Depression and suicide in gay and lesbian adolescents: a proactive clinical approach to a population at risk

Depression and suicide in gay and lesbian adolescents: a proactive clinical approach to a population at risk.

(Physician Assistant)

In 1989, the federally commissioned Report of the Secretary's Task

Force on Youth Suicide called gay and lesbian adolescent suicide "

a serious problem with cause for alarm."[1] According to this report,

gay and lesbian youth are two to three times more likely to attempt

suicide than other youth, and they may account for up to 30% of completed

youth suicides. These conclusions have been challenged in the lay

press, probably because no such correlations have been documented

for gay and lesbian adults; but the existing research suggests that

gay and lesbian teenagers are at increased risk of suicide.[2-4],

Many gay and lesbian youth are confused about their sexual orientation

and reluctant to discuss it with parents, peers, health professionals,

school counselors, or other adults in a society that is largely hostile

to homosexuality. PAs and other health care professionals who work

with adolescents are in a position to note suicide risk factors, provide

referrals to peer and family support groups, and give pertinent health

care education. To assist PAs in identifying and assisting young gay

and lesbian patients, this paper discusses adolescent homosexuality,

risk factors for suicide, and the clinical approach to addressing

the problems of gay and lesbian adolescents and their families.

HUMAN HOMOSEXUALITY

The percentage of the population that is gay or lesbian remains a

matter of controversy. Studies of the prevalence of homosexuality

are difficult to compare because of the lack of an objective standard

for classifying sexual orientation. Some studies restrict classification

as homosexual to those who identify themselves as exclusively gay

or lesbian, while others have used such parameters as the incidence

of homosexual contact to orgasm or the number of homosexual experiences

in a given time frame.[5] A reasonable estimate of the proportion

of the population that is gay or lesbian is 5% to 10%.[5,6]

The etiology of homosexuality in humans is uncertain. Health care

providers should be familiar with current theories when counseling

patients and their parents, but must use caution in attempting to

explain a phenomenon that is poorly understood. Homosexuality is probably

the result of a combination of genetic, biologic, environmental, social,

and emotional factors.[7] When working with adolescents and their

parents, the health care provider should know what does not cause

homosexuality. There is no scientific evidence to support ideas that

abnormal parental constellations (including parental homosexuality),

sexual abuse, or other traumatic events determine a child's sexual

orientation.[8]

It is also important for the health care provider to communicate

to patients and parents that homosexuality is not pathological. The

American Psychiatric Association removed the diagnosis of homosexuality

from the Diagnostic and Statistical Manual of Mental Disorders in

1973; in 1975, the American Psychological Association urged all mental

health professionals to remove the stigma of mental illness from homosexual

orientation.[1]

HOMOSEXUAL IDENTITY DEVELOPMENT

A model of the gradual process by which homosexual identity develops

provides a helpful framework for those working with gay and lesbian

adolescents. This model is based on surveys of adult homosexuals recalling

how they developed perceptions of themselves as gay or lesbian.[9]

The four stages of the process are sensitization, identity confusion,

identity assumption, and commitment (these stages do not necessarily

follow in distinct order).

Sensitization often begins prior to puberty. Many gays and lesbians

remember feeling somewhat or very different from their same-sex peers.

In some cases, this feeling was based on having gender-inappropriate

interests rather than actual same-sex attraction or homosexual activity.

More often, it was just a vague feeling of being different, not related

to any specific play interests or behaviors.

Identity confusion, the second stage, often occurs during adolescence,

with the growing awareness of same-sex attraction and the recognition

that such feelings could be regarded as homosexual. In a recent study

of 34,706 students (grades 7 through 12), 10.7% described themselves

as "unsure" of their own sexual orientation.[10] There are several

possible responses to identity confusion. Some young gays and lesbians

try to deny their homosexual feelings. Some adolescents or their families

seek "repair" through religious or psychological counseling. Others

try to avoid their own homosexual feelings, which may manifest in

such ways as limitation of opposite-sex exposure so as not to be found

out, limiting exposure to information about homosexuality, immersion

in overtly heterosexual or gender-appropriate behavior, escapism through

drugs and alcohol, and even adoption of homophobic attitudes and actions.

Another response to identity confusion is redefinition. The adolescent

rationalizes his or her behavior by redefining it along more conventional

lines: special case ("I'd only do this with you"), ambisexual strategy

("I guess I'm bisexual"), temporary identity ["This is only a phase"

), or situational ("It was only experimentation"). Not all gay and

lesbian adolescents use these coping mechanisms; some respond to identity

confusion with acceptance. The adolescent acknowledges his or her

homosexual feelings and begins to seek out sources of information

about homosexuality.

Identity assumption is the stage when homosexual self-identity

is established and explored. Retrospective studies of adult gays and

lesbians have found that this third stage occurs, on average, in the

late teens for gay men and early twenties for lesbians. The process

of "coming out" (voluntarily disclosing one's homosexual orientation)

also begins in this stage.

Commitment is the final stage, when homosexuality is adopted and

accepted as an integral and essentially permanent part of the person

as a whole. This stage is a gradual extension of the identity assumption

stage and may occur at any age thereafter.

RISK FACTORS FOR GAY AND LESBIAN ADOLESCENT SUICIDE

The Report of the Secretary's Task Force on Youth Suicide identified

specific risk factors in gay and lesbian youth suicide, and it is

worth noting that they are not significantly different from the risk

factors for suicide within the general adolescent population. These

risk factors include family problems, breaking up with a girlfriend

or boyfriend, social isolation, school failure, and identity conflicts.[11]

In a supportive and informed social and family environment, the

incidence of mental health problems and suicide would probably be

no greater in the young gay and lesbian population than in the general

adolescent population.[6,11] However, in the current environment,

these problems are indeed more prevalent among gay and lesbian teenagers.

Several specific factors have been identified as being particularly

useful in identifying gay and lesbian youth at increased risk for

suicide.[1] These factors include younger age, "internalized homophobia,

" family problems, school situation, homelessness, drug abuse, and,

surprisingly, some types of mental health treatment.

The higher risk among younger gay or lesbian adolescents may be

due to emotional and physical immaturity, dependence on parents who

are unwilling or unable to provide emotional support, and unfulfilled

developmental needs for identification with a peer group.[1,12] They

may also be at higher risk for substance abuse, dropping out of school,

psychiatric hospitalization, running away from home, and prostitution[1];

each of these circumstances, in turn, may contribute to the risk of

suicide. One study found that the strongest indicators of suicidal

behavior among gay youth are awareness of their sexual orientation,

depression and suicidal feelings, and substance abuse all occurring

before age 14.[1]

"Internalized homophobia" and the poor self-esteem it fosters also

contribute to the risk of suicide. As young gays and lesbians develop

and begin to understand who and what they are. they also learn society'

s negative response to homosexuality. These negative feelings may

become incorporated into the young person's self-image, resulting

in varying degrees of self-hatred and poor self-esteem.[6] Gay and

lesbian adolescents who have internalized images of homosexuals as

sick, bad, hopeless, or self-destructive are more likely to experience

despair and inner conflict.[1]

Family problems are a large factor in suicide. Gay and lesbian

youth may attempt suicide after being rejected by their families.

Some gay and lesbian adolescents are physically abused and verbally

harassed by family members because of their sexual orientation.[13]

Issues concerning the family's religion may also be a source of conflict.

The youth's homosexual orientation may be seen as incompatible with

the family's religion, or the youth may feel sinful because of his

or her homosexual orientation.[1]

Gay and lesbian youth are subject to verbal harassment, physical

abuse, and destruction of their property at school.[8,14,15] In a

survey taken at a Massachusetts high school, 98% of students reported

that they have "sometimes" or "very often" heard anti-gay remarks

at school.[16] Many gay and lesbian teenagers have had their lockers

ransacked and covered with abusive phrases and/or threats.[17] In

one sampling, 30% of gay and bisexual male youths reported that they

had been victims of physical assaults ("gay bashings"), with half

of these incidents occurring on school property.[14] Consequences

of peer harassment include poor school performance, truancy, and dropping

out of school.[15] An estimated 28% of gay and lesbian youth drop

out of school because of a hostile school environment.[1] Many teachers

and administrators who are aware that gay and lesbian students are

being harassed report that they are reluctant to intervene for fear

that they will themselves become targets for harassment.[16,18] Harassment

and abuse at school contribute significantly to the likelihood of

suicide.[1,15]

Homelessness or premature independent living (whether the youth

runs away from home or is thrown out) is another risk factor for gay

and lesbian youth suicide; drug abuse and prostitution are also independent

suicide risk factors. Gay and lesbian youth who leave home and move

to a big city hoping to find others like themselves and start a new

life may become disillusioned when they become aware of the lack of

opportunities for them. Suicidal feelings may emerge as they give

up hope for a better life.[1]

A surprising risk factor for gay and lesbian youth suicide is receipt

of professional help. Psychiatrists, psychologists, social workers,

and other mental health care providers who are unsupportive, who

try to "cure" the youth of homosexuality, or who are homophobic themselves

are apt to contribute to the erosion of the youth's self-esteem. Youth

who experience severe distress about their sexual orientation (which

used to be called "ego-dystonic homosexualiy"[19]) are especially

vulnerable to this type of treatment, and may experience extreme despair

after treatment has not eliminated their homosexual feelings. Mental

health treatment should focus on the youth's and the family's reaction

to homosexuality and should be aimed at developing healthy adaptive

patterns and good self-esteem. An approach that identifies homosexuality

itself as the main problem is not likely to help in the long run.[1]

Finally, a generally hopeless future outlook is a suicide risk

factor for gay and lesbian adolescents. They may believe that they

are doomed to an unhappy life in which they will never find love and

acceptance. Contributing factors to this kind of hopelessness include

the absence of positive adult gay or lesbian role models and the lack

of realistic information about what life could be like for them as

successful people who happen to be gay or lesbian.[1]

THE ROLE OF THE HEALTH CARE PROVIDER

A survey of medical schools in 1991 found that the mean amount of

course time devoted to the topic of homosexuality over the entire

4 years was just 3 hours and 26 minutes; the subtopic of adolescent

homosexuality was not separated out in this survey.[20] No comparable

studies of PA program curricula have been reported.

This lack of attention to the topic in medical education is reflected

in the lack of attention to it in clinical practice. In a survey of

120 gay and lesbian youths, ages 14 to 21, who were asked, "Have you

been able to talk to a personal physician concerning your homosexual

orientation?" only 19% of the males and 18% of the females answered

affirmatively.[21] It is not clear from the question or the responses

whether the adolescents wanted to talk about it but felt the provider

would be unsupportive or if they wanted to keep their sexual orientation

a secret. In another survey, 121 gay and lesbian adolescents, ages

14 to 17, were asked where they received information about homosexuality.[22]

Reported sources of information included sexual partners, television

and other media, word of mouth, the telephone directory, frequenting

locations thought to be gay or lesbian, association with people known

to be gay or lesbian, and health care facilities or practitioners.

The responses varied greatly between males and females: The top four

information sources for young gay men were sexual encounters, television

and media, word of mouth, and frequenting gay locations; the top three

for young lesbians were television and media, word of mouth, and associating

with gay or lesbian persons. By far, the least frequently reported

source of information for both gays and lesbians was health facilities

or practitioners. These studies indicate that only a minority of gay

and lesbian adolescents are receiving any help from health professionals

in dealing with their particular medical and emotional problems.

CLINICAL APPROACH TO GAY AND LESBIAN ADOLESCENTS

The first step in developing an effective clinical approach to gay

and lesbian youth is to not assume that all adolescents are heterosexual.

This point is not as obvious as it may seem; many routine questions

must be reworded so as not to exclude the possibility of homosexuality

in the reply. The assumption of heterosexuality is so strong in our

culture that asking questions in a neutral way with respect to sexual

orientation may feel strange at first. The practitioner must become

comfortable in using language that is neutral with regard to sexual

orientation, such as, "Do you have sexual feelings about boys, girls,

or both?" It is important to ask such questions of every adolescent

seen, including younger adolescents; as discussed earlier, younger

adolescents who are questioning their sexual orientation may be at

particularly high risk for depression and suicide.[1]

Like anyone else, health care professionals can fall prey to stereotyping.

The same practitioner who feels at ease in addressing questions about

sexual orientation to a girl who plays on the school hockey team or

a boy who studies fashion design may feel awkward in addressing the

same questions to a boy on the football team or a girl studying ballet;

it may also be difficult to address these issues with the child of

a friend or colleague. However, if health care providers are to help

the gay and lesbian adolescents most in need, they need to examine

and overcome their own assumptions and prejudices.

The environment and mechanics of a practice can either encourage

or discourage adolescents who want to discuss sensitive subjects.

One way to let adolescents know that it is acceptable to talk about

homosexuality is to place booklets or pamphlets about adolescent homosexuality

in the waiting room and examination rooms, along with the booklets

on such topics as contraception, sexually transmitted diseases (SIDs),

substance abuse, and nutrition.

Questionnaires can be effective tools for eliciting information

about personal matters. In some clinics, the adolescent and the parents

are given separate forms. It must be emphasized to the adolescent

that the form simply gives the provider an idea of what things might

be important to discuss, that the information is confidential, and

that the questionnaire need not be included in the medical record.

Other providers feel that sensitive information is better elicited

one-on-one after a rapport is established with the patient. How best

to establish rapport with adolescent patients depends upon the type

of practice, the comfort level of the provider in bringing up these

issues, the time allowed each patient, and other factors. Providers

should think about ways to foster the adolescent's confidence and

comfort in divulging such personal information.

The issue of confidentiality must be openly addressed, because

adolescent patients are likely to be unaware of their right to confidentiality.

Each state has slightly different laws on confidentiality, but the

patient-provider right to confidentiality generally applies to adolescents

except in situations of immediate danger to the adolescent about which

the parents must be notified.[11] Discussion and education about sexual

orientation should therefore be covered by the confidentiality laws.

Health care providers who truly wish to help their adolescent patients

might consider routinely bringing up the subject of confidentiality.

A sincere statement can have a tremendous impact: "I want to remind

you that anything you tell me or ask me about is strictly confidential,

and no one else will ever hear about it unless you are in immediate

danger. If you ever have concerns about drug use, depression, sexual

issues like birth control or sexual orientation, or anything else,

you can always talk to me about it and I will try to help you." Many

adolescents will respond with a blank stare, but those who need a

supportive adult will remember these words and may return to the office

when such an issue arises.

SPECIFIC MEDICAL ISSUES OF GAY AND LESBIAN ADOLESCENTS

When a gay or lesbian adolescent has confided in a practitioner regarding

his or her sexual orientation, the next step is to establish information

about specific sexual experiences and practices. A declaration of

sexual orientation says little or nothing about sexual behavior. The

sexual history should be comprehensive, but it should not be the sole

focus of the interview; there are other psychosocial and developmental

issues that must be addressed with all adolescents, regardless of

sexual orientation.

Medical issues related specifically to sexual activity in gay males-

-whether adolescent or adult--include human immunodeficiency virus

(HIV) and other STDs, and traumatic injuries related to sexual intercourse.

The clinical evaluation should therefore address such issues as anal

intercourse, rough sex, bisexual activities, number of sexual partners,

frequency of sexual contact, history of STDs, and attention to safer

sex practices.[23]

Young men should be questioned specifically about their HIV status

and any concerns they may have about HIV or being tested for HIV.

The provider may offer to order the test but should also be able to

give referrals to other facilities that offer anonymous (rather than

merely confidential) HIV testing and counseling. Hepatitis serologies

should also be obtained when appropriate, and vaccination of young

men at risk is advised.[8]

The physical examination in the gay male is the same as for a heterosexual

male. However, certain aspects of the physical examination that are

often deferred in the heterosexual male absolutely must be performed

in the gay male. Careful examination of the following systems are

required: skin, mouth, throat, and lungs, looking for signs of opportunistic

infection related to HIV; genitals, looking for signs of STDs or injury;

anus and rectum, looking for signs of injury, irritation, or infection;

prostate, looking for swelling, tenderness, and other signs of prostatitis.[23]

As is the case with young gay males, the medical issues related

to a young lesbian's sexual orientation depend upon the specific sexual

practices in which she engages.[8,11] Some lesbian adolescents are

sexually active with young men, either because they are truly bisexual

or because they are trying to prove that they are heterosexual.[9]

An accurate and complete sexual history is essential so that appropriate

counseling and medical care, especially with regard to prevention

of pregnancy and STDs, can be provided.

There are no gynecological problems unique to lesbians, and none

that occurs more often in lesbians than in bisexual or heterosexual

women.[24] However, one study found that lesbians are at slightly

higher risk for delayed detection of cervical dysplasia[24]; other

research suggests that adult lesbians tend to avoid routine gynecologic

screening.[25] It is important, therefore, to educate young lesbians

about screening with Pap smears and breast self-examination, and to

explain why all women should have routine gynecologic care even if

they are exclusively lesbian.

SUICIDAL GAY AND LESBIAN ADOLESCENTS

If an adolescent has confided to the practitioner that he or she feels

depressed, hopeless, or suicidal because of distress about sexual

orientation, family reactions or rejection, harassment at school,

or relationship problems, these feelings must be addressed. Although

the parents must be notified if their child is suicidal, the practitioner

need not immediately inform them of the reasons; these topics can

be explored later, after the crisis has subsided and the adolescent

and the family have an opportunity to talk with a mental health specialist.

The practitioner who sees a suicidal gay or lesbian adolescent should

think first about the adolescent's welfare: in some cases, it may

be advisable to consider hospitalization rather than sending the patient

home to a potentially volatile family situation.

COUNSELING THE GAY OR LESBIAN ADOLESCENT

Although primary health care providers will not be doing extensive

mental health counseling with the gay or lesbian adolescent patient,

they should be aware of some general principles. Some health care

providers feel that bringing up the topic of homosexuality will somehow

create it or trigger its expression. As discussed earlier, homosexual

orientation seems to be established early in life, and attempts to

change it one way or the other have been largely unsuccessful.[6]

By bringing up the issue of homosexuality, health care providers who

work with adolescents may actually be providing hope for the most

depressed and isolated gay and lesbian adolescents.

If an adolescent expresses concern about homosexual desires and/or

activity, the practitioner should not minimize these feelings.[6]

It may seem reassuring to say, "Don't worry, this is just a phase."

But while homosexual feelings may indeed be just a passing phase

in some adolescents, it is wrong to dismiss them as such automatically.

For gay or lesbian adolescents who are disturbed by the emergence

of their true sexual orientation, such summary dismissal of their

concerns will be either falsely reassuring or terrifying (the adolescent

who has had to overcome much fear and shame to confide in a health

care provider may interpret a dismissal as meaning that the provider

finds the idea too terrible to consider).

While health care providers should not minimize the adolescent'

s concerns about homosexuality, neither should they hurry the adolescent

into a premature resolution of sexual identity.[6,11] It may take

years to understand and accept one's sexuality, and adolescents should

be reassured that their own sexuality will emerge over time. Similarly,

bisexuality should be neither discounted nor pushed as an adolescent'

s true sexual orientation.[26]

Health care providers should remember that sexual orientation is

only one facet of human personality. Gay and lesbian adolescents will

benefit from the clear and consistent message that sexual orientation

does not determine a person's value, mental health status, or quality

of life.[6]

REFERRALS AND RESOURCES FOR GAY AND LESBIAN ADOLESCENTS AND THEIR

FAMILIES

Decisions on referring the gay or lesbian adolescent for emotional

support depend on the patient's level of adjustment or distress and

any coexisting mental health problems, such as depression. For many

gay and lesbian adolescents, support groups are the most valuable

resource, though they are not group therapy and generally do not focus

on in-depth psychological issues.[6] Support groups provide an opportunity

to discuss the meaning of sexuality and sexual identity, find understanding

from peers, share information, and socialize. Some gay and lesbian

adolescents require individual counseling, which would ideally be

with a mental health professional who is comfortable working with

gay and lesbian adolescents.

Families may also benefit from support groups such as those organized

by Parents and Friends of Lesbians and Gays (P-FLAG). These groups

can provide information to families, reduce the isolation they may

feel, and share their experiences. Families that are more dysfunctional

may require family therapy.

There are many organizations to assist young gays and lesbians

and their families. Health care providers should be familiar with

groups in their area or in the nearest city. The national headquarters

of P-FLAG can direct providers to local chapters and can supply excellent

booklets, pamphlets, and reading lists on adolescent homosexuality.

P-FLAG may be contacted at 1012 14th Street, NW, Suite 700, Washington,

DC 20005; (202) 638-4200.

REFERENCES

[1.] Feinleib MR, ed. Report of the Secretary's Task Force on Youth

Suicide. Vol. 3. Rockville, Maryland: US Department of Health and

Human Services, 1989.

[2.] Prenzlauer S, Drescher J, Winchel R. Suicide among homosexual

youth. Am J Psychiatry. 1992;149:1416.

[3.] Hendin H. Suicide among homosexual youth. Am J Psychiatry. 1992-

149:1416-1417.

[4.] Remafedi G, Farrow J, Diescher R. Risk factors for attempted

suicide in gay and bisexual youth. Pediatrics. 1991;87:869-875.

[5.] Singer BL, Deschamps D. Gay and Lesbian Stats: A Pocket Guide

of Facts and Figures. New York: The New Press; 1994:9-12.

[6.] Gonsiorek JC. Mental health issues of gay and lesbian adolescents.

J Adolesc Health Care. 1988;9:114-122.

[7.] Savin-Williams RC. Theoretical perspectives accounting for adolescent

homosexuality. J Adolesc Health Care. 1988;9:95-104.

[8.] Remafedi G. Fundamental issues in the care of homosexual youth.

Med Clin North Am. 1990;74:1169-1179.

[9.] Troiden RR. Homosexual identity development. J Adolesc Health

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[10.] Remafedi G, Resnick M, Blum R, Harris L. Demography of sexual

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[11.] Neinstein LS. Adolescent Health Care: A Practical Guide. 2nd

ed. Baltimore: Urban & Schwarzenberg, 1991.

[12.] Remafedi G. Adolescent homosexuality: psychosocial and medical

implications. Pediatrics. 1987;79:331-337.

[13.] Hunter J. Violence against lesbian and gay male youths. J Interpersonal

Violence. 1990;5:295-300.

[14.] Remafedi G. Male homosexuality: the adolescent's perspective.

Pediatrics. 1987;79:326-330.

[15.] Savin-Williams RC. Verbal and physical abuse as stressors in

the lives of lesbian, gay male, and bisexual youths: associations

with school problems, running away, substance abuse, prostitution,

and suicide. J Consult Clin Psychol. 1994;62:261-269.

[16.] The Governor's Commission on Gay and Lesbian Youth. Making Schools

Safe For Gay and Lesbian Youth: Breaking the Silence in Schools and

in Families. Publication No. 17296-60-500-2/93-C.R., 1993.

[17.] Heron A, ed. Two Teenagers in Twenty: Writings by Gay and Lesbian

Youth. Boston: Alyson Publications; 1994.

[18.] Treadway L, Yoakam J. Creating a safer school environment for

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[19.] Diagnostic and Statistical Manual of Mental Disorders. 3rd ed.

Washington DC: American Psychiatric Association; 1980.

[20.] Wallick MM, Cambre KM, Townsend MH. How the topic of homosexuality

is taught at US medical schools. Acad Med. 1992; 67:601-603.

[21.] Telljohann SK, Price JH. A qualitative examination of adolescent

homosexuals' life experiences: ramifications for secondary school

personnel. J Homosex. 1993;26:41-56.

[22.] Paroski PA. Gay and lesbian teens. In: Kus RJ, ed. Keys to Caring:

Assisting Your Gay and Lesbian Clients. Boston: Alyson Publications;

1990:160-169.

[23.] Bickelhaupt E. The health history: what to look for and how

to ask. In: Kus RJ, ed. Keys to Caring: Assisting Your Gay and Lesbian

Clients. Boston: Alyson Publications; 1990:12-18.

[24.] White J, Levinson W. Primary care of lesbian patients. J Gen

Intern Med. 1993;8:41-47.

[25.] Lucas VA. An investigation of the health care preferences of

the lesbian population. Health Care Women Internatl. 1992;13:221-228.

[26.] Paul JP, Nichols M. "Biphobia" and the construction of a bisexual

identity. In: Shernoff M, Scott WA, eds. The Sourcebook on Lesbian/Gay

Health Care. Washington DC: The National Lesbian/Gay Health Care Foundation;

1988:259-264.