TABLE 6. Asking gender-neutral questions

It is helpful to reassure all adolescents that questions about sexuality are a routine part of the health supervision visit. Questions such as these can be included in a written health history form or be part of an office interview. Adolescents should be assured that these questions are asked of all adolescents and that their responses are confidential. Examples of appropriate questions include: Do you have a boyfriend or a girlfriend? Some of my patients your age date—some boys, some girls, some both. Are you interested in dating? Have you ever dated or gone out with someone? Have you ever been attracted to any boys or girls? Are you especially attracted to any boys or girls? There are many ways of being sexual with another person: petting, kissing, hugging, as well as having sexual intercourse. Have you had any kinds of sexual experiences with boys or girls or both?  Are you currently involved in a steady relationship with a boy or a girl?  How do you protect yourself and your partner against sexually transmitted diseases and pregnancy?  Do you have any concerns about your sexual feelings or the sexual things you have been doing?  Have you discussed these concerns with your parents or any other adults? Any of your friends?  Do you consider yourself to be gay/lesbian, bisexual, or heterosexual (straight)?      

to serve as a support during and after the process. They may be able also to assist parents in their early attempts to cope with—and their eventual acceptance of—this information. Some parents may require professional help to deal with their confusion and possible feelings of anger, guilt, and loss. Referrals and consultations should be obtained carefully from medical specialists and mental health practitioners who are known to be nonjudgmental and accepting regarding homosexuality. Adolescents and their parents should be consulted regarding whether they want the clinician to pass along information about the teenager’s sexual orientation. Many parents find the information that their son or daughter is gay or lesbian shocking, discomforting, and difficult. Typically, parents “go into the closet” when their children “come out.” They may be reluctant to share the new information even with their other children, their parents, and their siblings. Most parents’ initial reactions include fear for their son’s or daughter’s health and wellbeing, grief at the loss of the adult child they had anticipated, and guilt about their own imagined role in the genesis of their child’s sexual orientation. When one of their children discloses his/her homosexuality, most parents mourn the loss of an imagined and long-anticipated heterosexual life for their child, usually including a partner of the opposite sex and grandchildren. The recent possibilities and acceptance of parenthood for gay and lesbian couples may facilitate the adaptation of families to the news that their son is gay or their daughter a lesbian. It is important for teenagers to recognize that their siblings, parents, and other family members may require time, information, and support to adapt to their

news. Referral to a local chapter of the national group, Parents and Friends of Lesbians and Gays (PFLAG), will provide support and access to extensive informational materials. Several books may be helpful as well to family members (see resource section). Children with One or Two Gay or Lesbian Parent(s). Health care for children whose parents are gay or lesbian differs little from health care that is appropriate for all children. Just as for all children, both parents should be invited to prepare for and to participate in health supervision visits. Parents and children should be invited to discuss their family’s structure and functioning, including any concerns they may have about it. Parents may need some encouragement and/or advice regarding how to help their child(ren) recognize, discuss, and cope with stigmatization or embarrassment that arise as a result of their parent(s)’ sexual orientation or their family constellation. Parents could be encouraged to build social relationships with other families in which the parents are gay or lesbian; it is helpful for children of all ages to know others in similar circumstances. Information about helpful reading materials as well as about national and local groups of families in which one or both parents is/are gay or lesbian is provided in the resource section. In the course of health supervision parents may ask for assistance in initiating discussions about the child’s original family or about her/his conception. If children are preoccupied or worried about the absent parent or donor, or if the relationship between divorced parents is strained, a short series of meetings with a family therapist may be helpful in ensuring open communication among family members and support for the

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child(ren). Adolescents may find their parents’ sexual orientation awkward; a family discussion may be helpful to make the home environment comfortable for teenagers and their friends.

their sexual orientation.150 Even videotaped accounts of personal and professional experiences of gay and lesbian adolescents and adults have been shown to increase both empathy and knowledge.

Medical Education Homosexuality has largely been ignored in the context of medical education. The concerns faced by gay and lesbian patients, students, physicians, and nurses have been rendered invisible by the fear that disclosure would jeopardize respect, medical care, or job status and security.148,149 Gay and nongay physicians and nurses associated with medical centers can be effective advocates and agents of change toward changing the pervasive stigma that surrounds homosexuality. Few medical schools currently have in place an appropriate system of support/advising for gay and lesbian medical students, nurses, faculty, or staff, and the content of medical school and residency curricula is scanty with regard to issues that focus on gay and lesbian concerns.59 At least five objectives need implementation in most medical and nursing schools: 1. Education: increased and broadened teaching regarding gay and lesbian issues, including the effects of stigmatization, in all departments; 2. Support: development of a system of explicit support within the medical center for nonheterosexual students, nurses, residents, and faculty members; 3. Visibility: institution of a “Gay and Lesbian Issues Subcommittee” as part of the Medical Center’s Affirmative Action Committee; 4. Clinical programs: improved access and welcome to nonheterosexual patients and their families in all clinical programs; 5. Research: development of investigative programs that address issues of particular concern to nonheterosexual youth and families. Interventions in selected medical schools already have yielded important changes in attitudes. Presentations by lesbian and gay adolescents and their parents, by lesbian and gay physicians, and by gay and lesbian parents and their children are particularly suited to child health care contexts. Addition of a two-hour lecture/discussion about gay and lesbian youth to a pediatric clerkship resulted in a documented decrease in homophobic attitudes and in increased confidence about appropriate care for adolescents questioning

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Summary Physicians, nurses, and other health care professionals can exert a powerful influence in support of gay and lesbian parents and their children, and of both gay and nongay adolescents and parents of teenagers in their community. We can do this by avoiding and challenging assumptions of heterosexuality in the process of clinical care for children of all ages; by helping children and their families to understand the wide range of normal variation in sexual orientation; by helping schools and community organizations in their efforts to provide information and support to all children and families whatever their particular constellation. Within our own professional organizations we can work against homonegative attitudes that reinforce discrimination and the personal and professional limitations caused by stigma. Expansion of medical education and research regarding issues central to gay and lesbian individuals and their families requires the creation of a context of support, visibility, and concern within medical centers and schools of medicine, nursing, and allied health professions.

Resources for Gay and Lesbian Patients and Their Families Organizations Adolescents and Their Parents ● The National Coalition for Gay, Lesbian, Bisexual, and Transgender Youth 369 Third Street, Suite B-362 San Rafael, CA 94901-3581 E-mail: [email protected] WEB: www.outproud.org Provides resources and referrals for GLBT and questioning youth. ● PFLAG (National Federation of Parents, Families, and Friends of Lesbian and Gays) 1726 M Street, Suite 400 Washington, DC, NW, 20036 (202) 467-8180; FAX: (202) 467-8194 E-mail: [email protected] WEB: www.Pflag.org A national organization devoted to the support, education, and advocacy regarding all issues of concern to gay men and lesbians and their families. Helpful publications. Check website

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for local chapters all over the world. Website and many publications in Spanish as well as in English. ● Lambda Youth Network P.O. Box 7911 Culver City, CA 90233 (310) 216-1312 E-mail: [email protected] Referrals to pen pal programs, newsletter, websites, hotlines, and other resources for youth ages 12 to 23. ● National Gay and Lesbian Task Force 1734 14th Street NW Washington, DC 20009-4309 (202) 332-6483 ● American Friends Service Committee, Bridges Project 1501 Cherry Street Philadelphia, PA 19102-1429 (215) 241-7133 E-mail: [email protected] ● National Youth Advocacy Coalition 1711 Connecticut Avenue, NW, Suite 206 Washington, DC 20009 (202) 319-7596; FAX: (202) 319-7365 E-mail: [email protected] Referral information for youth-serving agencies, services, and support groups.

Particular Focus on School Issues ● GLSEN: Gay, Lesbian, and Straight Education Network 121 West 27th Street, Suite 804 New York, NY 10001 WEB: www.glsen.org Advocacy and information resources for all school-related issues. Extensive and helpful website including “bookstore.” Excellent newsletter. ● GSA Network 160 14th Street San Francisco, CA 94103 (415) 552-4229 E-mail: [email protected] WEB: www.gsanetwork.org Guidance on starting and maintaining gay–straight alliances or diversity clubs in schools; online materials and fact sheets. ● Teaching Tolerance 400 Washington Avenue Montgomery, AL 36104 (334) 264-0286; FAX: (334) 264-3121 Curriculum materials, ideas, and strategies for teaching about diversity.

Gay and Lesbian Parents and Their Children ● Children of Lesbian and Gays Everywhere (COLAGE) 3543 18th St. #1 San Francisco, CA 94110 (415) 861-5437 E-mail: [email protected] WEB: www.COLAGE.org Many local chapters with family activities and support. ● Family Pride Coalition

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P.O. Box 65327 Washington, DC 20035-5327 (202) 331-5015 E-mail: [email protected] WEB: www.familypride.org Many local chapters all over the world that provide support, education, and advocacy for gay and lesbian parents.

Legal Concerns ● Gay and Lesbian Advocate and Defenders 294 Washington Street, Suite 740 Boston, MA 02108-4608 (617) 426-1350 WEB: www.glad.org ● Lambda Legal Defense and Education Fund 120 Wall Street, Suite 1500 New York, NY 10005-3904 CONTACT: David Buckel (212) 809-8585; FAX: (212) 809-0055 E-mail: [email protected] ● National Center for Lesbian Rights 870 Market Street, Suite 570 San Francisco, CA 94102 E-mail: [email protected] WEB: www.nclrights.org

Transgender Issues ● IFGE (International Foundation for Gender Education) P.O. Box 229 Waltham, MA 02254-0229 (781) 899-2212 E-mail: [email protected] WEB: www.ifge.org ● Harry Benjamin International Gender Dysphoria Association 1300 South 2nd Street, Suite 180 Minneapolis, MN 55454 (612) 625-1500 WEB: www.hbigda.org

Resources for Professionals ● Gay and Lesbian Medical Association (GLMA) 459 Fulton Street, Suite 102 San Francisco, CA 94102 (415) 255-4547; FAX: (415) 255-4784 E-mail: [email protected] WEB: www.glma.org ● Gay Lesbian and Straight Teachers Network (GLSTN) 112 West 26th Street, Suite 1100 New York, NY 10001 (212) 727-0135; FAX: (212) 727-0254 E-mail: [email protected] WEB: www.glstn.org/respect ● Society for Adolescent Medicine Gay and Lesbian Special Interest Group 19401 East 40 Highway, Suite 120 Independence, MO 04055 (816) 795-TEEN ● Lesbian Gay and Bisexual People in Medicine

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Committee of the American Medical Students Association 1902 Association Drive Reston, VA 20191 (703) 620-6600, ext. 458 E-mail: [email protected] WEB: www.amsa.org/sc/lgbpm.html ● Association of Gay and Lesbian Psychiatrists 4514 Chester Avenue Philadelphia, PA 19143 (215) 222-2800 E-mail: [email protected] ● American Psychological Association, Committee on Lesbian and Gay Concerns 750 First Street, NE Washington, DC 20002 (202) 226-6052

Pen Pals Services ● Alyson Publications, Letter Exchange Program 40 Plympton Street Boston, MA 02118 ● International Pen-Pal Program, Youth Outreach Los Angles Gay and Lesbian Community Services Center 1625 Shrader Street Los Angeles, CA 90028 (213) 992-7471 ● Lambda Youth Network P.O. Box 7911 Culver City, CA 90233 Lesbian and Gay Youth Network P.O. Box 20716 Indianapolis, IN 46220 (317) 541-8726

Additional Internet Sites

Nonfiction Books

● Gay and lesbian teen pen pals. http://www.chanton.com/ gayteens.html ● National resources for lesbian, gay, and bisexual youth. http://www.yale.edu/glb/youth.html ● Outright. http://outright.com/ ● Out Proud, National Coalition for Gay, Lesbian, and Bisexual Youth. http://www.cyberspaces.com/outproud ● LGBT youth forums, chat rooms, and brochures. www. youthresource.com ● A discussion group for GLB youth. www.youth.org/ssygld/ ● A listing of international groups advocating for GLB youth, listed by country. www.gaylesTeens.about.com/cs/ organizations ● Sexual Minority Youth and Family Services. www.ourtrue colors.org ● Youth Guardian Services. www.youth-guard.org/youth/ On-line peer-supervised support groups for lesbian, gay, bisexual, and transgender youth, and youth with a lesbian, gay, bisexual, or transgender family member. Three age groups: younger teens, older teens, college.

Essays, Advice for Heterosexual Parents of a Gay or Lesbian Adolescent

Hotlines ● GLBT Youth Peer Listening Hotline Fenway Community Health Center (617) 267-2535 (800) 399-PEER (7337) ● AIDS Foundation Hotline (English and Spanish) (800) FOR.AIDS ● Gay, Lesbian, and Bisexual Youth Hotline (800) 347-TEEN ● Gay and Youth Talk Line (415) 863-3636/(800) 246-PRIIDE ● LYRIC Youth Talkline and Infoline (800) 246-PRIDE ● National HIV/AIDS Hotline (800) 342-AIDS ● National Lesbian and Gay Crisis Line (800) 221-7044

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Bernstein R. Straight Parents, Gay Children: Keeping Families Together. Thunder’s Mouth Press; 1995. Baker J. Family Secrets: Gay Sons, A Mother’s Story. Harrington Park Press; 1998. Borhek MV. Coming Out to Parents: A Two-Way Survival Guide for Lesbian and Gay Men and Their Parents. Pilgrim Press; 1993. Borhek MV. My Son Eric. Pilgrim Press; 1984. Chandler K. Passages of Pride: Lesbian and Gay Youth Come of Age. Random Press; 1995. Cohen S, Cohen D. When Someone You Know Is Gay. Dell; 1989. Dew RF. The Family Heart: A Memoir of When Our Son Came Out. Ballantine; 1995. A very moving account. Eichberg R. Coming Out: An Act of Love. Dulton; 1990. Fairchild B, Hayward N. Now that You Know: What Every Parent Should Know About Homosexuality. Harcourt Brace Publishing; 1989. Griffin CW, Wirth AG, Wirth MJ. Beyond Acceptance: Parents of Lesbians and Gays Talk about Their Experience. St. Martin’s Press; 1990. McDougal B. My Child Is Gay: How Parents React When They Hear the News, 1998. Powers B, Ellis A. A Family and Friend’s Guide to Sexual Orientation: Bridging the Divide Between Gay and Straight. 1996. Rafkin L. Different Daughters: A Book by Mothers of Lesbians. Cleis Press; 1987. Savin-Williams RC. “And Then I Became Gay.” Young Men’s Stories. New York: Routledge; 1998. Savin-Williams RC. Mom, Dad I’m Gay: How Families Negotiate Coming Out. 2001.

Books for Adolescents and Their Parents Alyson S. Young, Gay and Proud. Alyson Press; 1991. Bass E. and Kaufman K. Free Your Mind. Harper Collins; 1996. Borhek MV. Coming Out to Parents: A Two-Way Survival Guide for Lesbian And Gay Men and Their Parents.

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Chandler K. Passages of Pride: Lesbian and Gay Youth Come of Age. Random House; 1995. Cohen S, Cohen D. When Someone You Know Is Gay. Dell; 1989. Day FA. Lesbian and Gay Voices: An Annotated Bibliography and Guide to Literature for Children and Young Adults. 2000. A superb collection of fiction and nonfiction books for all ages, accompanied by mini-reviews. Profiles of prominent writers of fiction with gay themes. Fricke A. Reflections of a Rock Lobster: A Story about Growing Up Gay. Alyson Publications; 1981. Harris RH. It’s Perfectly Normal: A Book about Changing Bodies, Growing Up, Sex and Sexual Health. Candlewick Press; 1994. Herdt G, Boxer A. Children of Horizons: How Gay and Lesbian Teens are Leading a New Way Out of the Closet. Beacon Press; 1993. Heron A. Two Teenagers in Twenty: Writings by Gay and Lesbian Youth. Alyson Publications; 1994. Hunt M. Gay: What Teenagers Should Know About Homosexuality and the AIDS Crisis. Farrar/Strauss/Giroux Publications; 1987. Jennings K. Becoming Visible: A Reader in Gay and Lesbian History for High School and College Students. Alyson Publications; 1994. Monette P. Becoming a Man: Half a Life Story. Harcourt Brace Jovanovich; 1992. A moving autobiography. Nycum B. The XY Survival Guide: Everything You Need to Know about Being Young and Gay. San Francisco: XY Publishing; 2000. Pollack R, Schwartz C. The Journey Out: A Guide For and About Lesbian, Gay, and Bisexual Teens. Penguin Books; 1995. Powers B, Ellis A. A Family and Friend’s Guide to Sexual Orientation: Bridging the Divide Between Gay and Straight. 1996. Savin-Williams RC. “And Then I Became Gay.” Young Men’s Stories. New York: Routledge; 1998. Sherrill J, Hardesty C. The Gay, Lesbian, and Bisexual Students’ Guide to Colleges, Universities, and Graduate Schools. NYU Press, 1994. Woog D. School’s Out: The Impact of Gay and Lesbian Issues on America’s Schools. Alyson Press, 1995.

Books for GLB Parents Arnup K. Lesbian Parenting. Gynergy Books, 1995. A collection of essays by and about lesbian parents. Benkov, L. Reinventing the Family: Lesbian and Gay Parents. Crown Trade Paperbacks; 1994. Historical review of legal and cultural evolution of gay and lesbian families. Excellent summary and analysis of issues and progress. Brill, S. The Queer Parents’ Primer: A Lesbian and Gay Families’ Guide to Navigating the Straight World. New Harbinger Publications; 2001. Clunis DM. The Lesbian Parenting Book; A Guide to Creating Families and Raising Children. Seal Feminist Publications; 1995. Drucker J. Families of Value: Gay and Lesbian Parents and Their Children Speak Out. Persens Press; 1998. Glazer DF, Drescher J. Gay and Lesbian Parenting. Haworth Press; 2001.

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Green J. The Velveteen Father. Ballantine; 1999. A poignant and heart-warming account of the journey to fatherhood. Howey N. Out of the Ordinary: Essay on Growing up with Gay, Lesbian and Transgender Parents. St. Martin’s Press; 2000. Martin A. The Lesbian and Gay Parenting Handbook: Creating and Raising Our Families. HarperCollins Press; 1993. A practical guide to many common dilemmas. O’Connor E, Johnson SM. For Lesbian Parents. Guilford Press; 2000. Rafkin L. Different Mothers: Sons and Daughters of Lesbians Talk about Their Lives. Cleis Press; 1990. Short essays by teenagers and adults. Rizzo C. All the Ways Home: Parenting and Children in the Lesbian and Gay Communities. New Victoria Publishers; 1995. A collection of short fiction.

Additional Recommended Nonfiction Books Boykin K. One More River to Cross: Black and Gay in America. 1996. Brown M, Rounsley CA. Understanding Transexualism—For Families, Friends, Coworkers, and Helping Professionals. JosseyBass Publishers; 1996. Casper V, Schultz SB. Gay Parents, Straight Schools: Building Communication and Trust. 1999. Coll CG, Surrey JL, Weingarten K. Mothering Against the Odds: Diverse Voices of Contemporary Mothers. Guilford Press, 1998. Essays on mothering, including lesbian, single, and adoptive mothers. Ettner R. Gender Loving Care. WW Norton Co.; 1999. Harbeck K, editor. Coming Out of the Classroom Closet. Haworth Press, 1992. Hutchings L, Kaahumanu L. Bi Any Other Name: Bisexual People Speak Out. 1991. Israel GE, Tarver DE. Transgender Care: Recommended Guidelines, Practical Information, and Personal Accounts. Temple University Press; 1997. Lipkin A. Understanding Homosexuality, Changing Schools. 2001. Lobenstine G. Children, Lesbians, and Men: Men as Known and Anonymous Sperm Donors. Alternative Families Project, 442 Warren Wright Road, Belchertown, MA 01007, 1994. Perrin EC. Sexual Orientation in Child and Adolescent Health Care. New York: Kluwer-Plenum, 2002. Rothblum ED, Bond LA. Preventing Heterosexism and Homophobia. Sage; 1996. Ryan C, Futterman D. Lesbian and Gay Youth: Care and Counseling. New York: Columbia University Press, 1998. Sears J, Williams W. Overcoming Heterosexism and Homophobia. 1997. Vercollone CF, Moss H, Moss R. Helping the Stork: The Choices and Challenges of Donor Insemination. MacMillan, New York; 1997.

Fiction Books Relating to Gay/Lesbian Issues Ages 2 to 5 Bosche S. Jenny Lives with Eric and Martin. 1983. Daily life and a birthday party in a family with two dads. Combs B. 123 A Family Counting Book.

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Combs B. ABC A Family Alphabet Book. Wonderful alphabet and counting books for very young children that incorporate lesbian and gay families naturally into the story. Edmonds BL. Mama Eat Ant, Yuck! About a one-year-old girl, her two moms, and her sister. Johnson-Calvo S. A Beach Party with Alexis. Alyson, 1993. A light-hearted coloring book that includes friends and family of many colors and sexual orientations. Kennedy J, et al. Lucy goes to the Country. 1998. A humorous story about a cat who lives with two gay men, various escapades. Newman L. Belinda’s Bouquet. A girl wonders if she is too fat but her friend’s two moms tell her that everyone is fine as they are. Newman L. Heather Has Two Mommies. 1999. One of the first stories for young children about growing up with lesbian moms. Has stirred up a lot of controversy. Skutch R, Nienhaus L. Who’s In a Family? Tricycle Press; 1995. Charming look at various family forms for children from 3 up. Valentine J. One Dad Two Dads Brown Dad Blue Dads. Alyson; 1994. Charming Seuss-like rhyming book that incidentally includes two dads. Valentine J. The Daddy Machine. Alyson Press; 1992. A whimsical book describing the machine built by two children with lesbian moms who wonder what it would be like to have a dad. Valentine J. Two Moms, the Zark, and Me. 1993. A little boy with two moms gets lost, until a magical creature named a Zark helps him out. Wickens E. Anna Day and the O-Ring. Photographs of a little boy, his two moms, and his dog in a very sweet story. Willhoite M. Daddy’s Roommate. Alyson Press; 1990. A sweet story about a little boy talking about his dad and his dad’s partner. Willhoite M. Daddy’s Wedding. 1996. A sequel to the book above, in which the boy is the best man at his dad’s commitment ceremony.

Heron A, Maran M. How Would You Feel if Your Dad Was Gay? Alyson Press; 1991. Michael and Jasmine have two gay dads and Noah has a lesbian mom in this story in with all three have to deal with homophobia at their school. Hoffman E. Best Best Colors/Los Mejores Colores. Redleaf Press; 1999. In English and Spanish, the little boy has trouble deciding which is his favorite color. His two moms help him learn that he doesn’t have to choose just one. Jenness A. Families: A Celebration of Diversity, Commitment and Love. 1993. Seventeen young people describe many different kinds of families. Illustrated by wonderful photographs. Jordon MK. Losing Uncle Tim. Albert Whitman & Co.; 1989. A beloved uncle dies of AIDS. Newman L. Saturday Is Pattyday. 1993. A young boy worries about how he will maintain his relationship with his two moms when they get divorced. They reassure him that they will always be his family. Nones E. Caleb’s Friend. Farrar, Straus & Giroux; 1993. The tender and caring bond between two boys is celebrated with exquisite paintings and lyrical text. Tax, M. Families. Feminist Press; 1996. Six-year-old girl introduces her multicultural friends and their families, which take many forms—adoptive, divorced, stepfamilies, and same-sex families. Valentine J. The Duke Who Outlawed Jelly Beans. Alyson Publication; 1991. A collection of fairy tales in which the children all have gay or lesbian parents.

Early Adolescents (11-14)

Abramchik L. Is Your Family Like Mine? 1996. A little girl with lesbian moms explores differences among families. Alden J. A Boy’s Best Friend. 1993. A little boy gets a birthday surprise from his two moms. Arnold J. Amy Asks a Questionѧ: Grandma—What’s a Lesbian? Probably the first book about lesbian grandparents. Carrera SJ. The Families Book: True Stories About Real Kids and the People They Live With and Love. Cohen S. All Families are Different. Prometheus Books; 2000. Edmonds BL. When Grown-Ups Fall in Love. A sweet poem that is inclusive of same sex parents. Elwin R, Paulse M. Asha’s Mums. Women’s Press; 1990. A first-grade girl has to educate her teacher and her classmates about her lesbian moms. Gordon S. All Families are Different. 2000. Affirmation of a variety of family structures, including adoptive and foster families, multiracial families, and same sex parents.

Barger G. What Happened to Mr. Forster? Clarion Books, 1981. Set in the Midwest in 1958, the story is of a beloved teacher who is fired for being gay. Brett C. S.P. Likes A.D. The Women’s Press; 1989. A teenage girl who is in love with a female classmate. Durbin P, Feldman S. And Featuring Bailey Wellcom as the Biscuit. A young girl discovers that her mother is a lesbian and in a relationship with another woman. Garden N. Holly’s Secret. 2000. A girl moves to a new town and tries to hide the fact that she has two moms— getting herself into a lot of trouble in the process. Greenberg KE. Zach’s Story: Growing Up with Same-Sex Parents. Lerner Publication; 1996. A story told by 11-year-old Zach who has two lesbian moms. Hesse K. A Time of Angels. The girl who narrates the story about the flu epidemic in World War I is being raised by two women who are a couple. Nelson T. Earthshine: A Novel. Orchard; 1994. A 12-year-old girl lives happily with her actor father who is gay and his partner, but must learn how to cope with loss when she learns that he has AIDS. Salat C. Living in Secret. Bantam Skylark, 1993. Lesbian mother kidnaps her 11-year-old daughter after custody is awarded to the father, so that she can continue to live with her

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Ages 6 to 10

mother and her partner. Addresses racism, legal rights of children, and custody.

Adolescents Bauer MD. Am I Blue: Coming Out from the Silence. Harper Collins; 1994. Short stories dealing with homosexuality; the title story is especially delightful. Bechard M. If It Doesn’t Kill You, Viking; 1999. Story of a high school freshman whose father comes out as gay. Includes a sensitive explanation to his son of his recently recognized homosexuality. Block F. Weetzie Bat. Harper Collins; 1989. Block F. Baby Be-Bop, Demco; 1997. Block F. Witch Baby, Harper Collins; 1992. Three delightfully absorbing books that use imagination and fantasy to address issues about gayness, fitting in, and diversity. Brown T. Entries from a Hot Pink Notebook. Pocket Books; 1995. A teenage boy comes to understand his homosexuality and the homophobic high school he attends as he records his thoughts in a pink notebook. Cart M. My Father’s Scar. Simon and Schuster; 1996. During his first year in college the protagonist reflects on his dysfunctional family and his sadness growing up. Garden N. Annie on My Mind. Farrar, Strauss & Giroux; 1982. Delightful love story about two teenage lesbians. Garden N. Good Moon Rising. Farrar, Straus and Giroux; 1996. Teenage lesbian actress helps to direct a play in which she had wanted to perform—and falls in love with the girl who is playing the part she had wanted. Guy R. Ruby. Viking; 1976. Black teenage girl falls in love with a female classmate. Kerr ME. Deliver Us From Evie. Harper Collins; 1994. A 16-year-old farm boy learns that his sister is a lesbian and in love with the daughter of a prominent town leader. Kerr ME. Night Kites. Harper and Row; 1986. A heterosexual teen finds out that his older brother is gay and has AIDS. Koertge R. The Arizona Kid. Little Brown; 1988. A heterosexual teenage boy visits his gay uncle, learns about training horses, and has a short romance with an exercise girl, gets a glimpse of gay life in the early days of AIDS. Mosca F. All American Boys. Alyson Publications; 1983. A coming out and love story between two teenage boys. Murrow L. Ketchum. Twelve Days in August, 1993. Deals with homophobia from the perspective of a heterosexual adolescent who struggles with loyalty in the face of homophobia. Sinclair A. Coffee Will Make You Black. 1994. Story of a young adolescent in a working class urban family struggling with issues of racial and sexual identity. Singer B. Growing Up Gay/Growing Up Lesbian: A Literary Anthology. New York Press; 1994. An anthology of essays and stories mostly about the coming out process. Walker K. Peter. Houghton Mifflin; 1993. Fifteen-year-old boy’s struggles with his emerging sexual identity.

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Winterson J. Oranges Are Not the Only Fruit. Atlantic Monthly Press; 1997. Describes the development of a lesbian teenager in the context of a fundamentalist household; funny, delightful, and wise. Wittlinger E. Hard Love. Simon & Schuster; 1999. A teenager, John, who isn’t sure if he is gay, straight, or “neutral”, becomes friends with zine creator Marisol, who is a lesbian—and falls in love with her. Woodson J. The House You Pass on the Way. Delacorte; 1997. Charming story of a 14-year-old girl who struggles with her emerging confusion about her sexual orientation.

Pamphlets ● Available from PFLAG, Washington DC: Our Daughters and Sons: Questions and Answers for Parents of Gay, Lesbian and Bisexual People. 1995. Be Yourself: Questions and Answers for Gay, Lesbian, and Bisexual Youth. 1994. About Our Children Can We Understand? Teens Tell Their Own Stories Why is My Child Gay? ● Available from the American Psychological Association: Answers to our questions about sexual orientation and homosexuality.

Videos Straight From the Heart: Stories of Parents’ Journeys to a New Understanding Of Their Gay and Lesbian Children. Dee Mosbacher. 1994. Motivational Media, 8430 Santa Monica Blvd., Los Angles, CA 90069 (800) 848-2707. Parents talk about their lesbian and gay children. 24 minutes. Queer Son: Family Journeys to Understanding and Love. Vickie Seitchik. 1994. 19 Jackson St., Cape May, NJ 08204 (212) 929-4199. A compelling personal documentary with interviews of families from diverse ethnic, racial, and social backgrounds. 48 minutes. Both of My Moms’ Names are Judy. Lesbian and Gay Parents Association, 1994. Family Pride, P.O. Box 43,206, Montclair, NJ 07043 (202) 583-8029. A racially diverse group of 6- to 10-year-old children talking about their love for their gay and lesbian parents. 10 minutes. Gay Youth: An Educational Video for the Nineties. Pam Walton. 1992. Wolfe Video, Box 64, New Almaden, CA 95042 (408) 268-6782. A documentary highlighting two teens’ stories— one with a positive outcome, one a suicide; won an award. For adolescent and adult audiences. Comes with a study guide. 40 minutes. Just for Fun. Gordon Seaman. 1994. Direct Cinema Limited, P.O. Box 10003, Santa Monica, CA 90410-1003, 1-800-525-0000. Stimulating drama examining homophobia and gay-bashing. 24 minutes. Sticks, Stones, and Stereotypes. Cindy Marshall, Equity Institute. 1988. ETR Associates, P.O. Box 1830, Santa Cruz, CA 95061-1830, 1-800-321-4407. Discussion of homophobia, name-calling; for high school and college viewing. Comes with a study guide in English and Spanish. 26 minutes.

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References

Too Close . . . for Comfort. Wild Ginger Productions. 1990. ETR Associates. P.O. Box 1830, Santa Cruz, CA 95061-1830, 1-800321-4407. Deals with fear of AIDS, homophobia, and discrimination. Appropriate for high school. 27 minutes. From a Secret Place. Karin Heller and Bill Domonkos. Fanlight; 1994. Productions, 47 Halifax St., Boston, MA 02130 (617) 524-0980. Interviews by a therapist with six gay and lesbian teens and three parents. 40 minutes. I Just Want to Say. GLSEN; 1998. Addresses antigay violence and stigma in high schools. 14 minutes. I Know Who I Am . . . Do You? Louis Pereg. Skyline Community; 1998. Black and Latino gay youth who are successful despite discrimination and other struggles. 10 minutes. It’s Elementary: Talking About Gay Issues in School. Women’s Educational Media. 2180 Bryant St., Suite 203, San Francisco, CA 94110 (415) 641-4616. Explores the teaching and understanding of diversity and tolerance in elementary school classrooms. 78 minutes. Our House. Sugar Pictures; 1999. Documentary featuring the children of five diverse families facing varied reactions to their parents’ sexual orientation. 56 minutes. That’s a Family! Women’s Educational Media; 2000. Children discuss various family forms: adoption, mixed-race families, same-sex parents, divorce, and single parent families. Comes with a curriculum guide for use in elementary classrooms. 30 minutes. Trevor. Peggy Rajski; 1998. Follows a 13-year-old as he reads from his diary. When his classmates learn that he is gay, they ostracize him and he attempts suicide. The supportiveness of a hospital volunteer inspires him. The film sparked a project to promote tolerance and prevent suicide. 23 minutes. DeGrassi Junior High: He Ain’t Heavy. WGBH, Box 222-TV, South Easton, MA 02375. A 14-year-old boy learns that his older brother is gay. DeGrassi Junior High: Rumor Has It. WGBH, Box 222-TV, South Easton, MA 02375. A young girl struggles to understand her own sexuality when she learns that a favorite teacher is lesbian. Homo Teens. Available from Joan Jubila, P.O. Box 1966, New York, NY 10013. Five very different teens speak for themselves. Sexual Orientation. Wisconsin Public Television’s Cooperative Education Service Agency, 800-622-7445. Out: Stories of Lesbian and Gay Youth. 1993. National Film Board of Canada, 1251 Ave. of the Americas, 16th Floor, New York, NY 10020. (212) 596-1770. A sensitive look at the lives of a cross-section of gay and lesbian teens and their families. Boys Don’t Cry. Moving commercial film exploring the pain of homophobia and gay-bashing.

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