Gay and lesbian youth belong to two groups at high risk of suicide: youth and homosexuals. A majority of suicide attempts by homosexuals occur during their youth, and gay youth are 2 to 3 times more likely to attempt suicide than other young people. They may comprise up to 30 percent of completed youth suicides annually. The earlier youth are aware of their orientation and identify themselves as gay, the greater the conflicts they have. Gay youth face problems in accepting themselves due to internalization of a negative self image and the lack of accurate information about homosexuality during adolescence. Gay youth face extreme physical and verbal abuse, rejection and isolation from family and peers. They often feel totally alone and socially withdrawn out of fear of adverse consequences. As a result of these pressures, lesbian and gay youth are more vulnerable than other youth to psychosocial problems including substance abuse, chronic depression, school failure, early relationship conflicts, being forced to leave their families, and having to survive on their own prematurely. Each of these problems presents a risk factor for suicidal feelings and behavior among gay, lesbian, bisexual and transsexual youth.
The root of the problem of gay youth suicide is a society that discriminates against and stigmatizes homosexuals while failing to recognize that a substantial number of its youth has a gay or lesbian orientation. Legislation should guarantee homosexuals equal rights in our society. We need to make a conscious effort to promote a positive image of homosexuals at all levels of society that provides gay youth with a diversity of lesbian and gay male adult role models. We each need to take personal responsibility for revising homophobic attitudes and conduct. Families should be educated about the development and positive nature of homosexuality. They must be able to accept their child as gay or lesbian. Schools need to include information about homosexuality in their curriculum and protect gay youth from abuse by peers to ensure they receive an equal education. Helping professionals need to accept and support a homosexual orientation in youth. Social services need to be developed that are sensitive to and reflective of the needs of gay and lesbian youth.
Suicide is the leading cause of death among gay male, lesbian, bisexual and transsexual youth.* They are part of two populations at serious risk of suicide: sexual minorities and the young. Agency statistics and coroner reports seldom reflect how suicidal behavior is related to sexual orientation or identity issues. The literature on youth suicide has virtually ignored the subject. Research in recent years, however, with homosexual young people and adults has revealed a serious problem with cause for alarm.
There is a high rate of suicidality among lesbians and gay men. Jay and Young found that 40 percent of gay males and 39 percent of lesbians surveyed had either attempted or seriously contemplated suicide (1). Bell and Weinberg similarly found that 35 percent of gay males and 38 percent of lesbians in their study had either seriously considered or attempted suicide (2). Homosexuals are far more likely to attempt suicide than are heterosexuals. A majority of these attempts take place in their youth. Bell and Weinberg found that 25 percent of lesbians and 20 percent of gay men had actually attempted suicide. Gay males were 6 times more likely to make an attempt then heterosexual males. Lesbians were more than twice as likely to try committing suicide than the heterosexual women in the study. A majority of the suicide attempts by homosexuals took place at age 20 or younger with nearly one-third occurring before age 17.
Suicidal behavior by gay and lesbian youth, however, occurs today within the broader context of an epidemic increase in suicide among all young people in our society. Between 1950 and 1980, there was an increase of more than 170 percent in suicides by youth between the ages of 15 and 24 (3). The suicide rate for all age groups rose only 20 percent during that time. At least 5,000 youth now take their lives each year with the number believed to be significantly higher if deliberate auto accidents, victim precipitated homicides, and inconclusive coroner reports are taken into account. The rate of suicide attempts to completions is much higher among young people than any other age group with as many as 500,000 attempts annually. This leads us to believe that many times a suicide attempt by a young person is really a cry for help.
Gay and lesbian youth have been a hidden population within the adolescent and young adult age group. Those programs and studies able to document suicidality in gay youth have found they have a high rate of suicidal feelings and behavior that places them at substantially greater risk of taking their own lives compared to other youth (See Appendix A). Statistics from the Institute for the Protection of Gay and Lesbian Youth in New York, the University of Minnesota Adolescent Health Program in Minneapolis, Roesler and Deisher in Seattle, and the Los Angeles Suicide Prevention Center consistently show that 20-35 percent of gay youth interviewed have made suicide attempts (4,5,6,7). Statistics from Minneapolis, Los Angeles and San Francisco find that more than 50 percent of gay youth experience suicidality including serious depression and suicidal feelings (5,7,8). The Larkin Street Youth Center in San Francisco found that among their client population of homeless youth, 65 percent of homosexual/bisexual youth compared to 19 percent of heterosexual youth reported ever being suicidal, and that gay youth had a rate of suicidality nearly 3.5 times greater than other youth (8). The Los Angeles Suicide Prevention Center in preliminary data from an unpublished study, found that the suicide attempt rate for gay youth is more than 3 times higher than that of heterosexual youth; their rate of suicidality is more than twice that of other youth (7).
Why are feelings of self-destructiveness and suicidal behavior so prevalent among gay and lesbian youth? How can we learn to recognize these youth better and help them more effectively in coping with the problems that often lead them to want to take their own lives? The rest of this paper attempts to address these issues by providing an overview of the tasks and problems facing gay youth, an understanding of who they are, factors that place gay youth at risk of suicide, and an approach for society as a whole and the individual helping professional in effectively helping these youth and preventing them from taking their: lives.
Tasks of the Gay Adolescent
Gay youth face the double jeopardy of surviving adolescence and developing a positive identity as a lesbian, gay male, bisexual, or transsexual in what is frequently a hostile and condemning environment. Contrary to popular belief, adolescence is not the time of our lives. It is a difficult and complex period of development filled with anxiety and few clear guidelines for helping youth resolve the problems they face, often for the first time, and making the transition to adulthood. Youth are going through physical changes, emotional changes, intellectual changes and sexual development all within the context of their particular culture, family, peer group, and capacity as individuals. They must accomplish several formidable tasks including separating from their families while retaining a core sense of belonging (individuation), learning to form relationships with other people while fitting in with a social structure (socialization), establishing an integrated, positive, individual identity (identity formation) and preparing themselves for the future in an increasingly complex and uncertain world (future orientation).
Problems in accomplishing these tasks play a critical role in the suicidal feelings of any youth but present special hardships for those who are gay or lesbian. First they must come to understand and accept themselves in a society that provides them with little positive information about who they are and negative reactions to their inquiries. Second, they must find support among significant others who frequently reject them. Finally, they must make a social adaptation to their gay or lesbian identity. They must find where they belong and how they fit in with a social structure that either offers no guidelines for doing so or tells them that they have no place.
With the advent of the sexual revolution and gay liberation movement of the past two decades, gay and lesbian youth have been increasingly aware of their feelings and coming to terms with their orientation at an earlier age than ever before. This has placed them into direct conflict with all of the traditional childrearing institutions and support systems of our society. Increasingly, this occurs while the youngsters are still living at home with their family, attending public school and developing a sense of their own self worth in comparison with their peers and the expectations of society as a whole.
Problems Facing Gay Youth
Lesbian and gay youth are the most invisible and outcast group of young people with whom you will come into contact if open about who they are, they may feel some sense of security within themselves but face tremendous external conflicts with family and peers. If closed about who they are, they may be able to "pass" as 'straight" in their communities while facing a tremendous internal struggle to understand and accept themselves. Many gay youth choose to maintain a facade and hide their true feelings and identity, leading a double life, rather than confront situations too painful for them. They live in constant fear of being found out and recognized as gay. The reasons for their silence are good ones.
Gay youth are the only group of adolescents that face total rejection from their family unit with the prospect of no ongoing support. Many families are unable to reconcile their child's sexual identity with moral and religious values. Huckleberry House in San Francisco, a runaway shelter for adolescents, found that gay and lesbian youth reported a higher incidence of verbal and physical abuse from parents and siblings than other youth (9). They were more often forced to leave their homes as "pushaways" or "throwaways" rather than running away on their own. In a study of young gay males, Remafedi found that half had experienced negative parental response to their sexual orientation with 26 percent forced to leave home because of conflicts over their sexual identity (5).
Openly gay and lesbian youth or those "suspected" of being so can expect harassment and abuse in junior high and high schools. The National Gay Task Force, in a nationwide survey, found that 45 percent of gay males and nearly 20 percent of lesbians had experienced verbal or physical assault in secondary schools (10). The shame of ridicule and fear of attack makes school a fearful place to go resulting in frequent absences and sometimes academic failure. Remafedi reports 28 percent of his subjects were forced to drop out because of conflicts about their sexual orientation (5). Gay youth are the only group of adolescents with no peer group to identity with or receive support from. Many report extreme isolation and the loss of close friends.
Gay youth also face discrimination in contacts with the juvenile justice system and foster and group home placements.* Many families and group homes refuse to accept or keep an adolescent if they know he or she is gay. A report by the San Francisco Juvenile Justice Commission found that gay youth stay in detention longer than other youth awaiting placement because of a lack of appropriate program resources (11). Many programs are unable to address the concerns or affirm the identity of a gay adolescent. They can be subjected to verbal, physical, and even sexual abuse with little recourse. Even sympathetic staff often don't know how to relate to a gay youth or support them in conflicts with other residents. They frequently become isolated, ignored by youth and staff who feel uncomfortable with them. They are easy targets for being blamed and scapegoated as the "source" of the problem in efforts to force them to leave.
The result of this rejection and abuse in all areas of their lives is devastating for lesbian and gay youth and perhaps the most serious problems they face are emotional ones. When you have been told that you are sick:, bad, and wrong for being who you are, you begin to believe it. Gay youth have frequently internalized a negative image of themselves. Those who hide their identity are surrounded by homophobic attitudes and remarks, often by unknowing family members and peers, that have a profound impact on them. Hank Wilson, founder of the Gay and Lesbian Teachers Coalition in San Francisco, believes these youth constitute a large group who are silently scapegoated, especially vulnerable to being stigmatized, and who develop poor self esteem (12). Gay youth become fearful and withdrawn. More than other adolescents, they feel totally alone often suffering from chronic depression, despairing of life that will always be as painful and hard as the present one.
In response to these overwhelming pressures, gay youth will often use two coping mechanisms which only tend to make their situation worse: substance use and professional help. Lesbian and gay male youth belong to two groups at high risk for substance abuse: homosexuals and adolescents. Rofes found, in a review of the literature, that:
Lesbians and gay men are at much higher risk than the heterosexual population for alcohol abuse. Approximately 30 percent of both the lesbian and gay male populations have problems with alcoholism (13).
Substance use often begins in early adolescence when youth first experience conflicts around their sexual orientation. It initially serves the functional purposes of (1) reducing the pain and anxiety of external conflicts and (2) reducing the internal inhibitions of homosexual feelings and behavior. Prolonged substance abuse, however, only contributes to the youth's problems and magnifies suicidal feelings.
Several studies have found that a majority of gay youth received professional help for conflicts usually related to their sexual identity (5,6). These interventions often worsen conditions for these youth because the therapist or social worker is unwilling to acknowledge or support an adolescent's homosexual identity. Many gay and lesbian youth are still encouraged to "change" their identities while being forced into therapy and mental hospitals under the guise of "treatment."
Those who seek help while hiding their identity often find the source of their conflicts is never resolved because the therapist is unable to approach the subject. This silence is taken as further repudiation of an "illness" that dare not speak its name.
A suicide attempt can be a final cry for help by gay youth in their home community. if the response is hostile or indifferent, they prepare to leave. Alone and frightened, they go to larger cities hoping to find families and friends to replace the ones that did not want them or could not accept them. The English group "The Bronski Beat" describes the plight of the gay adolescent in their song "Smalltown Boy":
You were the one they talked about
Around town as they put you down
But as hard as they would try just to make you cry
You would never cry to them
--just to your soul
Runaway, turnaway, runaway, turnaway, runaway (14).
While it has become easier in recent years to be a gay male or lesbian adult it may be harder than ever to be a gay youth. With all of the conflicts they face in accepting themselves, coming out to families and peers, establishing themselves prematurely in independent living and, for young gay males, confronting the haunting specter of AIDS, there is a growing danger that their lives are becoming a tragic nightmare with living only a small part of dying.
UNDERSTANDING GAY AND LESBIAN YOUTH
Lesbian and gay male youth are young people with a primary attraction to members of the same sex for sexual and intimate relationships. Bisexual youth have an attraction to members of both sexes for sexual and intimate relationships. We use the term orientation rather than preference to describe this attraction because we still do not know how it originates. We are not certain to what extent genetics, socialization factors or individual choice determines either a homosexual or heterosexual orientation. Transsexual youth are young people who believe they have a gender identity that is different from the sex they were born with. This includes young males who believe they are really females mistakenly born in a male body and young females who believe they are really males mistakenly born in a female body. Sexual orientation and gender identity are separate issues for each individual. Transsexuals may have a heterosexual, homosexual, or bisexual orientation. Homosexuals are rarely confused about their gender identity with lesbians believing they are women and gay males believing they are men.
There are indications that individuals maybe predisposed to their sexual orientation from an early age. A gay or lesbian orientation in adolescence is not just a phase the youth is going through. Bell, Weinberg, and Hammersmith found that sexual orientation is likely to be formed by adolescence -- even if the youth is not yet sexually active (15).
Childhood and adolescent homosexuality, especially pronounced homosexual feelings, can not be regarded as just a passing fancy... [it] seems to be relatively enduring and so deeply rooted that it is likely to continue as a lasting homosexual orientation in adult life.
Huckleberry House found that, when given a choice, adolescents demonstrate a greater degree of conviction than confusion in identifying their sexual orientation, with 75 percent self-reporting as heterosexual, 15 percent homosexual, 5 percent bisexual, and only 5 percent confused or undecided (9). Most youth who identity as heterosexuals and homosexuals will continue to do so as adults. Youth are more likely to underreport a homosexual orientation because of difficulties in accepting themselves and the fear of a hostile response. Jay and Young found that 56 percent of the lesbian respondents in their survey had previously identified as bisexual while only 16 percent currently did so (1). Forty-six percent of the gay males had previously identified as bisexual while only 20 percent currently did so.
Homosexuality is not a mental illness or disease. It is a natural and healthy expression of human sexuality. In 1935, Sigmund Freud wrote that "Homosexuality...is nothing to be ashamed of, no vice, no degradation, it can not be classified as an illness" (16). In 1973, the American Psychiatric Association removed homosexuality from the list of psychiatric disorders and, in 1975, the American Psychological Association urged all mental health professionals to remove the stigma of mental illness long associated with a homosexual orientation. In 1983, the American Academy of Pediatrics encouraged physicians to become involved in the care of homosexuals and other young people struggling with the problem of sexual expression (5). If homosexuality is not an illness or a disorder, it can not be regarded as such to the extent that it occurs in the young.
Gay and lesbian youth come from all ethnic backgrounds. The ethnicity of gay youth will reflect the ethnicity of youth in your community or seen by your agency. The Institute for the Protection of Gay and Lesbian Youth reports the ethnic breakdown of youth it served, matched the population of New York's public school system with 40 percent black, 35 percent white, 20 percent Hispanic, 2 percent Asian and 3 percent other (4). Huckleberry House in San Francisco found that more than half of their overall client population and gay youth seen by the program were ethnic minorities (9).
There are far more gay youth than you are presently aware of. Kinsey found a significant amount of homosexual behavior among adolescents surveyed with 28 percent of the males and 17 percent of the females reporting at least one homosexual experience (17,18). He also found that approximately 13 percent of adult males and 7 percent of adult females had engaged in predominantly homosexual behavior for at least three years prior to his survey. This is where the figure that 10 percent of the population is homosexual comes from. It is difficult to assess the prevalence of a homosexual orientation given our knowledge that sexual behavior actually occurs along a continuum of feelings and experiences. Prevalence is even more difficult to estimate among adolescents because of the complex identity issues with which they are struggling and the scarcity of research on the subject. It is apparent, however, that a substantial minority of youth -- perhaps "One in Ten" as one book suggests -- have a primary gay male, lesbian, or bisexual orientation. Given the higher rates of suicidal feelings and behavior among gay youth in comparison with other young people, this means that 20-30 percent of all youth suicides may involve gay youth. Parris believes that as many as 3000 gay and lesbian young people may be taking their lives each year (19).
Coming Out: The Early Stages
Coming out is the process through which a person comes to understand and accept his/her sexual identity and shares it with others. This is seldom a conscious undertaking for heterosexual youth who find that being "straight" is a given status in our society. It is as automatic as attending school or getting a driver's license. However, identifying oneself as gay or lesbian is a long and painful process that only occurs gradually over an extended period of time. Stages in the coming out process are identified in Appendix B with the ages reflecting those of gay and lesbian youth whom I worked with at Huckleberry House (20,21).. This population represents the bias of self-identified gay youth seeking services at a runaway program. It is important to recognize, however, that this process begins for many lesbian and gay youth at an early age with an awareness of their orientation often developing by adolescence. It is then that they experience significant conflicts involving understanding of whom they are, handling negative reactions from others and making a social adaptation which can lead to suicidal feelings and behavior. These conflicts must be resolved before the youth can develop a positive identity as a gay male or lesbian.
The first stage in the development of a lesbian or gay identity is an awareness of being different. This often occurs several years prior to puberty with the youth seldom aware of what this feeling means or how it relates to their sexuality. Lewis, in describing this stage for young lesbians, notes that;
Fewer of the homosexual (13%) than heterosexual (55%) women said they enjoyed typical girls' activities (e.g., playing house, hopscotch) very much.
The second stage of the coming out process is an awareness of being attracted to members of the same sex. This also commonly occurs prior to puberty with many gay and lesbian youth reporting childhood crushes on other children and adults. Bell, et al. found these sexual feelings typically occurred three years or so before any homosexual experiences and appear to be the most crucial stage in the development of adult homosexuality (15). Most children are unaware of the meaning and implications of these attractions. However, for those who are able to make a connection between their "difference"--homosexual feelings and gay or lesbian identity--depression and suicidal feelings may already be present.
With adolescence, many gay and lesbian youth have their first contact with homosexuality and it is all bad. They are told it is no longer acceptable to engage in sexual behavior with members of the same sex and that those who do are sick. The only images of homosexuals that society provides them with are derisive stereotypes of lesbians who are like men and gay men who are like women. Many experience their first pervasive contact with the fear and hatred of homosexuality--homophobia.
Nowhere are these harshly negative attitudes towards homosexuality more pronounced than in junior high and high school. These institutions are the brutal training grounds where traditional social roles are rigidly rein-forced. Boys are going to play sports and drink beer with the guys. Girls are going to start paying more attention to their physical appearance in the hopes of attracting boys. Adolescence will be the last stronghold of these stereotyped roles and behaviors because young people are looking for identity. Homosexuality and gender nonconformity are threats to many youth and an easy target for their fears and anxieties about being "normal"
Youth who have a growing awareness of a gay or lesbian orientation become painfully aware that they do not fit the "social script." They see the hostility directed towards homosexuals by others and hear taunts of "dyke" and "faggot" used indiscriminately by peers. They become alarmed and realize that they must make some social adaptation to the situation. Martin describes their predicament:
All young people face tremendous pressures to desist from any homosexual behavior and develop a heterosexual orientation. It is easy to see why adolescents with predominantly homosexual feelings and experiences would try to deny a lesbian or gay identity. They have internalized an image of being a homosexual as wrong and dangerous to their physical and mental health. They have seen the stereotypes of lesbians and gay men and they don't like them. These youth who don't want to live like that decide they are going to conform to the social roles and start dating members of the opposite sex and become heterosexuals.
Many youth engage in heterosexual sexual behavior in an effort to change their orientation. This often turns out to be a losing battle. Jay and Young found that 83 percent of the lesbians and 66 percent of the gay men in their survey had previously engaged in heterosexual sex (1). Bell and Weinberg similarly found that 87 percent of lesbians and 68 percent of gay males interviewed had prior heterosexual experiences (2). Two studies with gay male youth found that at least 50 percent had prior heterosexual experiences (5,6). Jay and Young add that 55 percent of the lesbians and 46 percent of the gay males reported feeling negative about these experiences. Bell, et al. in their study on the development of sexual orientation conclude that:
Youth who try to change a homosexual orientation and are unable to do so are at high risk of emotional and behavioral problems. They often develop feelings of hatred and rage that can be turned against themselves or others. They may engage in self-destructive behaviors such as substance abuse as an unconscious expression of feelings too painful to face. Others become involved in verbal and physical attacks against other homosexuals as a way of defending against their own fears. Finally, when the youth comes to recognize for the first time that he/she have a primary homosexual orientation, overt suicidal behavior may result.
The DSM III includes a new disorder called "Ego-Dystonic Homosexuality" which describes many of the conflicts faced by youth engaged in denial of homosexual feelings (25). It is characterized by "a desire to acquire or increase heterosexual arousal...and a sustained pattern of overt homosexual arousal...(that is) unwanted and a persistent source of distress." Associated features include guilt, loneliness, shame, anxiety and depression. Age of onset occurs in "early adolescence when the individual becomes aware that he or she is homosexually aroused and has already internalized negative feelings about homosexuality." The course of the illness indicates that "in time, many individuals...give up the yearning to become heterosexual and accept themselves as homosexuals...(with the help) of a supportive homosexual subculture." Remafedi notes that the usefulness of this term is still not known since distress is so prevalent among youth first recognizing a homosexual identity (5). However, it clearly identifies a phenomena in many young homosexuals that places them at a greater risk of taking their own lives.
Those Who Hide
Many youth are aware of their gay or lesbian identity but decide not to be open about it and try to pass as "straight" with their families and peers. They have seen the negative response to homosexuality from society and the brutal treatment of gays by their peers. Sometimes they have been the recipients of verbal or physical abuse as "suspected" homosexuals. Martin believes that hiding is the primary adaptation for gay and lesbian youth (24). He observes that many realize that their lives are based on a lie with "the socialization of the gay adolescent becoming a process of deception at all levels, with the ability to play a role." While remaining in-visible to others, the pain and loneliness of hiding often causes these youth serious harm to their mental health and social development.
A serious consequence of this adaptation is that these youth suffer their fears and low self esteem in silence. They are unknown victims of scapegoating with every homophobic assault or remark they witness. They live in perpetual fear that their secret will be discovered. Gay youth become increasingly afraid to associate with others and withdraw socially in an effort to avoid what they perceive as a growing number of dangerous situations. They spend more and more Lime alone. Aaron Fricke relates the problems of hiding a gay identity in his book Reflections of a Rock Lobster: A Story About Growing Up Gay (26). He describes his response to being victimized by a homophobic assault as he was about to begin high school
The only goal left to me in life was to hide anything that could identify me as gay. I became neurotic about this. I once heard that gay people talked with a lisp. I was horrified when I discovered that I had a slight lisp, and it made me self-conscious about how I sounded every time I spoke. Self-doubt set in. I thought that anything I did might somehow reveal my homosexuality, and my morale sank even deeper. The more I tried to safeguard myself from the outside world, the more vulnerable I felt. I withdrew from everyone and slowly formed a shell around myself. Everyone could be a potential threat to me. I resembled a crustacean with no claws; I had my shell for protection yet I would never do anything to hurt someone else. Sitting on a rock under thousands of pounds of pressure, surrounded by my enemies, the most I could hope for was that no one would cause me more harm than my shell could endure.
Martin also believes this adaptation hinders the social development of gay and lesbian youth (24). There is an absence of social Out-lets for gay youth that makes it very difficult for them to meet others like themselves. They shy away from attachments to friends for fear of getting too involved or experiencing rejection. Open relationships or displays of affection with others of the same sex is not tolerated in the gay youth's home and social environment, making extreme secrecy a requirement in developing romantic attachments. (Indeed, these issues form the essence of discrimination against homosexuals in our society.) Consequently, lesbian and gay youth do not learn how to establish and maintain intimate relationships in the way heterosexual youth do.
Young gay males often experience their same-sex relationships as casual sexual contacts with strangers. Because of their age, many of these encounters occur in clandestine meeting places where gay males congregate. Roesler and Deisher found that 76 percent of their subjects had met sexual partners in parks, 62 percent in theaters, and 32 percent in restrooms (6). Remafedi found that 63 percent of young gay males be surveyed had met other males in gay bars; only 28 percent said they had known their partner for a week prior to having sex (5). Martin expresses concern that these encounters condition the young gay male to respond to other gay males on a sexual level only.
Young lesbians are even more isolated than young gay males in their efforts to form intimate relationships. There are few meeting places for lesbians in our society and casual sexual contacts are a less frequent part of their development. Lewis writes that:
Openly Gay and Lesbian Youth
Those who accept their orientation and are open about it with others form a smaller but visible segment of the lesbian and gay male youth population. They learn that only part of developing an identity as a gay male or lesbian is coming to understand and accept your sexual orientation. Now they must find out what their place is and where they belong within the confines of the traditional social structure available to them. There are few role models to emulate and society offers them little support in this process. Gay youth usually don't begin to be open about their orientation until middle to late adolescence.
Many of these youth will have an atypical social role that includes gender nonconformity. Bell, et al. found that 62 percent of lesbians surveyed described themselves as "very masculine" while growing up (15). Remafedi found more than half of young gay males interviewed saw themselves as "less masculine" than their peers (5). Gender nonconformity maybe more pronounced in youth first openly identifying themselves as gay. Sometimes it is a natural and permanent expression of who they are and sometimes it is a transitional process youth go through in learning that they don't have to behave in any particular way to be gay. Weinberg and Williams found that younger gay males identified themselves as effeminate three times more frequently than did older gay males (27).
Gender nonconformity in gay youth may reflect natural qualities that do not fit cultural stereotypes (e.g., men who are gentle, women who are strong). Youth may have expressed these attributes since childhood and will continue to do so as adults. Gender non-conformity may also fit the expectations that society sets for gay and lesbian youth. Gay youth are especially susceptible to cultural stereotypes while struggling to find an appropriate identity. One young gay male told me that he literally thought that he had to be "like a girl" because he was gay. There is not a diversity of gay male and lesbian adult role models for gay youth to pattern themselves after. For many young lesbians and gay men, the earliest images of adults they thought were homosexuals were people who fit the traditional stereotypes.
Gender nonconformity may finally be a conscious effort to reject traditional roles and establish a separate and viable identity. One young lesbian told me she threw away her dolls in disgust when she was a child. It is not unusual for individuals sharing a common identity to separate themselves from others by establishing particular behaviors, appearances, terminology and interests. Effeminacy in young gay males and masculinity in young lesbians is often a way for them to affirm a homosexual identity and assist them in finding each other. According to Wolf, culturally defined masculine attire is "more strongly assumed by young women who are newly aware of their lesbianism and looking for a community" (22).
Gay and lesbian youth take tremendous risks by being open about who they are. You have to respect their courage. They remain at high risk to suicidal feelings and behavior because of the pressures they face in conflicts with others about their homosexual orientation and the disappointments they experience at the initial hardships of an openly gay and lesbian lifestyle. Rofes warns that no myth is more dangerous to gay adolescents than the notion that "coming Out" will insure them against feelings of self-destructiveness (19).
The immediate conflicts that openly gay youth face are with their peers and family. Openly homosexual youth are an affront to a society that would like to believe they don't exist. Our culture seems to have particular disdain for those gay youth who do not conform to gender expectations. Rejection or abuse can become so intense that suicidal feelings and behavior result. Openly gay youth are more likely to be forced to leave their schools and families and survive on their own.
Those gay youth forced to become self sufficient prematurely find that they face the discrimination of society against both youth and homosexuals in trying to do so. Often these youth have not had vocational training and some have not completed their secondary education. They are discriminated against in finding housing and employment because of their sexual orientation. Perhaps most disappointing, gay youth find they often cannot depend on help from adult gay males and lesbians in getting established because of the fears adult homosexuals have of being seen as "recruiting" young people. Gay youth often become involved with a small and unstable population of gay males and lesbians living on the streets. Here, they are at high risk at substance abuse, sexually transmitted diseases, and unstable relationships. The hardships of this lifestyle combined with the early rejection by family and peers may result in a suicide attempt.
Ethnic Minority Gay Youth
Ethnic minority youth (i.e. Black, Hispanic, Asian, and American Indian) comprise a substantial number of youth who are gay, lesbian, bisexual, or transsexual. Ruth Hughes, Coordinator of Gay Youth Services at the Center for Special Problems in San Francisco, reports that these youth face more severe social and cultural oppression than other gay youth and far more serious problems than other adolescents (29). Bell and Weinberg found that black gay males and lesbians attempted or seriously considered suicide at a rate less than white homosexuals but greater than black heterosexuals (2). However, they found that a higher percentage of suicide attempts by black homosexuals took place during their youth. 36 percent of black lesbians compared to 21 percent of white lesbians and 32 percent of black gay males compared to 27 percent of white gay males attempted suicide before age 18. This indicates that black gay youth may face particular hardships during adolescence.
Ethnic minority gay youth face all of the problems that other gay and lesbian youth face growing up in a hostile and condemning society. They also face the same economic discrimination and prejudice confronted by other ethnic minority youth because of racism. Davis notes a dramatic increase in suicides among young blacks over the past two decades that has brought their suicide rate nearly equal to that of white youths (30). Hendin, in his book Black Suicide, offers an explanation:
Little has been written about Third World sexual minorities, and when generalities were made about our lifestyles, attitudes, and behaviors, they were often made in reference to white cultures--white cultures being the basis for Third World cultures to deviate from or strive for (33).
Finally, ethnic minority gay youth must contend with discrimination and special problems from their own ethnic group because of their sexual orientation. Hughes believes that ostracism and separation from their own ethnic group is particularly painful and difficult for these youth to cope with:
Ethnic minority cultures have historically believed that homosexuality is a sin according to the faiths to which they predominantly belong. Parents frequently use religion as the standard to evaluate homosexuality. A homosexual orientation in their son or daughter becomes incompatible with religious beliefs. Ethnic minority gay youth often internalize these religious values, and feel guilty for having homosexual feelings and experiences, fearing they are condemned to hell.
The family also plays a central role in the lives of these youth with strong expectations that they will fulfill social roles and perpetuate the extended family. A homosexual orientation is sometimes seen as a sign of disrespect to the family by the youth and a threat to the family's survival.
Ethnic minority gay youth have tremendous fears of losing their extended family and being alone in the world. This fear is made greater by the isolation they already face in our society as people of color. These ethnic minority gay youth who are rejected by families are at risk of suicide because of the tremendous pressures they face being gay and a person of color in a white homophobic society.
Transsexual youth are perhaps the most outcast of all young people and face a grave risk of suicidal feelings and behavior. Huxdly and Brandon found that 53 percent of 72 transsexuals surveyed had made suicide attempts (34). Harry feels that "transsexuals may be at higher risk than homosexuals and much higher risk than the general population" to suicidal behavior (35). Transsexual youth believe they have a gender identity different from the sex they were born with. They often manifest this belief beginning in childhood through an expressed desire to be a person of the opposite gender, repudiation of their genitalia, gender nonconformity and cross dressing (25). These behaviors may subside by adolescence due to extreme pressures to conform to social expectations. Some transsexual youth, however, try to "pass" in junior high and high school as a person of the opposite sex or engage in increasingly pronounced behaviors that do not conform to gender expectations. These adaptations present serious internal and external conflicts for these youth.
All transsexuals are vulnerable to internalizing an extremely negative image of themselves. They experience tremendous internal conflict between this image and their persistent desire to become the person they believe they are. Heller notes that suicidal transsexuals tend to feel hopelessly trapped in their situation (36). These feelings may be particularly pronounced in young transsexuals who are forced to hide their identity. While wanting to change their sex, they are seldom able to do so and feel condemned to a Life they are convinced is a mistake. The DSM III notes that transsexuals frequently experience "considerable anxiety and depression, which the individual may attribute to inability to live in the role of the desired sex" (25). This depression combined with a poor self esteem can easily result in suicidal feelings and behavior in transsexual youth.
Some transsexual youth, however, make increasingly braver attempts to live as a person of the opposite sex They experience conflicts in making a social adaptation to their believed identity. Many young transsexuals will adapt the most stereotyped roles and behaviors traditionally associated with being a "male" and a "female" in our society. Like other youth, they are trying to define themselves by rigid adherence to these roles. Sometimes transsexual youth experience problems similar to this:
It is important to distinguish between transsexual youth and gay and lesbian youth who do not conform to gender expectations. Gender nonconformity is common among gay youth in both childhood and adolescence. Some gay and lesbian youth may experience gender identity confusion during adolescence in the coming out process because of the intense social pressures for gay males to be like women and lesbians to be like man. Gay youth may feel they actually have to be a person of the opposite gender to meet those expectations. Hughes, in her work with both homosexual and transsexual youth, emphasizes the importance of working with a young person over a period to time to determine if they are truly a transsexual (29). Gay and lesbian youth come to recognize that they neither want to change their sex nor live as a person of the opposite gender.
RISK FACTORS IN GAY AND LESBIAN YOUTH SUICIDE
Gay young people face the same risk factors for suicidal behavior that effect other youth. These include family problems, breaking up with a lover, social isolation, school failure, and identity conflicts. However, these factors assume greater importance when the youth has a gay or lesbian orientation. Jay and Young found that 53 percent of gay males and 33 percent of lesbians surveyed believed their suicide attempts involved their homosexuality (1). Bell and Weinberg report that 58 percent of gay males and 39 percent of lesbians felt their first suicide attempts were related to the fact that they were homosexuals (2). Suicide attempts by gay and lesbian youth are even more likely to involve conflicts around their sexual orientation because of the overwhelming pressures they face in coming out at an early age.
Bell and Weinberg found that initial suicide attempts related to homosexuality more frequently involved acceptance of self and conflicts with others for gay males, while lesbians tended to cite problems with lovers as the reason (2). Self acceptance may be especially critical for young gay males who tend to have homosexual experiences and are aware of their orientation at a somewhat earlier age than lesbians (1,15). Conflicts with others may be more salient for young gay males "identified" as homosexuals. Gender non-conformity elicits a negative response from others for lesbian and gay male youth, but society seems to have particular disdain for effeminate young males. Young lesbians may experience more extreme social isolation, often reporting an absence of same-sex experiences or knowing others like them during adolescence. They also face stronger social pressures to fulfill the woman's traditional role of marrying and having children and may experience more depression related to not meeting social expectations. Problems with lovers may be especially critical for young lesbians because their sexuality is often explored within the context of their early intimate relationships.
The earlier a youth is aware of a gay or lesbian orientation, the greater the problems they face and more likely the risk of suicidal feelings and behavior. Remafedi observes that:
It is a sobering fact to realize that we are the greatest risk factors in gay youth suicide. No group of people are more strongly affected by the attitudes and conduct of society than are the young. Gay and lesbian youth are strongly affected by the negative attitudes and hostile responses of society to homosexuality The resulting poor self-esteem, depression, and fear can be a fatal blow to a fragile identity. Two ways that society influences suicidal behavior by gay and lesbian youth are: 1) the ongoing discrimination against and oppression of homosexuals, and 2) the portrayal of homosexuals as being self-destructive.
It is the response of our society as a whole to homosexuality, and specifically those institutions and significant others responsible for their care, that pose the greatest risk to gay and lesbian youth. Gock believes that homophobia, the irrational fear and hatred of homosexuals, is the root of the problem (37). Gay males and lesbians are still routinely the victims of violence by others. In a recent survey of nearly 2,100 lesbians and gay men nationwide, the National Gay Task Force found that more than 90 percent had been victims of verbal and physical assault be-cause of their sexual orientation (10). Tacit and explicit discrimination against homosexuals is still pervasive in virtually all areas of life. Half of the States still prohibit homosexual relationships between consenting adults (37). Homosexuals are not allowed to legally marry and form "legitimate" long-term relationships. The vast majority of States and municipalities still discriminate against lesbians and gay men in housing, employment and other areas. Gay and lesbian youth see this and take it to heart.
Rofes warns us against the myth that homosexuality, in and of itself, encourages suicide (13). There is nothing inherently self-destructive in homosexual feelings and relationships that could be a source of suicidal behavior. In his book, I Thought People Like That Killed Themselves Rofes maintains we have created a stereotyped image of the unhappy homosexual in literature and the media (e.g., Boys in the Band) for which suicide is the only appropriate resolution. This image is reinforced by the fact that homosexual characters in novels and films invariably kill themselves in the end. The myth is perpetuated by the absence of positive adult gay role models in our society where, historically, the only known homosexuals were those exposed by scandal arid disgraced in their communities. Rofes maintains this creates a strong negative con text for the early identity formation of young gay males and lesbians effectively socializing them into suicidal feelings and behavior. He sees a strong correlation between sexual orientation, social response to that sexual orientation, and subsequent suicidality in an individual.
A predisposing factor in suicidal feelings among many adolescents is poor self esteem. This is especially true for gay adolescents who have internalized a harshly negative image of being bad and wrong from society, religion, family, and peers. For youth, a poor self-image contributes substantially to a lack of confidence in being able to cope with problems. The images of homosexuals as sick and self-destructive have impact on the coping skills of gay youth, rendering them helpless and unable to improve their situation. Gay youth who have internalized a message throughout their lives of being worthless and unable to cope from abusive and chaotic families are at even greater risk.
Youth with a poor self-esteem and poor coping skills are particularly vulnerable to suicidal feelings when confronting a problem for the first time. They really don't know how to resolve it or even if they can. Gay youth are highly susceptible to suicidal feelings during the "coming out" process when first facing their own homosexuality arid the hostile response it evokes in others, They may attempt suicide when they first realize they have homosexual feelings or a gay orientation. Some youth deny their homosexual feelings and engage in unconscious self-destructive behavior out of self hatred. Others try to "change" their Orientation and make a suicide attempt when they recognize their homosexuality will not go away and is part of who they are.
Many youth realize they are gay or lesbian but attempt to hide their orientation from others. They suffer from chronic loneliness and depression. They may attempt suicide because they feel trapped in their situation and believe they do not deserve to live. A suicidal gesture may be a cry for help from these youth for others to recognize and understand their situation. Finally, those youth who are open about being gay; lesbian, or bisexual face continuous conflict with their environment They remain vulnerable to suicide because they face these extreme pressures with a more fragile sense of self worth and ability to cope with life than other youth.
Family problems are probably the most significant factor in youth suicide. Youth derive their core sense of being cared about and belonging from their families. Gay youth may make suicide attempts after being rejected by their families. For gay and lesbian youth forced to leave home, the loss of parental love and support remains a critical issue for them. Sometimes the youth's sexual orientation becomes a convenient excuse for parents to reject a son or daughter they did not want Youth from abusive and dysfunctional families are at even greater risk. Wandrei found, in comparing suicide attempts by lesbians and heterosexual women, that lesbians were more likely to come from broken homes (39).
Gay and lesbian youth face more verbal and physical abuse from family members than do other youth. The National Gay Task Force found that more than 33 percent of gay males and lesbians reported verbal abuse from relatives because of their orientation and 7 percent reported physical abuse as well (10). These figures are substantially higher for youth open about their sexual orientation while still living at home. Sometimes this harassment becomes too much to bear for gay youth and a suicide attempt results.
Gay and lesbian youth may feel suicidal because of a failure to meet family expectations. All youth need approval from their parents. Some youth report only feeling loved by parents when they are fulfilling their parents image of who they should be. Gay youth often feel they can not meet their parents standards and may attempt suicide after real or anticipated disappointment by their families that they will not fit the social script of heterosexual marriage and grandchildren. This pressure is particularly strong for lesbians. Gay youth fear they will not have families of their own and be alone as adults with no one to care for them.
Communication problems also play a serious role in family issues for gay youth. Many lesbian and gay youth hide their orientation from their parents out of fear of rejection. They have often seen a strong negative reaction to homosexuality by parents and siblings including homophobic remarks. The anticipated inevitable loss of love can precipitate a suicide attempt Parris related a call to a suicide hotline in Washington, D.C.:
Religion presents another risk factor In gay youth suicide because of the depiction of homosexuality as a sin and the reliance of families on the church for understanding homosexuality. Many traditional (e.g., Catholicism) and fundamentalist (e.g., Baptist) faiths still portray homosexuality as morally wrong or evil. Family religious beliefs can be a primary reason for parents forcing youth to leave home if a homosexual orientation is seen as incompatible with church teachings. These beliefs can also create unresolvable internal conflicts for gay youth who adhere to their faith but believe they will not change their sexual orientation. They may feel wicked and condemned to hell and attempt suicide in despair of ever obtaining redemption.
Many gay and lesbian youth feel trapped in school settings because of a compulsory obligation to attend and the inability to defend themselves against verbal and physical assaults. Schools do not adequately protect gay youth with teachers often reluctant to stop harassment or rebut homophobic remarks for fear of being seen as undesirable role models (19). Verbal and physical attacks against gay youth have increased in recent years as students become increasingly threatened by the presence and openness of peers with a lesbian or gay orientation. This abuse begins as early as late elementary school, becomes pronounced in junior high when youth are still immature, and continues into high school The failure of schools to address this concern can be tragic:
Social isolation has been consistently identified as one of the most critical factors in suicide attempts by youth. The isolation and alienation young people experience in all aspects of their lives can be overwhelming. Those youth hiding their identity often withdraw from family and friends out of fear of being discovered. They feel there is no one they can talk to and no one who will understand. Tartagni, based on his experience teaching in public school, writes that "one of the loneliest people in any high school in America is the rejected and isolated gay adolescent" (41). This isolation may be more extreme for young lesbians who often report a total lack of contact with others like themselves during high school. 3oanne, in One Teenager in Ten, describes her feelings after realizing her lesbianism in adolescence:
Some gay and lesbian young people cope with the many problems they face by using alcohol and drugs. The age of onset for sub-stance use among all youth has become lower in recent years and in 1985 is estimated to be 11.9 years for boys and 1Z7 years for girls (42). This coincides with the age that many youth are becoming aware of a gay or lesbian orientation. Rofes found that lesbians and gay men have a higher rate of substance abuse than heterosexuals and found this to be correlated with increased suicidal feelings and behavior (13).
Gay youth are especially susceptible to substance abuse in trying to cope with the conflicts of the coming out process. Remafedi believes there may be a higher rate of substance abuse among gay youth than among gay adults (5). He found that 58 percent of young gay males he interviewed could be classified as having a substance abuse disorder in the DSM III. Gay youth forced to live on the streets experience more severe drug problems. The Larkin Street Youth Center in San Francisco reported that more than 75 percent of their clients identified as gay had serious and chronic disorders (8). The Los Angeles Suicide Prevention Center found a strong correlation between substance abuse and suicide attempts among gay young people (7).
Perhaps no risk factor is as insidious or unique to the suicidal behavior of gay and lesbian youth than receiving professional help. The large number of gay youth who have had contact with mental health and social work services during their turbulent adolescent years would seem to be a positive indicator for improving their stability and future outlook. This is sadly not often the case. Many helping professionals still refuse to recognize or accept a homosexual orientation in youth despite growing evidence that sexual orientation is formed by adolescence (15). They refuse to support a homosexual orientation in youth despite the fact that homosexuality is no longer viewed as a mental disorder (25). They continue to insist that homosexual feelings are just a passing "phase", while making the goal of treatment arresting or changing those feelings and experiences. Martin pointedly describes this process:
Youth who deny their feelings and experience "ego-dystonic homosexuality" are especially vulnerable to this type of adverse treatment. Rather than helping these youth to accept and understand predominantly homosexual feelings and experiences, we see their denial as a "hopeful" sign that they can still develop a heterosexual orientation. When homosexual feelings persist after treatment has attempted to change them, the youth despairs and is at potentially greater risk for suicide than if we tried to help him/her towards acceptance.
Youth who are aware of their lesbian or gay orientation but hide it from others, may seek help without identifying their concerns about their sexuality. We often do not recognize these youth because we don't acknowledge they exist. We are uncomfortable in discussing or addressing the issue and consequently are unable to identify or resolve the source of the youth's conflicts. A suicide attempt may be an effort by the youth to force the issue and bring it to our attention. It may also be an act of despair over a problem that they feel can not be addressed through professional help.
Even openly gay and lesbian youth are subjected to treatment with potentially adverse effects. Frequently, informing family and counselors that a youth is gay is the impetus for imposed treatment. We assume that the youth's gay orientation is the source of the problem rather than the response of others to his/her being lesbian or gay. Encouraging these youth to change can cause regression in the development of a healthy gay identity and reinforce traditional stereotypes of homosexuals as sick and self destructive. This, in turn, further weakens the youth's self-esteem and ability to cope with problems. Even those professionals who accept the youth as gay or lesbian are often unable to support the youngster in dealing with conflicts at home and in school.
There is a critical lack of program resources for gay and lesbian youth. Many social and recreational programs for youth make no effort to incorporate gay young people into their services. Few programs will accept or support a gay adolescent in their sexual orientation. Agency policies tacitly or explicitly forbid the hiring of openly gay and lesbian staff, denying gay youth access to positive adult gay role models. Homophobic remarks and attitudes by youth and staff in many of these programs go unrebutted. Consequently, gay youth do not use many of the youth service resources available to them or soon leave if they do. This increases their social isolation and alienation from their peers.
Other gay and lesbian youth who are wards of the juvenile court have little choice but to live in those placements to which they are referred. Here, they re-experience many of the problems they bad in their home communities. Many foster families are rejecting of gay and lesbian youth, feeling less investment than a youth's natural family to keeping the youth in the home. Gay male and lesbian adults are prohibited in most States from being foster parents with gay youth again denied access to supportive adults who could serve as positive role models for them.
Group home placements present special hardships for gay youth because abusive peers often live in the same home with them. Those programs without an on-site school require gay youth to return to public school for their education. Program staff have seldom received training on issues and concerns related to homosexuality. They are frequently unable to understand or work with gay youth effectively. Group homes become a living hell of harassment, isolation, and conflicts with other staff and residents offering gay youth little support and no resolution. A suicide attempt may be an effort to force removal from the placement and find a different home. Many homes, however, will not accept gay youth and few offer specialized services to meet their needs.
Relationships with Lovers
We are all victims of the myth that our first love will be our one true love until death do us part (e.g., Romeo and Juliet). Young people are especially vulnerable to this misconception and breaking up with a lover is one of the most frequent reasons for their suicide attempts. The first romantic involvements of lesbian and gay male youth are a source of great joy to them in affirming their sexual identity, providing them with support, and assuring them that they too can experience love. However, society places extreme hardships on these relationships that make them difficult to establish and maintain. Bell and Weinberg found that relationship problems were the single most frequently cited reason for the initial suicide attempts of lesbians (62%) and gay males (42%)(2).
Intimate relationships are the primary focus of hostility and discrimination against homosexuals. Society severely restricts where homosexuals can meet, prevents public displays of affection between them, and does not allow legal marriages to be formed. Gay and lesbian youth suffer greater isolation than homosexual adults and far greater social deprivation than other adolescents. It is extremely difficult for them to meet other homosexuals and they frequently do not know anyone like themselves. Gay youth who hide their identity often form their first romantic attachments to unknowing friends, teachers, and peers. These are often cases of unrequited love with the youth never revealing their true feelings. Gay youth are fragile in these situations and may experience despair or suicidal feelings from never being able to fulfill their hopes for a relationship. Some gay youth bravely reveal their feelings and may attempt suicide after blatant rejection by a teacher or the loss of a close friend.
Young gay males often experience their first homosexual relationships as brief sexual encounters in clandestine meeting places (e.g., parks). The extreme need for secrecy and anonymous nature of these contacts seriously hinder their further development. The intensity of sexual feelings that accompany these encounters can easily be mistaken for romantic attachment by young gay males. They may feel suicidal at the failure of these experiences to meet intimacy needs and the inability to fulfill the social expectation of sustaining the relationship. Young lesbians experience greater isolation than young males. They are less likely to explore their sexuality or have relationships during adolescence. They may feel suicidal at the despair of ever finding love in relationships with other women.
Gay and lesbian youth develop intimate relationships at a later age than other youth and are unable to develop relationship skills in the manner of other adolescents. Their first romances are an emotionally turbulent trial and error process that resembles a second adolescence. Gay youth bring to these relationships extreme dependency needs resulting from the deprivation experienced in their relationships with family and peers. They also are still in the process of forming their identity and have unresolved issues of guilt and poor self-esteem. When conflicts arise in homosexual relationships there are few social supports available to assist them. This is compounded for gay youth by their frequent need for secrecy and the fact that they may not be open about their identity with family and friends.
Breaking up with a lover may confirm earlier negative experiences and concepts associated with being a homosexual. Young lesbians often explore and define their sexuality within the context of their first relationships. A relationship failure for them may be synonymous with problems in developing a positive lesbian identity. For some gay youth, relationships become a way of filling needs for love and belonging missing from family and peers. When the relationship ends, the youth feel as though they have lost everything. They fear that they will always be alone, that no one cares, and nothing is worth living for.
Gay and lesbian youth are more likely than other adolescents to be forced to leave home and become self sufficient prematurely. Some of these youth have been hiding their identities and can no longer stand the extreme isolation in their lives. Many others have been rejected by families and have dropped Out of school, effectively forced out of their communities because of their sexual orientation. Gay youth come to large cities hoping to find others like themselves, legitimate employment, a lover and a new "family." They soon become aware of the lack of opportunities available to them and become enmeshed in the problems of survival. Suicidal feelings emerge as the hope for a new and better life begins to pale.
Most gay youth are unprepared for the difficulties they encounter. They are discriminated against in finding employment and housing by virtue of being both young and homosexual. Many have no vocational training and some were not able to finish high school. They often find limited support from the lesbian and gay male adult community who fear involvement with youth. Many are forced to turn to the streets for survival. A recent study on adolescent male prostitution found that nearly 75 percent identified themselves as gay or bisexual, with family conflicts as the primary reason for leaving home (43). Many gay youth become homeless. Others depend on relationships with people they meet on the streets to obtain shelter and survival needs.
Gay youth living on the streets are at greater risk of suicide due to repeated exposure to chronic substance abuse, physical and sexual assault, and sexually transmitted diseases including AIDS. Their contact with the limited segment of gay adults involved in street life confirms a negative image of homosexuality and they remain unaware of the variety of positive adult gay lifestyles open to them. Their relationships are tenuous and complicated by dependence on their lovers for support Some gay and lesbian youth engage in increasingly reckless and self-destructive behavior as an expression of the sadness and anger they feel because of the unresolved issues with their families and despair over their new life. A suicide attempt may result from a negative contact with their family, breaking up with a lover, or failure to make it on their own.
AIDS (Acquired Immune Deficiency Syndrome)
Gay and bisexual male youth again belong to two groups at high risk of contracting sexually transmitted diseases: gay/bisexual males and adolescents. Although the number of confirmed cases of AIDS and ARCs (AIDS Related Conditions) among adolescents is small, it is believed that cumulative exposure to the virus, beginning in adolescence, may result in a diagnosis or symptoms as a young adult. Gay and bisexual males have always been subject to a greater number of health problems through sexually transmitted diseases (STD). They comprise a substantial majority of confirmed cases of AIDS and more than 50 percent of adult gay males will contract Hepatitis Type B during their lifetime (44).
Young people are taught in our society that sex is a secretive and spontaneous activity. Adolescent males are not encouraged to take responsibility for their sexual behavior; the vast majority do not take precautions in their sex practices. They engage in impulsive and unplanned sexual activity with grave consequences. Young people contract several million cases of STDs every year (45). Gay and bisexual male youth are particularly vulnerable because of their need for secrecy in sexual contacts and the frequency with which they engage in unplanned sexual activity. Those gay and bisexual male youth living on the streets face a substantially greater risk of exposure to STDs because of repeated sexual contacts in their relationships and prostitution experiences. Street youth face additional exposure through intravenous drug use.
Sexual experiences are important to gay male youth as a way of exploring and affirming their sexual orientation. Many do not take precautions and share a feeling of invulnerability to future consequences that is common among all youth. Remafedi found, however, that 45 percent of young gay males interviewed had a history of STDs (5). The attitudes of young gay males towards exposure to AIDS ranges from denial to extreme fear to not caring. One young male said he was not concerned because "teenagers do not get AIDS." Another was convinced that a head cold he had developed was the first symptom of AIDS. Those who are at greatest risk may be those who simply do not care whether they are exposed to the virus. Some gay youth have an uncaring approach to life that reflects a "suicidal script." They are more prone to self-destructive behavior because of the severity of the problems they have experienced throughout their lives and specifically in relation to their sexual orientation. Contracting AIDS becomes for them the fulfillment of a life of pain and suffering they no longer want to cope with. They feel that they deserve to die.
A final risk factor for gay and lesbian youth suicide is a bleak outlook for the future. Young people have difficulty seeing a future life that is different from the present. Gay and lesbian youth fear their lives will always be as unhappy and hard as they presently are. They do not know that they will receive any more caring, acceptance, and support than they are getting now. The little information they have about homosexuality usually reinforces these mistaken beliefs. Gay youth do not understand what life could be like as a gay male or lesbian adult. They do not have accurate information about homosexuality, positive role models to pattern themselves after, or knowledge of gay and lesbian adult lifestyles and communities. Lesbian and gay youth frequently don't know that many lesbian and gay male adults lead stable, happy, and productive lives. They go through adolescence feeling lonely, afraid, and hopeless. Sometimes they take their own lives.
ENDING GAY AND LESBIAN YOUTH SUICIDE
We can substantially reduce the risk of suicide among gay and lesbian youth. The problem is clearly one of providing information, acceptance, and support to gay youth for coping with the pressures and conflicts they face growing up as homosexuals in our society. However, in addressing their concerns we confront two issues of greater magnitude: 1) the discrimination against and maltreatment of homosexuals by our society and 2) the inability of our society to recognize or accept the existence of homosexuality in the young. The homophobia experienced by gay youth in all parts of their lives is the primary reason for their suicidal feelings and behavior. Rofes notes that it is no longer difficult to document the violence, shame, and hatred by society with which lesbians and gay men have lived (13). This is the issue we must address to save the lives of gay males and lesbians who are young.
The first step in ending gay youth suicide is to end the discrimination against and stigmatization of homosexuals in our society. We have tenaciously clung to lies and prejudices about homosexuals for far too long. Too many lives have been brutalized and lost A growing body of research contradicts our negative biases and assumptions about gay males and lesbians. We do not, as a society, want to continue to hold the untenable position of senselessly hurting others—especially the young. Gay males and lesbians need to be accepted as equal partners in our society. Laws should safeguard their individual rights and not permit discrimination against them in housing, employment, and other areas. Laws prohibiting homosexual relationships between consenting adults should be repealed and marriages between homosexuals should be recognized. Special attention should be paid to the enforcement of laws that punish those who commit violence against homosexuals. Laws can help to establish the principle of equality for lesbians and gay men and define the conduct of others in their interactions with them.
It is an even more comprehensive task to address the negative attitudes about homosexuality held by so many people. A conscious effort must be made to dispel the destructive myths about homosexuality at all levels of society. We must promote a positive image of gay males and lesbians to reduce oppression against them and provide gay youth with role models to pattern themselves after. Massive education efforts need to take place that would provide people with accurate information about homosexuality. These efforts especially need to be directed to those who have responsibility for the care of the young including families, clergy, teachers, and helping professionals. The media needs to take responsibility for promoting a positive image of homosexuals that presents a variety of gay male and lesbian lifestyles. We must also take personal responsibility for revising our own homophobic attitudes and behavior as an example to others in the same way that we have worked towards revising discriminatory racial attitudes and conduct. It is at the personal level that we have the greatest impact on the lives of those around us.
Third, we must directly address the issue of homosexuality in the young. Our society has historically denied the sexuality of young people. We must educate ourselves on the issues and problems related to sexual development in young people. Society needs to promote a positive image about sexuality and provide youth with accurate information on the subject. We need to recognize that youth are sexually active from an early age and that sexual orientation is frequently formed by adolescence. All youth need to be provided with positive information about homosexuality that presents it as a viable adaptation. We must accept a homosexual orientation in young people in the same manner we accept a heterosexual orientation. Finally, we need to assist gay and lesbian young people in the coming our process and support them in the many conflicts they presently face.
Gay and lesbian youth need to receive acceptance and understanding from their families if we are to reduce their risk of suicide. Parents need to be educated as to the nature and development of homosexuality in individuals. They often feel guilty and ashamed upon first learning that their child is gay because they have been told that it is wrong and they are to blame. Parents should know that homosexuality is a natural and healthy form of sexual expression. They do not need to feel bad about something that is good. Parents should also know that we still do not know the origins of a heterosexual or homosexual orientation. Research indicates a predisposition towards sexual orientation in children that limits the role of family in its development.
Families have a great deal of influence on how their children feel about their sexual orientation; Parents should be made aware of the potential negative impact homophobic remarks and behavior have on their child. Homophobic conduct can be taken as rejection by youth struggling with their sexual orientation or encouragement by other youth to victimize homosexuals as they grow older. Families need to take responsibility for presenting homosexuality in a positive context to their children. Parents need to accept and understand a son or daughter with a homosexual orientation. Those parents who have difficulty accepting their lesbian daughter or gay son should get more information on the subject and not try to "change" them. They should let the child know they are still loved and cared about as individuals regardless of their sexual orientation.
Ethnic minority families need to understand and accept their gay and lesbian children. Ethnic minority gay youth depend even more strongly on their extended family and culture for support because of the additional oppression they face as a racial minority within society as a whole and the homosexual community. Parents need to be educated as to the extent and diversity of lesbians and gay males within ethnic minority cultures. They need to understand that their child means no disrespect to the family and cannot be any different from whom they are.
Society needs to reinforce parental responsibilities for the care of their children, irrespective of sexual orientation, until they become adults. Parents need to be held accountable for the abuse of their children related to their homosexual orientation. We need to become more conscious of the extent to which the abuse of gay adolescents occurs within their own families.
Religions need to reassess homosexuality in a positive context within their belief systems. They need to accept gay youth and make a place for them in the church and include them in the same activities as other youth. Religions should also take responsibility for providing their families and membership with positive information about homosexuality that discourages the oppression of lesbians and gay men. Faiths that condemn homosexuality should recognize how they contribute to the rejection of gay youth by their families and suicide among lesbian and gay male youth.
Public and private schools need to take responsibility for providing all students at the junior high and high school level with positive information about homosexuality. Curriculum materials should include information relevant to gay males and lesbians as it pertains to human sexuality, health, literature and social studies. Family life classes should present homosexuality as a natural and healthy form of sexual expression. Information on critical health issues such as AIDS should be presented to all students. Curricula should include values clarification around social roles to increase the respect for individual differences and reduce the stigma attached to gender nonconformity. A variety of gay male and lesbian adult lifestyles should be presented as positive and viable for youth. All youth should learn about prominent lesbians and gay males throughout history. Social studies courses should include issues relevant to gay male and lesbian concerns and provide youth with positive gay and lesbian adult role models in our society.
Schools need to take responsibility for protecting gay and lesbian youth from abuse by peers and providing them with a safe environment to receive an education. School staff need to receive training on how to work with gay youth and handle conflicts involving gay youth. Teachers should feel secure in being able to rebut homophobic remarks and defend gay youth against harassment. Strong disciplinary actions should be imposed on those who victimize gay and lesbian youth. It is important for schools to hire openly gay male and lesbian teachers to serve as role models and resource people for gay youth. Counseling services that are sensitive to the needs and concerns of gay youth should be available to them. Special educational programs may need to be developed for those' youth who cannot be incorporated into existing school settings to ensure that young gay males and lesbians receive an equal education.
Gay and lesbian youth need access to the same social supports and recreational activities that other youth have. This would reduce their isolation and enhance their positive social development. Communities need to develop social groups and activities (i.e., dances) specifically for gay and lesbian youth as a way of meeting others like themselves and developing relationship skills. Existing youth programs such as the Boy and Girl Scouts should incorporate gay youth into their activities. Youth programs such as Big Brothers and Sisters should enlist gay and lesbian adults to work with gay youth. It is very important for gay youth to see the potential of a happy and stable lifestyle as adults. Lesbians and gay men need to become more involved in supporting gay youth and being positive role models for them. This requires assurance for gay adults that they will not be harassed and accused of "recruiting" youth in doing so.
Lesbian and gay youth must have access to social services and professional counseling that is sensitive to their needs and able to address their concerns. This is critical to reducing their risk of suicide. Sexuality is one of the most important issues facing all young people. We need to he open about sexuality and accepting of homosexuality in young people. All social service agencies and mental health professionals working with youth need specialized training on homosexuality and issues relevant to gay and lesbian youth. We also need to address issues of suicide and depression in young people. Suicidality needs to be explored with youth who have a gay, lesbian, bisexual or transsexual identity. Problems related to a homosexual orientation should be assessed as a possible reason for suicidal feelings. The goal of treatment should be to assist lesbian and gay youth in developing a positive identity and to support their sexual orientation in the conflicts they face with others. Additional counseling guidelines are provided in Appendix B.
Youth agencies need to provide outreach to gay and lesbian youth to make them aware of services and assure them that they are welcome. Gay youth are often afraid to seek help because of potential negative reactions from others. Programs should hire gay staff that reflect the population of gay youth under their care. Helping professionals should be prepared to offer referrals to gay-identified services and therapists if requested by the youth. It is an accepted premise in social services that individuals have access to programs and staff that reflect their cultural background. This principle is no less true for gay young people who often would prefer to talk about their problems with a lesbian or gay man.
Specialized services should he developed for gay and lesbian youth that reflect their particular needs. Health care programs aimed at preventing AIDS and other sexually4rans-mitted diseases need to he directed towards young gay males. Alcohol and substance abuse programs need to target gay and lesbian youth as a population at risk. Pregnancy-related services should not assume a heterosexual orientation in young women and be prepared to discuss lesbian concerns. Vocational training and independent living skills programs may need to address special problems gay youth face in becoming self-sufficient and in being incorporated into an adult gay community.
The juvenile justice system needs to take responsibility for ensuring that gay and lesbian youth receive fair treatment by the juvenile court and are placed in safe, nurturing, and supportive environments. Specialized training in working with and understanding gay youth should be provided to foster parents, group home personnel, treatment center staff, and juvenile hall counselors. Gay youth should be incorporated into placements, whenever possible, where the staff has been taught how to support gays in issues with other residents. It is critical for the juvenile court to show leadership in preventing discrimination against gay youth by prohibiting placements that refuse to accept them or that provide them with inferior care. The needs of some gay and lesbian youth might best be served in the immediate future by placement in a gay identified foster or group homes. Extremely few such placements presently exist. The juvenile court should facilitate the licensing of gay male and lesbian foster parents along with the development of residential programs specifically for those gay youth who cannot be incorporated into existing placements.
The lack of information about gay and lesbian youth suicide is a reflection of the oppression of homosexuals by our society and the invisibility of large numbers of gay males and lesbians within the youth population. There is growing awareness that a serious problem exists but we have only started to break down the wall of silence surrounding the issue. Comprehensive research is needed to determine the extent and nature of suicide among young gay males, lesbians, bisexuals, and transsexuals. These studies need to ensure that the entire spectrum of gay youth is adequately represented including lesbians, homeless youth, and ethnic minorities. This research can be the foundation for greater recognition of the problem and the allocation of resources designed to address it. Hopefully, the work done in recent years will serve as the beginning of the end of suicide among gay and lesbian youth.
RISK FACTORS IN GAY AND LESBIAN YOUTH SUICIDE
Awareness/identification of homosexual orientation at an early age
Self acceptance of homosexual orientation
Conflicts with others related to homosexual orientation
Problems in homosexual relationships
Discrimination/oppression of homosexuals by society
Portrayal of homosexuals as self destructive by society
Poor Self Esteem
Internalization of image of homosexuals as sick and bad
Internalization of image of homosexuals as helpless and self destructive
Denial of a homosexual orientation
Despair in recognition of a homosexual orientation
Rejection of child due to homosexual orientation
Abuse/harassment of child due to homosexual orientation
Failure of child to meet parental/social expectation
Perceived rejection of child due to homosexual orientation
Child's homosexual orientation seen as incompatible with family religious beliefs
Youth feels sinful, condemned to hell due to homosexual orientation
Abuse/harassment of homosexual youth by peers
Lack of accurate information about homosexuality
Rejection of homosexual youth by friends and peers
Social withdrawal of homosexual youth
Loneliness and inability to meet others like themselves
Substance use to relieve pain of oppression
Substance use to reduce inhibitions on homosexua1 feelings
Refusal to accept homosexual orientation of youth
Refusal to support homosexual orientation of youth
Involuntary treatment to change homosexual orientation of youth
Inability to discuss issues related to homosexuality
Refusal to accept/support homosexual orientation of youth
Isolation of homosexual youth by staff and residents
Inability to support homosexual youth in conflicts with residents
Inability to develop relationship skills like heterosexual youth
Extreme dependency needs due to prior emotional deprivation
Absence of social supports in resolving relationship conflicts
Lack of support from family
Lack of support from adult gay community
Involvement with street life
AIDS (Acquired Immune Deficiency Syndrome)
Unsafe sexual practices
Secrecy/unplanned nature of early sexual experiences
Despair of life as hard as the present
Absence of positive adult gay/lesbian role models
COUNSELING GAY AND LESBIAN YOUTH
Those of us who work with young people need to be able to identity gay and lesbian youth, accept them for whom they are and support them in resolving their problems. Many of these problems are directly related to their sexual orientation. If we can't identity these youth, we probably won't be able to help them. The first step is being able to talk about sexuality concerns with any youth under your care.
Don't be afraid to talk with youth about sexuality issues. You do not incur any liability for doing so. Initial interviews should include questions about the youth's sexuality just as they include other issues that affect their life (i.e., family, school, substance use, suicide, and depression). It is appropriate to do further sexuality counseling with a young person if you have a good relationship with him/her and necessary if you feel that sexuality conflicts are an important part of the situation. It is good to examine your own attitudes and minimize prejudices so that youth can feel free to convey their feelings and experiences to you. The principle of nonjudgmental therapeutic intervention is especially important in working with gay and lesbian youth. Feel comfortable with your own sexuality in order to keep tensions between you and your client to a minimum.
Don't be afraid to ask youth directly about their sexual orientation. Sexual orientation should be routinely included in questions and discussions related to sexuality concerns. Some youth will volunteer the information that they have a gay or lesbian orientation. If you strongly feel that a youth is gay, the only way to find out may be simply to ask. This does not reflect negatively on you, and your intuition is often correct. Even if you are wrong, it rarely hurts your rapport with the youth if approached in a sensitive way. If you are unable to broach the subject with them, it is most likely a reflection of your own discomfort with the issue. Remember that one of the greatest risk factors in the problem gay youth face is the wall of silence surrounding the subject. The silence needs to be broken if you are to enter the lonely place where many gay and lesbian youth reside. It may be good to let youth know in some way that you accept young people regardless of their sexual orientation before asking them. Be prepared to give youth accurate and positive information about homosexuality. Assure them it is a healthy and positive form of human expression. Gay youth will be listening closely.
Accept the youth's sexual orientation as they report it to you. Their sexual identity should be based on the self reporting of their feelings and experiences. Do not label a youth as heterosexual or homosexual based on your own assumptions. Assure gay youth it is not sick, bad or wrong for them to be the way they are and that you are not going to try and change them. Let them know you care about them just as much after the disclosure as before. They are used to being rejected by others who find out they are gay. Respect them for being open and honest with you. It was probably hard for them to do and shows that they trust you.
Sexual Orientation Confusion
Do not assume a youth is confused about their sexual orientation if they identify as gay or bisexual. Many people both gay and straight have trouble accepting that an individual is bisexual. It Is important to validate bisexuality as a viable option for youth. However, some youth are genuinely confused about their sexual orientation. It is important for them to know that it is alright to be confused. They should not feel pressured to label themselves one way or another. A useful method in helping them to clarify a confused or undecided orientation is the Kinsey Percentage Scale. This technique allows the youth to be any combination of homosexual and heterosexual feelings and experiences that adds up to 100 percent. They can be 85 percent straight and 15 per-cent gay. Or they can be 40 percent straight and 60 percent gay. It is important to let them know you will accept them no matter where they fall on this scale. The purpose of this method is to give youth a context that allows them to identify their orientation along a continuum. It is easy to move from here to discussing specific feelings and experiences with them.
Assure effeminate young gay males and masculine young lesbians that it is alright for them to be that way. Gender nonconformity is common among gay youth and may be a way for them to affirm their identity. Some gay youth, however, become confused by cultural stereotypes that insist gay men be like women and lesbians be Like men. They feel they actually have to be a person of the opposite gender in order to be gay. Be prepared to talk with them about their perceptions of what it is like being a young gay male or lesbian. Help them to separate social adaptation issues from whether they really believe they are a person of the opposite sex Assure them they do not have to be any particular way in order to be gay. Transsexual youth will express a persistent desire to be a person of the opposite sex and live as that person over time. They will engage in frequent cross dressing and adapt the name of a person of the opposite sex. It is important for you to accept these youth for who they believe they are and call them by the name they want to be called. This is critical to establishing basic rapport with these youth and effectively addressing their concerns.
Gay and lesbian youth frequently suffer from low self esteem. They have often received a disproportionate amount of negative attention because of their sexuality. Being gay has been the focus of problems and stigmatization for them. Assure them there is nothing wrong with being gay and that it is the response of others to homosexuals that is the source of the problem. Help them to develop pride in who they are and a positive identity as a gay male or lesbian. Sometimes they have had too much of their identity focused on their sexuality. It is easy for them to come to see themselves as sexual beings after be-coming known as homosexuals. Assure them that sexuality is only part of who they are. Explore other areas of potential growth that give them a broader understanding of them. selves as individuals. Know the potential of gay youth under your care and work with them in a way that allows them to achieve more success than failure. Give positive feedback whenever possible. Be confident and optimistic of their ability to improve their situation and lead stable and happy lives as gay male and lesbian adults.
Gay and lesbian youth sometimes mistake their parents inability to accept their sexual orientation as a rejection of them as individuals. Frequently, parents still love their child but need time to come to understand and accept them as gay. Gay youth have trouble recognizing that an initial negative reaction by parents may change in the future. Help families to clarify their feelings for each other and encourage gay youth to be patient in gaining acceptance. Those gay and lesbian youth who have not come Out to their parents should not be pressured to do so. It is a personal decision that they should make carefully. Finally, assure gay and lesbian youth that they too will have families as adults. While not the traditional family, their families will be comprised of those friends, lovers, and relatives who remain close with them over a long period of time. Their relationships can be as rich and rewarding as those of other people. Being a gay male or lesbian does not mean that you are going to be alone.
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