Gay, Lesbian, and Bisexual Adolescents: A Critical Challenge to Counselors

ELI COLEMAN and GARY REMAFEDI

Meeting the health care needs of gay, lesbian, and bisexual teenagers has become a public health imperative, and mental health professionals should be prepared for the challenge. The stigma of homosexuality often gives rise to psychosocial problems for adolescents, who are in the process of sexual identity development. The stigma also may complicate delivery of appropriate, ethical, and sound mental health treatment. Suggestions are offered to support healthy development, to assist recovery from stigma, and to avert the disastrous consequences of suicide and AIDS.

ecent years have seen a growing interest in the subject of adolescent homosexuality, reflected in professional

services, and advocacy by professional organizations (Remafedi, 1988a). The American Academy of Pediatrics (1983) provided early leadership with its statement of policy:

Teenagers, their parents, and community organizations with which they interact may look to the pediatrician for clarification of the medical and social issues involved when the question or fact of adolescent homosexual practices arise... The American Academy of Pediatrics recognizes the physician's responsibility to provide health care for homosexual adolescents and for those young people struggling with the problems of sexual expression. (pp. 249-250)

The importance of professionals' involvement has become even more apparent with the spread of AIDS. In 1987, gay and bisexual teenagers headed the list of youth in need of special preventive services that was formulated by the Surgeon General's Workshop on Children with HIV Infection and Their Families (U.S. Department of Health and Human Services, 1987).

To date, theoretical and empirical writings on adolescent homosexuality have clustered in pediatric and adolescent health care publications. Although mental health professionals are more likely than are physician colleagues to be involved in service to gay, lesbian, and bisexual adolescents, mental health professionals have had relatively less exposure to new perspectives and approaches to care. Thus, our intent is to provide counselors with an introduction and a challenge to the care of homosexually oriented youth. We will focus on the meaning of homosexuality from the adolescent's perspectives, developmental issues, special mental health and medical concerns, and the counselor's role in these issues. We refer the reader elsewhere for more detailed discussion of prevalence (Remafedi, 1987a), etiology of sexual orientation (Savin-Williams, 1988),

social concerns (Martin, 1982), family issues (Borhek, 1988), and medical issues (Zenilman, 1988).

INITIAL ENCOUNTER WITH LESBIAN, GAY, AND BISEXUAL ADOLESCENTS Based on interviews with gay, lesbian, and bisexual teenagers, it seems that many, if not most, of these young people consult counselors during adolescence (Remafedi, 1987c; Roesler & Deisher, 1972). As with other young clients, they may be self-referred, referred by other professionals, or mandated to treatment by parents or legal authorities. The reasons for consultation are diverse, but among the most common concerns are efforts to clarify or change sexual orientation; family conflict regarding sexuality; anxiety; attempted suicide; grief over the dissolution of a first relationship; substance abuse; and other disorders of conduct.

At the time of referral, many young clients have not definitively labeled their sexual orientation, and the contribution of sexual orientation to the presenting problem is often unclear. Familial and societal expectations regarding the outcome of treatment may also complicate their care. Although there is no evidence that adults sustain long-term change in sexual orientation through therapy (Coleman, 1982), some young patients, their parents, and even therapists still seek a heterosexual conversion. Such attempts to change sexual orientation have been rejected by authorities (Coleman, 1978; Gonsiorek, 1988) as unscientific, unjustified, unethical, and psychologically scarring.

Thus, from the first encounter with homosexually oriented adolescents, the counselor sets sail between Scylla and Charybdis. Focusing too closely on the sexual orientation issues or pushing toward premature resolution of sexual orientation. questions could exacerbate adjustment problems or jeopardize rapport with young patients or parents, and dismissing the legitimacy or relevance of homosexual feelings could also be damaging. It is not surprising then that many professionals try to maneuver through psychotherapy with homosexually oriented adolescents by avoiding the issue altogether.

ACQUISITION OF

HOMOSEXUAL IDENTITY

Until quite recently, adolescent homosexuality was thought to be a passing phase on the road to adult heterosexuality, and the possibility that a healthy adolescent could have a wellestablished homosexual identity was "flatly rejected" (Glasser,

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1977). Retrospective studies in which adolescents and adults recalled childhood sexual feelings, and prospective investiga-

tions that followed sexual development of children through young adulthood, however, provided evidence that sexual orientation is actually established during childhood (Remafedi, 1987a). Theorists have devised various stage theories to depict the acquisition of homosexual orientation as an orderly sequence of events. They share in common a belief that homosexual self-identification is not a sudden awakening during adulthood (Troiden, 1988), but a gradual process that often begins with a vague sense of "differentness" during childhood. These perceptions take on sexual meanings during puberty as homosexual attractions stir. After a period of confusion the individual typically adopts a homosexual label but still may need years to reach a final stage of self-acceptance or integration (Coleman, 1981/1982). Although this process is similar for men and women, patterns of sex role socialization may account for some observed gender differences (Browning, 1987).

Progression from one stage to another is a tentative to-and-fro movement, rather than a steady, self-assured march. Adolescents' sexual fantasies and behaviors are not always congruent with the labels that they apply to themselves. Our own clinical impression is that most teenagers describe themselves as heterosexual unless there is compelling evidence to the contrary; and predominantly homosexual adolescents often waffle between heterosexual, homosexual, and bisexual labels. According to interviews with gay and bisexual teenagers, homosexuality means more than sexual intercourse with persons of the same sex (Remafedi, 1987b). For the majority of them, it implies a basic affinity to other men; and for some, it signifies positive qualities such as self-awareness and courage.

PSYCHOSOCIAL PROBLEMS

If one were to choose a time in the life cycle when the acquisition of a homosexual or bisexual identity might be most disruptive, adolescence would be a prime candidate. The central tasks of adolescence and young adulthood are, according to Erikson (1963), to find identity and to develop intimacy with another individual. Both accomplishments can be easily derailed by sexual minority status. The gay and bisexual adolescents we have studied (Remafedi, 1987b) commonly expressed ambivalence toward their own sexual identities, abandoned educational and career goals, and suffered losses of friendships, all of which might signal trouble in accomplishing the tasks of adolescence. Young women and men who are rejected by their families, communities, and peers, or who are without essential food, clothing, shelter, vocational and academic training, have special difficulties recouping developmental losses.

Although several decades of sound research have indicated that homosexuality per se is not associated with illness (Gonsiorek, 1988), the experience of hostility and rejection during adolescence can lead to a wide array of psychosocial and medical problems. During interviews with gay teenagers (Remafedi, 1987c), the majority of gay teenagers reported deteriorating academic performance and serious substance abuse. Nearly half of the sample had run away from home, been arrested, or had a sexually transmitted disease. A sizable minority had attempted suicide, accepted money in return for sex, or been sexually victimized.

Among the serious problems facing gay, lesbian, and bisexual adolescents, perhaps the most urgent problems are the risks for suicide and HIV infection. Since the early 1970s, an association between homosexuality and attempted suicide re-

Gay, Lesbian, and Bisexual Adolescents peatedly surfaced as an incidental finding in studies of human sexuality. Bell and Weinberg (1978) compared 1,000 adult homosexual participants to genderand racially matched heterosexual controls and found a higher prevalence of suicidal ideation and attempts among homosexual participants than heterosexual men. White and Black homosexual men were three and 12 times more likely to endorse serious ideation or attempts. The majority of attempts in homosexual men, but not in heterosexual men, occurred before they were 21 years old. Saghir and Robins (1973) found that 7% of homosexual men and 12% of lesbians attempted suicide; once again, all attempts by men occurred during adolescence. Of 5,000 homosexual men and women studied by Jay and Young (1979), 40% seriously considered or attempted suicide. More than half of the men and a third of the women implicated sexual orientation as a precipitant. Two smaller-scale studies that focused exclusively on male adolescents in Seattle (Roesler & Deisher, 1972) and Minneapolis (Remafedi, 1987c) found that approximately one-third of participants had attempted suicide.

More insidious, but no less fatal, is the danger of AIDS. As of November 1988, nearly 77,000 cases of AIDS were reported in the United States (Centers for Disease Control, 1988). Although the 311 cases in teenagers accounted for less than 1% of all U.S. cases, the numbers of AIDS cases do not accurately reflect the magnitude of the problem for gay teenagers. Of persons with AIDS, 21% were between the ages of 20 and 29 at the time of diagnosis, and the long latency period of the illness suggests that many, if not most, of these infections were acquired during adolescence. For older adolescents, as for adults, the most important modes of HIV transmission are homosexual and bisexual activity. Nationwide, these account for 79% of infections in older adolescents and young adults (Manoff, Rogers, D'Angelo, & Dondaro, 1987), outnumbering intravenous drug use transmission, 7:1 (Allen & Curran, 1988). Even in New York City, with its heavy concentration of intravenous drug users, HIV transmission to adolescents by homosexual-bisexual activity is twice as common as by needle sharing (Hein, 1988).

Complicating the high risk of exposure to HIV, social stigma is an added obstacle to AIDS prevention for gay teenagers (Remafedi, 1988b). Some young men who engage in homosexual intercourse dismiss their homosexual feelings and avoid confronting the reality and risks of their sexual behavior. Gayidentified teenagers are often abused by peers in classrooms and leave the schools where AIDS prevention might be taught. Others are rejected by families and resort to the streets in search of a peer group and source of income. There they find fee-forservice sex and drugs that impair compliance with risk-reduction guidelines (Coleman, 1989; Remafedi, 1988b).

HELPING THE ADOLESCENT

Counselors are in a unique position to address the developmental issues and mental health and medical concerns of homosexually oriented youth and their families. Given the current sociocultural climate and the health risks to our youth, this challenge is no longer an option but an imperative for every counselor working with young people.

Counselors can first create an atmosphere in which sexuality can be discussed. Any assumption of heterosexuality will discourage many adolescents from mentioning homosexual behavior or feelings. It is the counselor's responsibility to bring up the topic. The counselor should assume that the issue of homosexual feelings or behavior is on the mind of most adoles-

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