Adolescent homosexuality: a primary care perspective

Adolescent homosexuality: a primary care perspective – Medicine and Society

Summer Smith

Adolescence can be a difficult time of transition from childhood to adulthood for youth and their families. Of the 34 million adolescents in the United States, an estimated 10 percent are also struggling with the isolation and rejection of being homosexual.[1] Because of the stigmatization that marks homosexuality, gay and lesbian teenagers may be reluctant to reveal their sexual orientation to physicians. Specific problems of homosexual youth may never be addressed in a medical setting.

Thirty-five percent of an medical visits by adolescent patients are to family physicians,[2] and family physicians should be able to recognize adolescents who are struggling with issues surrounding homosexuality as an emerging sexual orientation. The normal progression of adolescent development can create turmoil and tension, even in families that are stable and well adjusted. When additional concerns about the development of homosexual feelings, attractions or behaviors arise, the family physician is in a position of being able to help the parents and the teenager.


Homosexuality is defined as consistent fantasy, interest and arousal toward a person of the same sex. Disagreement exists about the explanation of homosexuality.[3] However, evidence supports the fact that homosexuality has existed throughout the history of mankind and is not just a development of the 20th century.

Early psychoanalytic theory concluded that homosexuality developed from conflicts derived from early developmental disturbances. Investigators more recently have explored neuroendocrine explanations as a cause of homosexual development. The results of these studies have been controversial. However, many experts believe that sexual orientation, whether heterosexual or homosexual, is the result of a complex interaction between anatomic and hormonal influences during fetal development. As investigators try to answer the question of etiology, others have worked to further define the incidence of homosexuality.

The most well-known studies of sexuality are the Kinsey studies, published in 1948 and 1953, which examined 5,000 men and 6,000 women.[4,5] The limitations of these studies are that they are more than 30 years old, and most of the subjects were white and were not randomly selected. Nevertheless, these studies have been cited many times in papers on sexuality from lay, professional and governmental organizations. The Kinsey studies reported that 2 percent of women and 10 percent of men engaged in exclusively homosexual behavior and fantasy.

Numerous other studies have attempted to look at homosexual behavior, but none examined adolescents exclusively until Remafedi’s study of 35,000 junior high and senior high school students aged 12 to 20 years.[6] In this study, 10.7 percent of students described themselves as being “unsure” of their sexual orientation, 88 percent described themselves as mostly or totally heterosexual, and 1.1 percent as bisexual or homosexual. The percentage of students who identified themselves as being unsure of their sexual orientation declined with increasing age, suggesting that sexual orientation “unfolds” between childhood and adulthood. As teenagers become older and more experienced, the uncertainty diminishes.

Development of Homosexual Identity

Cognitive and social development during adolescence is a complex process characterized by the acquisition of a sense of self separate from family, a sexual identity, the capacity for intimacy and the ability to be self-sufficient. For those adolescents who develop a homosexual orientation in a culture based on heterosexuality, the transition during adolescence is expanded and expressed somewhat differently during the stage of acquiring a sexual identity. Interviews with gay and lesbian youth indicate a common pattern in which an adolescent accepts his or her own homosexuality.[7] Troiden described four stages in this process.[8]

Stage 1 consists of “sensitization,” in which a young teenager begins to feel different and set apart from same-sex peers’ interests and activities. This process of feeling different (although not a sense of being sexually different) may begin as young as 12 years of age.

Stage 2 is called “identity confusion,” in which the adolescent uses various defense mechanisms to deflect homosexual arousal, but has inner turmoil and confusion about his or her sexuality. These defense mechanisms include denial, repair, avoidance and redefinition, and are a means of attempting to reject a lifestyle that is unpopular in American society.

“Identity assumption” occurs in Stage 3 and is characterized by self-definition as homosexual, by identity tolerance and by self-acceptance. At this stage, teenagers begin to explore the homosexual lifestyle and culture. This experience is different for women and men. A study of adolescents revealed that the majority of the 89 gay participants used sexual encounters to learn more about the homosexual lifestyle, whereas the majority of the 32 lesbian adolescents used television programs and other media for obtaining more information about the homosexual hfestyle.[7]

Stage 4 is highlighted by commitment, both to another person in an intimate relationship and to self. Homosexuality becomes internalized and integrated as a way of life.

The process occurs in a society where few support systems are available for gay and lesbian youths. Acceptance of one’s homosexuality comes at a time when acceptance by peers is vitally important and, for homosexuals, visibly lacking. Self-acceptance also comes despite the loss of societal benefits, such as family, friends, job security, police and legal protection, religious tolerance and legal benefits of marriage.[9]

Psychosocial Problems

Individuals who work with gay youth believe that the most important need of gay and lesbian youth is acceptance, support and validation. The majority of lesbian and gay adolescents, given the opportunity to develop within a supportive and informed environment, present no more serious mental health problems than the general adolescent population.[10] Physicians need to be aware of the importance of homophobia and its contribution to the discomfort that arises when adolescents discuss their concerns. Unfortunately, sexual orientation of the adolescent, and not the overall psychosocial issue of the person, may often become the focus of treatment.

Gay and lesbian youth face a variety of psychosocial problems. For most adolescents facing the initial self-awareness of homosexuality, support and acceptance do not begin at home. Virtually all of the youth in one study reported rejection by their family when they disclosed their sexual orientation.[7] In a study of 29 young men aged 15 to 19 years, mothers were reported to be supportive by only 21 percent of the participants and fathers were considered supportive by only 10 percent.[11]

Other areas of importance in an adolescent’s life are peer activities and school. In interviews of the 29 homosexual adolescents, 93 percent identified friends as the most important source of help with problems and worries. However, 42 percent reported the loss of a friend when they disclosed their sexual orientation.[12] In this same study, 80 percent of the youth interviewed reported deteriorating school performance. The drop-out rate for the group was 28 percent. These youth reported verbal abuse plus physical abuse from other students. Some schools have established special programs to address the added problems faced by youths who are homosexual.

When home life and school become intolerable, some gay and lesbian youth tend to leave home. Of 620 street youth receiving medical care at Children’s Hospital in Los Angeles, 11 percent identified themselves as being gay, lesbian or bisexual. In Los Angeles, 25 to 35 percent of street youth are estimated to be homosexual; the estimate for Seattle is 40 percent.[13] Homosexual youth appear to be overrepresented in the estimated 500,000 homeless youth in this country.[2]

Homosexual youth are also at risk for suicide. In 1986, 5,000 youth and young adults (up to age 24) committed suicide.[14] A 1989 report from the Department of Health and Human Services found that gay and lesbian youth are two to three times more likely to attempt suicide than other youth and suggested that they may comprise up to 30 percent of completed suicides by youth.[15]

One way that adolescent homosexuals cope with their problems is by using alcohol and drugs. In one survey, 58 percent of gay youth reported substance abuse as a means of coping.[12]

Role of Physicians

Because of the controversy surrounding the topic of homosexuality, many adolescents fear revealing their homosexual orientation to a physician. In several surveys that elicited information from adult lesbians about their experiences with health care providers, 10 to 72 percent reported negative reactions and a subsequent perceived change in the way that they were treated after they revealed they were lesbian.[16] These patients were concerned that the quality of their medical care would also be compromised.

What can a physician do to help homosexual adolescents? First, physicians must obtain a good history. Numerous messages can be sent to alleviate a teenager’s fear and encourage openness. Physicians should not assume that an adolescent patient is heterosexual.[13] Noncategorical questions should be asked before obtaining a sexual history. Patients should be reassured that questions are asked in confidence and to help provide the best care possible. Instead of asking a young woman about her boyfriend, the physician should first ask if there is anyone the patient likes or to whom she feels closest. Then, the patient can be asked if this person is an emotional, psychologic or sexual partner. Open-ended questions that do not imply a particular sexual orientation are best.

Another way in which a physician can be of help to these young people is to be aware of support groups for gay and lesbian youth in the area. Support groups help gay and lesbian youth clarify and work through shared issues, in addition to providing a safe environment with peer support. These groups have developed as lesbian, gay and other concerned adults have become more aware of the problems gay and lesbian youth face as a result of their isolation.


[1.] Gans JE, Blyth DA, Elster AB, Gaveras LL. America’s adolescents, how healthy are they? Chicago: American Medical Association, 1991. [2.] Gans JE, McManus MA, Newacheck PW. Adolescent health care: use, costs, and problems of access. Chicago: American Medical Association, 1991. [3.] Savin-Williams RC. Theoretical perspectives accounting for adolescent homosexuality. J Adolesc Health Care 1988;9:95-104. [4.] Kinsey AC, Pomeroy WB, Martin CE. Sexual behavior in the human male. Philadelphia: Saunders, 1948. [5.] Kinsey AC, et al. Sexual behavior in the human female. Philadelphia: Saunders, 1953. [6.] Remafedi G, Resnick M, Blum R. Demography of sexual orientation in adolescents. Pediatrics 1992;89:714-21. [7.] Paroski PA Jr. Health care delivery and the concerns of gay and lesbian adolescents. J Adolesc Health Care 1987;8:188-92. [8.] Troiden RR. Homosexual identity development. J Adolesc Health Care 1988;9:105-13. [9.] Borhek MV. Helping gay and lesbian adolescents and their families. A mother’s perspective. J Adolesc Health Care 1988;9:123-8. [10.] Gonsiorek JC. Mental health issues of gay and lesbian adolescents. J Adolesc Health Care 1988;9:114-22. [11.] Remafedi G. Male homosexuality: the adolescent’s perspective. Pediatrics 1987;79:326-30. [12.] Remafedi G. Adolescent homosexuality: psychosocial and medical implications. Pediatrics 1987;79:331-7. [13.] Kruks G. Gay and lesbian homeless/street youth: special issues and concerns. J Adolesc Health 1991;12:515-8. [14.] Vital statistics of the United States. Hyattsville, Md.: National Center for Health Statistics, 1986; DHHS publication no. (PHS)88-1147. [15.] Report of the Secretary’s Task Force on Youth Suicide. Rockville, Md.: Alcohol, Drug Abuse, and Mental Health Administration, 1989: DHHS publication no. 89-1621. [16.] Stevens PE. Lesbian health care research: a review of the literature from 1970 to 1990. Health Care Women Int 1992;13:91-120.

COPYRIGHT 1993 American Academy of Family Physicians

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