At least 5% to 10% of all adolescents may be gay, lesbian,
or bisexual
[1-3]. Present from early childhood, one's sexual identity has a strong
biogenetic influence [4,5]. Gay youths are disproportionately affected
by preventable leading causes of morbidity and mortality in all adolescents.
The impetus behind these staggering statistics is the social isolation
and heterosexist bias permeating our society; it is not because of
an innate predisposition to self-destructive behaviors or thought
processes [6,7].
Sexual Identity Formation
The identity of one's sexual being, regardless of orientation, evolves
over time [8]. However, the acceptance of this identity depends on
multiple internal and external factors. Different models have been
proposed that outline the developmental tasks involved in the sexual
identification of gay persons. These models include the following
stages: (1) sensitization and awareness; (2) identity confusion and
acknowledgment; (3) identity assumption and acceptance; and (4) commitment
and affirmations [8,9].
For gay youths, a sense of being different from peers of
the same
gender commonly begins in early to middle childhood [8]. The majority
of feelings of differentness at this age are attributed to socially
determined "gender-inappropriate" behaviors or interests [8]. For
example, a boy may be more interested in "playing house" than in playing
sports on a regular basis. In this first stage of sexual identity
awareness, the identification with being gay is rare despite same-
gender affectional and sexual feelings [8,9]. In one study of gay
male adolescents, the average age of initially sensing their difference
from other boys was 5 to 7 years old [8].
With puberty, these feelings of differentness commonly
begin to
be equated with their being gay. The initial realization that one
is homosexual or bisexual commonly creates inner conflict, anxiety,
and confusion [8]. Social heterosexism, the assumption that all
healthy
persons are heterosexual, is the predominant message presented to
children in this society. This constant message of heterosexism contributes
to the confused gay youth's social isolation, denial, and self-destruction
[8,9]. On average, gay males consider themselves as "probably" homosexual
at 17 years old (lesbians at 18 years old) [10,11]. In addition, gay
males tend to report having same-gender attractions and sexual experiences
at an earlier age on average than do lesbians [8].
The factor most commonly cited as leading to acceptance
or "identity
assumption" is recognition of the larger gay community, where the
similarities of the struggling gay person and others in this community
are recognized [8,9]. In fact, gay youths from more homophobic societies
(i.e., societies less tolerant of homosexuality) tend to internalize
to a greater degree socially held negativities about gay people. These
youth are significantly more likely to view themselves and homosexuality
negatively. They tend to believe the myths and stereotypes of the
society relating to gay people [12].
With acceptance of one's being gay comes the expression
of being
gay. This process, "coming out," includes self-definition as gay,
gradual acceptance, and association with others within the gay community
[8]. Internal and external commitment contributes to a complete identity
and satisfaction with being gay. Externally this may be expressed
in terms of being openly gay to heterosexual persons, and in having
an intimate same-gender relationship. An ability to maintain a positive
self-identity and to respond in self-preserving ways in spite of pronounced
social hatred towards gay persons is also achieved [8,9].
Despite the self-empowerment that "coming out" entails,
gay youths
must be the ones to initiate the process of disclosure of their sexual
identity to others. These youths are at great risk for being kicked
out of their homes, being victims of violence related to their sexual
identity, and of being verbally, emotionally, and financially victimized
by peers and family. The youth generally knows best when it is safe
to "come out," and should not be pushed to do so until he or she is
ready.
Suicide
Suicide is the leading cause of death of gay youths. At least 30%
of all adolescent suicides in the United States are estimated as being
committed by gay youths [13]. This is staggering in light of the fact
that suicide is the third leading cause of death of all adolescents
in the United States [14]. There exists a two-to-three times greater
incidence of suicide attempts by gay youths than by heterosexual youths
[13]. In fact, rates as high as 42% of gay youths report a history
of suicide attempts [15]. Gay and bisexual male youths who report
a history of suicide attempt(s) tend to recognize homosexual attractions
at a significantly younger age. They tend to inform others of their
homosexual feelings at a younger age, and have greater gender nonconformity
when compared to bisexual and gay male youths who do not report a
history of suicide attempts [16]. Gay youths who report a history
of a suicide attempt score significantly lower on scales of family
support, self-perception and self-esteem, and extrafamilial social
support when compared to similar youths without a reported history
of suicidal ideation or attempts [17]. Gay youths with only a history
of suicidal ideation score significantly lower than those who have
attempted suicide and significantly higher than those who have neither
attempted suicide nor reported suicidal ideation. [17]. In a survey
of psychiatrists working with adolescents, 41% reported having worked
with homosexual youths; these psychiatrists expressed the feeling
that the likelihood of suicide among homosexual youths was greater
than among other youths [18]. The psychiatrists attributed the higher
suicide rate to a greater sense of isolation and dependency needs
when compared to heterosexual youths because of feelings of nonacceptance
and of being different.
HIV Infection
Since 1989, Human Immunodeficiency Virus (HIV) disease
has been
the sixth leading cause of death of all persons 15 to 24 years old
in the United States [19]. Approximately one-quarter of persons in
the United States with AIDS are in their 20s or early 30s. This group
was most likely infected initially as adolescents [20]. Because of
the route of HIV transmission, men who have sex with men and women
who have sex with men are at the highest risk of becoming HIV infected
through unprotected intercourse.
In New York City, Los Angeles, and San Francisco, the number
of
adult gay men who are HIV infected is as high as 140,000 [21]. The
adult gay male population becomes a direct link to the adolescent
gay male population when gay youths explore their sexuality in the
community of adult gay men. Avenues of exploration with others in
local communities are usually nonexistent, and the gay male adolescent
may feel safer in a community where he is not known. Nine percent
of 18- to 24-year-old gay males in a New York City (NYC) study (n=87)
were found to be HIV-positive, along with a 2% annual increase of
HIV infection among those who initially tested negative (22). Of these
NYC youth, 40% of all black youth (n=10) and 30% of all Latino youth
(n=10) tested HIV-positive. In a study done in San Francisco/Berkeley,
9.4% of all 17- to 22-year-old gay and bisexual males (n=425)
were
found to be HIV-positive with 21.2% of all black youths (n=52) testing
positive [23]. A 7% seroprevalence rate among adolescent gay males
was found in. Pittsburgh in populations studied in 1984 (n=121), and
in 1992 (n=61) [24]. These figures are staggering in light of the
fact that the route of transmission has been known since the mid-1980s,
and educational efforts geared toward adult gay men have been
found
to have a stabilizing effect on rates of new infection [25,26]. Studies
continue to document that, even after educational efforts, younger
gay men continue to engage in high-risk sexual behaviors [27-30].
Several factors have been related to HIV infection in young
gay
and bisexual males. One-third of all participants surveyed reported
unprotected anal intercourse in the previous 6 to 12 months [22-24].
Unprotected anal intercourse has correlated significantly with using
nitrites, a history of "forced sex" or sexual abuse, and perceived
decreased peer support for safer-sex practices [23]. A history of
other (non-HIV) sexually transmitted diseases, multiple sexual partners,
crack cocaine use, and homelessness have also been correlated
with
HIV infection among gay and bisexual male adolescents and young adults
[23].
Lesbian and bisexual female adolescents are also at risk
for HIV
infection, and need to be included in HIV risk-reduction measures
and educational efforts. Lesbian youths may "experiment" with heterosexual
behaviors and relationships just as heterosexual adolescents may experiment
with homosexual behaviors. A lesbian adolescent may try to "prove"
to others that she is heterosexual by having sex with males or
by
becoming pregnant, thus putting herself in the direct path of HIV
and other sexually transmitted infections.
Violence
Violence is a leading cause of morbidity and mortality of all adolescents
in the United States. Homicide is the second leading cause of death
of all persons 15 to 24 years old [14], and the leading cause of death
among black and Latino adolescents. However, within the population
of lesbian, gay, and bisexual youth, violence takes on added dimensions.
In one study of self-identifying gay and lesbian youth in NYC, 40%
reported being victims of violence. Forty-six percent of these youth
reported that the violence was anti-gay in origin [31]. Of this 46%,
61% reported that the anti-gay violence came from family members
[31]. In addition to intrafamilial abuse, gay youths also face a disproportional
amount of violence and abuse in school. Fifty-five percent of a sample
of 15- to 19-year-old bisexual and gay males reported being verbally
abused from classmates on a regular basis. Fifty percent of these
youths reported that the assaults occurred on school grounds [32].
In another study of gay and lesbian youths (15 to 21 years old). anti-
gay abuse was documented as such: 80% reported a history of verbal
abuse, 44% reported being physically threatened, 30% reported being
stalked, 29% of females and 22% of males reported being physically
injured by another student, 10% reported being assaulted with a weapon,
and 7% reported abuse by a teacher [33].
Other Psychosocial Issues
In response to the social stigma and hatred focused toward gay people
in this society, gay youths commonly develop low self-esteem and become
socially isolated [3]. Depression and anxiety disorders have therefore
been found to be common within this population [34]. In one study,
41% of a sample of gay and bisexual males ages 15 to 19 years
old
reported losing at least one friend because of being gay or bisexual
[32]. Studies indicate that gay youths have a significantly greater
incidence of substance use when compared to their heterosexual peers
[35,36]. In one study, 68% of gay adolescents reported alcohol use
and 44% reported other substance use [37].
Gay youths account for 25% to 40% of the homeless youths
in the
United States, with a four times greater incidence of being "kicked
out" or "forced out" of their homes [13,38]. Once out on the streets,
many of these youths turn to prostitution or "survival-sex" as
a
means of support and self-identity. As many as 75% of male prostitute
youths self-identify as gay or bisexual [39]. In one study of lesbian
youth, 25% reported having engaged in survival-sex [40]. Despite the
increased risks of exploitation and abuse these youths experience
as sex workers, they commonly express a greater sense of worthiness,
acceptance, and being needed than they received from their nuclear
families [39]. These "street" youths have higher rates of substance
use, sexually transmitted diseases, and HIV infection compared to
youths not living on the streets [41].
Social Barriers
Multiple systems within this society perpetuate the isolation and
hatred of gay youths. The family system disproportionately abuses
and "disowns" its gay members. Gay youths who end up in child protective
services meet many of the same abuses. Staff commonly accept anti-
gay verbal and physical abuse in group home settings, and do not tolerate
same-gender relationships while approving opposite-gender relationships
within these settings [42].
A contributing factor to these systems' "acceptable" anti-gay
abuse
is the nonacceptance of homosexuality within a majority of organized
religious institutes. Because many child placement services are operated
by religious organizations which do not support self-affirming care
of openly gay and lesbian youths, many such adolescents end up living
on the streets where they report finding more support [42]. One study
of gay male youths found that 24% reported inner conflict and self-
esteem loss because of religious condemnation of their homosexuality
[32].
Within the educational system, similar barriers exist for
gay youths-
-primarily a lack of support and sensitivity. In a study of 15- to
19-year-old self-identifying gay or bisexual males, 69% reported school-
related problems secondary to anti-gay verbal and physical abuse.
Twenty-eight percent reported having dropped out of high school as
a result of these abuses [32]. The health care system presents yet
more barriers to gay youths struggling with both the externalized
and internalized hate and fear of homosexual and bisexual persons.
These barriers lead to avoidance of needed support and health care
by struggling gay youths. For example, 70% of gay and bisexual male
youths found to be HIV-positive in a San Francisco seroprevalence
study were unaware of their positive status. Of those who knew their
status, only 22.5% were receiving HIV-related health care [23]. In
a survey of nurses working with adolescents,49% reported having insufficient
skills or knowledge base in dealing with issues related to homosexuality
[43]. In a study of adult lesbians and gay men, 27% reported having
gone to a primary health care provider in the past who they perceived
to be hostile or prejudiced toward gay and lesbian persons. Twenty-
one percent felt that their current provider was not hostile but simply
unsupportive of homosexuality in general [44].
Reducing the Barriers within Health Care Settings
First and foremost the health care provider must acknowledge and be
sensitive to the full spectrum of sexual identity and gender identity
orientations. By using nonbiased language in questioning and nonjudgmental
responses with all youths the health care provider is acknowledging
this spectrum. Such wording is particularly important when first establishing
a trusting relationship with the adolescent. For example, the word
"partner" can be used instead of the word "girlfriend" or "boyfriend"
[44]. Using the words "gay" and "lesbian" are generally less
threatening
to gay and lesbian persons than is the word "homosexual" [44], in
that the term "homosexual" is commonly used in a negative manner by
persons seeking to degrade gay people. A provider will not "scare
away" a heterosexual adolescent by using gender neutral wording to
ask about relationships and interests, but the suicidal, anxious,
"closeted" gay or lesbian adolescent may internalize the "unacceptance"
of their feelings when asked only about opposite-gender friends
by
the health care provider. The struggling gay youth may answer the
clinician in a "socially acceptable" way, but may never return again.
It is critical that the health care provider take a thorough
history
exploring feelings and sexual behaviors regardless of how the adolescent
initially presents. Youths should be asked how they feel inside in
terms of their male or female identity. This allows the person to
express his or her gender identity more fully than if the practitioner
solely assumed their gender by their name, appearance, or biological
gender (if known). Because one's sexual orientation is interconnected
to one's gender identity, persons struggling with their gender identity
will also struggle with their sexual orientation. This gender and
sexual orientation difference can be extremely anxiety provoking and
confusing to the adolescent in the early stages of sexual identity
formation. For example, the 12-year-old boy who has physical and emotional
attractions only to other males may question his identity as a male
until he feels more secure and healthy about his gay sexual orientation.
The health care provider must also explore the adolescent's
feelings
about body image; home; school; daily activities; substance or drug
use; depression; suicidal ideation; suicidal attempts; physical; emotional;
and sexual abuse or mistreatment; sexual behaviors; and sexual identity-
-a HEADSS assessment (HEADSS is an acronym for home, education, activities,
drug use, suicide/depression, and sexuality.) [45] with the addition
of body image. Before questioning the adolescent about these sometimes
painfully personal issues, the clinician must explain the confidentiality
of their interaction, and explain how these questions help the provider
to individualize the care provided. It is essential that clinicians
make it clear to gay youths that all aspects of their health are important.
Gay youths need to know that their sexual identity is healthy and
a part of their whole person, and not a deviation or disease which
needs to be studied. The greater concern is the adolescent's feeling
about self, how he or she accepts himself or herself, and how he or
she deals with any anxieties, or nonacceptance (internal or external).
An essential awareness that all health care providers should
have
is that `behavior does not always equate to identity'. It is therefore
of great importance that the health care provider remain gender neutral
in questioning the adolescent about partners despite their previous
answers. For example, if an adolescent female reports only having
had male sexual partners, that does not necessarily equate to her
identifying as heterosexual. A gay person remains gay regardless of
his or her sexual behaviors. Adolescents, as well as adults, are involved
in sexual behaviors for different reasons including: abusive or forced
sex, consensual or recreational sex. and survival sex or sex-for-trade.
Hence the heterosexual male adolescent who lives on the street may
engage in survival sex with other men, but does not identify as gay.
If the practitioner asks only about his identity and any female partners
he may have had, important health-related concerns may be missed.
Similarly, the child or adolescent who was sexually abused may also
have questions and concerns about his or her own sexual identity.
A thorough sexual history includes questions about gender identity,
sexual identity, age of coitarchy (first sexual intercourse),
number
of male partners (if any), number of female partners (if any), history
of any sexual abuse, and history of survival-sex (particularly for
youth living on the streets). Adolescents commonly do not include
survival-sex partners, or abusive sex perpetrators in their count
of "sexual partners."
The environment in which the health care provider sees
the adolescent
client must also convey sensitivity and inclusiveness to gay youth.
Posters on the walls, clinic videos, and educational materials need
to be inclusive and supportive of all, including gay youths. An openness
about the issues disproportionately effecting gay youths needs to
be clearly visible so that these youths can feel a sense of supportiveness
within this environment without necessarily having to be open about
their being gay. For example, a large gay-positive poster that can
be seen and read from a distance lets the struggling lesbian adolescent
know that she is okay without having to take the chance of going close
to the poster and be seen reading it.
Conclusion
Gay youths struggle with the same developmental tasks as their heterosexual
peers. However, they must also work through the additional tasks of
accepting themselves as gay persons within a commonly anti-gay or
homophobic society. The health care provider, whether in a school-
based clinic, a primary care clinic, an emergency department, an inpatient
unit, a specialty clinic, or a shelter for homeless youth, is unquestionably
in a position to assist these struggling adolescents to reduce self-
harm and to increase self acceptance. Health care providers must first
look at themselves and their environments to make sure they are "safe"
enough to enable gay youths to confide openly.
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John A. Nelson, RN, MSN, CPNP, is a nurse practitioner for Elmhurst
Hospital Center providing care to adolescents in a high-school based
clinic in Queens, N.Y.
Nelson, John A., Gay, lesbian, and bisexual adolescents: providing esteem-enhancing
care to a battered population.. Vol. 22, The Nurse Practitioner,
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