Mental Health Issues in Sexual and Gender Minority Youth

Research Challenges

The first empirical study of sexual minority youth was published by Roesler and Deisher in 1972 in the Journal of the American Medical Association (noted by Savin-Williams, 2005). The 1980s were a time of intense research productivity, particularly in the areas of same-sex sexual identity development, suicide, and HIV. The bulk of the research incorporated convenience samples of sexual minority youth who sought mental health services or who attended social, recreational, or educational programs specifically for sexual minorities (Savin-Williams, 2005).

Most studies employed retrospective or cross-sectional designs and lacked uniform and well-defined questions. Sexual orientation was assessed using single items such as the following: “Are you gay, lesbian, bisexual, heterosexual?” “Have you had sex with males, females, or both?” (D’Augelli, Grossman, Salter et al., 2005). Because of the negative stigma associated with homosexuality, researchers were hard-pressed to capture youth who covertly thought of themselves as gay or lesbian but were not open with others about their identities (Anhalt & Morris, 2003). Ethnic minorities were typically underrepresented in these samples (Diamond, 2006). Bisexual youth were usually omitted from consideration or grouped together with gay- and lesbian-identified participants and mislabeled as such (Russell & Seif, 2002). The research on gender minority children and adolescents was largely based on the autobiographical accounts of gender minority adults and the case reports of practitioners who worked in clinical settings with gender minority youth, many of whom were diagnosed with gender identity disorder (GID). Many researchers also relied on the retrospective recall of adults, many of whom were affiliated with gay or transgender organizations.

Recent advances in research design and methodology have permitted investigators to develop more-sophisticated research agendas. Some of these include the use of multiple recruitment strategies like the Internet to reach stigmatized populations (Cochran & Mays, 2006; Savin-Williams, 2005). Others use alternative measures of sexual orientation, including questions to assess same-sex sexual behaviors and attractions (Savin-Williams, 2005). Still others use existing data sets on comprehensive national health issues (Cochran & Mays, 2006).

Suicide

Sexual Minority Youth

Suicide among sexual minorities has been a hotly debated and well-researched issue. In 1989, the U.S. Department of Health and Human Services (DHHS) released a report in response to what was perceived to be an epidemic of suicides in children and adolescents. The report indicated that gay and lesbian youth were two to three times more likely than their peers to attempt and succeed in committing suicide (Gibson, 1989). In a later response to the report, the Secretary of the DHHS, Dr. Louis W. Sullivan, repudiated this section of the report, stating “I am strongly committed to advancing traditional family values.... In my opinion, the views expressed in the paper run contrary to that aim” (Sullivan, 1989).

Despite the controversy over this report, a limited number of states (e.g., Massachusetts, Vermont, and Washington) began including sexual minority youth as part of the Youth-Risk Behavior Surveillance Surveys administered in public and private secondary schools. Thus far, results of these surveys have been remarkably consistent with the information reported by Gibson in 1989 (Morrison & L’Heureux, 2001).

In 2005, D’Augelli, Grossman, Salter et al. attempted to address methodological problems associated with prior research by distinguishing among three groups. First, they looked at sexual minority youth who had never attempted suicide, then those who reported suicide attempts related to their sexual orientation, and finally those whose suicide attempts were unrelated to sexual orientation.

D’Augelli and his colleagues also addressed the effect of several risk factors associated with suicide, including age of self-recognition and self-disclosure, victimization experiences, and childhood history of gender nonconformity. Significant determining factors among those who attempted suicide were greater psychological abuse from parents and more childhood gender-atypical behavior, especially for males. Similar results were reported by Friedman et al. (2007). Using data from the Urban Men’s Study, Friedman et al. reported that early gay-related harassment was related to depression, attempted suicide, and HIV seropositivity in adulthood.

Gender Minority Youth

Estimates of attempted suicides by gender minorities range from a low of 17% (Brown & Rounsley, 1996) to a high of 50% (Israel & Tarver, 1997). DiCeglie, Freedman, McPherson, and Richardson (2002) conducted an audit of 124 cases seen in their gender clinic since 1989. The mean age at referral was 11 years. DiCeglie et al. reported that incidents of harassment and persecution were significantly more common in boys than in girls. Older children were more likely to report dislike of bodily sex characteristics than were younger children. DiCeglie et al. observed that their patients experienced “considerable difficulties with their relationships with adults and peers which may lead to significant isolation.” Girls in their sample reported more depression than boys and high rates of depression. DiCeglie et al. concluded that “gender identity disorder represents a high suicide risk.”

Results from a convenience sample of 54 gender minorities between 15 and 24 years of age were consistent with those observed in DiCeglie’s et al. clinical sample. Grossman and D’Augelli (2007) reported that 50% of their sample had serious thoughts about suicide and 25% had made at least one attempt. Verbal and physical abuse by parents and lower body esteem were significantly correlated with suicide attempts by these youth.

Swann and Herbert (1999) noted that transgender youth are at risk for self-harm, as many were apt to self-mutilate in order to bring about their own cross-gender body modification. Many engaged in self-destructive activities, such as cutting their breasts.

Harassment and Victimization

Sexual Minority Youth

Sexual minority youth reported higher rates of harassment, bullying, and victimization in schools than did their heterosexual counterparts (Bontempo & D’Augelli, 2002). Garofalo, Wolf, Kessel, Palfrey, and DuRant (1998) reported that one-third of their sample indicated they had been threatened with a weapon at school, in contrast to 7% of their heterosexual counterparts. The Gay, Lesbian, and Straight Education Network (GLSEN), a national advocacy organization, indicated that among its national sample of sexual and gender minority youth, 42% had been physically harassed in school (GLSEN, 2001). Both national and regional studies (Murdock & Bolch, 2005; Peters, 2003) found that sexual minority youth were subjected to verbal harassment on a daily basis in school.

Gender Minority Youth

There is a disproportionate amount of violence and abuse that gender minority persons experience for their failure to conform to gender norms. In the case of gender minority children and adolescents, the abuse was experienced at home, in school, and on the playground. In schools, children who are gender nonconforming are regarded as disruptive and are often punished or expelled (Israel & Tarver, 1997). In Devor’s (1994) interviews with 45 female-to-male transgender adult participants, 60% indicated that they had been psychologically, physically, or sexually abused in their childhood. Gagne and Tewksbury (1999) described the childhood experiences of their gender minority interviewees: as feminine males, they were “stigmatized, ostracized, beaten, cajoled, corrected, scolded, punished and otherwise socially pressured to be masculine males” (p. 78).

Grossman et al. (2006) conducted interviews with 31 male-to-female transgender youth ranging in age from 15 to 21 years regarding gender expression milestones in development and experiences of verbal, physical, and sexual victimization. All participants reported feeling “different,” being told they were “different” during their middle childhood years, and being called derogatory names like “sissies.” Most considered themselves to be transgendered or transsexual and disclosed this to someone else in their late adolescent years. All reported being the recipients of verbal abuse. Gehring and Knudson (2005) explored the incidence of abuse among 42 adult participants who were referred by their family physicians to outpatient clinics for the treatment of GID. Of these participants, 77% reported verbal abuse, 81% were insulted, 55% were embarrassed in front of others, 58% were made to feel guilty, and 55% reported being embarrassed by one of their parents before the age of 15.

The brutality of the violence against gender minority youth is illustrated in the following two incidents. In the first, Fred C. Martinez, Jr., a Native American student of Navajo ancestry at Montezuma-Cortez High School in Colorado, was attacked and beaten to death in June 2001. His assailant was a teenage male who bragged about the attack, saying he beat a “fag” (Moser, 2005). The second incident occurred in October 2002 and was the subject of a recent television movie titled A Girl Like Me (Holland, 2006). Gwen Araujo, a 17-year-old biological male, expressed a desire to be female at an early age and started to live as a woman while in school. Gwen stopped attending Neward Memorial High School in California in response to the harassment she received. Later she was attacked while attending a party. Her skull was bashed in with a pan and a barbell; she was strangled with a rope and buried in a shallow grave in a remote wooded area. None of her attackers was charged with a hate crime.

Lack of Familial Support

Sexual Minority Youth

D’Augelli (2006) explored developmental processes in a sample of over 500 sexual minority youth who attended community-based gay-friendly social organizations. The data for this study were collected over a 10-year period. Twenty-four percent of the sample described their mothers as “intolerant” or “rejecting” of their sexual orientation, in contrast to 37% of their fathers. Their mothers were described as more positive and more knowledgeable than their fathers. Thirty percent of the participants feared verbal harassment at home, while 13% feared physical attack from family members. Studies that have compared the rates of verbal and physical abuse in the families of disclosing and nondisclosing youths reported that victimization acts as a strong deterrent to coming out to family members (D’Augelli, Hershberger, & Pilkington, 1998). It is estimated that 50% of homeless youth are struggling with sexual orientation issues (Little, 2001).

Gender Minority Youth

Rejection by families and schools prompts many gender minority teens to drop out of school and leave home, ending up on the streets (Oggins & Eichenbaum, 2002). Many homeless gender minority youth seek out sex work because it is a source of self-worth and validation and because it is an important means of financing expensive cosmetic and sex reassignment surgery (Oggins & Eichenbaum, 2002).

Substance Abuse

Sexual Minority Youth

Early studies reported that self-identified sexual minority youth were at higher risk for substance use and abuse than were their heterosexual counterparts (Remafedi, 1987). A recent meta-analysis of several studies continues to demonstrate that sexual minority youth are more vulnerable to substance use disorders (Marshal et al., 2008). The reasons for this are numerous. Drugs and alcohol may be used as a means of rationalizing same-sex sexual activities; fitting into the gay and lesbian subculture, which in many places is organized around bars (Jordan, 2000); and coping with the minority stress.

Recent studies have used population-based surveys to explore substance abuse. Youth-Risk Behavior Surveillance Surveys were administered in Massachusetts and Vermont to a sample of 9,188 students in 9th through 12th grade. The students were asked to select a label to describe their sexual orientation and then were asked a series of questions about health risk behaviors such as substance use, sexual risk, and at-school victimization. Sexual minority youth reported significantly higher rates of cigarette, alcohol, and marijuana use than did nonminority youth (Garofalo et al., 1998).

The National Longitudinal Study of Adolescent Health (ADD Health) was the first nationally representative study of adolescents in the United States to incorporate questions related to sexual orientation. The study was initiated in 1995 and covered a period of two “waves,” which incorporated over 90,000 youths in grades 7 through 12. Data were collected during the second wave through the use of the audio computer-aided self-interview (Audio-CASI), during which adolescents listened to audiotaped questions and used a laptop computer to respond. Adolescents were questioned about their romantic attractions but not their sexual behaviors in this study. Adolescents who reported same-sex romantic attractions were more likely to abuse alcohol (Russell & Joyner, 2001).

A cross-sectional study using a national data set of early and middle adolescent youths ages 9 to 14 reported that girls who described themselves as “mostly heterosexual” or “lesbian/bisexual” were at elevated risk for alcohol-related behaviors, compared to heterosexual girls (Ziyadeh et al., 2007).

There is some recent evidence to suggest that youth who report relationships with both sexes may have more difficulties with substance abuse than do those whose orientation is more exclusively same-sex (Marshal et al., 2008; Russell, 2006). One study found that teens who reported bisexual attractions were at greater risk for alcohol abuse than were those who reported heterosexual attractions (Russell, Driscoll, & Truong, 2000). And bisexual girls seem at particular risk for substance abuse (Russell, 2006).

Gender Minority Youth

In a recent study (Garofalo, Deleon, Osmer, Doll, & Harper, 2006) of 51 self-identified ethnic minority male-to-female transgender youth aged 16 to 25 years, high rates of risky sexual behavior were reported. All participants indicated they had sex with men, 47% self-identified as gay, 26% referred to themselves as heterosexual, 16% identified as bisexual and 11% unlabeled. High rates of substance use were reported and alcohol and drugs were used as a coping strategy to deal with numerous psychosocial stressors, including limited familial support, unstable housing, economic hardships, and little access to competent health care. The use of hormones purchased on the streets or through the Internet with no input from doctors or other adults was high. Of 61% of youth reporting the use of feminizing hormones, only 29% received hormones from their medical providers. Twenty-nine percent of gender minority youth reported lifetime use of injection silicone. These findings are consistent with other anecdotal and survey data of gender minority youth (Dean et al., 2002).

The risks associated with the use of illegal hormones include the possibility that these hormones are not pharmaceutically pure or taken in the correct dosage (Jennings, 2003). Bodily changes caused by the hormones are irreversible even after the hormones are withdrawn (Cole et al., 2000). For example, facial hair continues to grow even without continued testosterone injections, and electrolysis would be necessary to stop this. However, youth who undergo hormonal transitions and take testosterone injections are not at the same risk level as adults for elevated cholesterol and coronary artery disease (Cole et al., 2000). Journalist Cris Beam, in her book Transparent (2007), chronicled the experiences of several teenage gender minorities, many of whom live temporarily on the streets in Los Angeles. Beam described the practice among these youth who are desperate to transition. Without family or financial support, they turn to black market hormones and the practice of “pumping” or shooting loose silicone directly into the body to make parts of the body look fuller and more feminine (Beam, 2007).