Counseling issues with gay and lesbian adolescents

Janet H. Fontaine

In a culture already uncomfortable about adult sex and worried about adolescent sexual behavior, the idea of homosexual sex generates hostile and almost reflexive contempt. Society's abhorrence, and hence avoidance, of homosexuality is reflected in the dearth of articles in the professional literature of counseling and psychology. From 1978-1989, only 43 of 6,661 articles published in six major psychological journals addressed gay and lesbian issues (Buhrke, Ben-Ezra, Hurley, & Ruprecht, 1992). This omission is even more striking when reviewing literature on adolescent homosexuality. For example, from 1977 to 1993, only three articles on gay and lesbian adolescents were published in The School Counselor, the primary professional journal for a counseling group which has access to the entire population of adolescents. This neglect coupled with lack of coverage in counselor preparation programs (Buhrke, 1989; Bodnar & Fontaine, 1993; Graham, Rawlings, Halpern, & Hermes, 1984) essentially precludes professionals from receiving adequate preparation for ethical and competent counseling of gay, lesbian, and bisexual adolescents.

That the need for this training exists is well documented. Although the American Psychiatric Association depathologized homosexuality in 1973 by removing it from the Diagnostic and Statistical Manual list of psychological disorders, and the American Psychological Association acted similarly in 1975, psychologists have maintained resistance to this new perspective. A recent survey of psychologists found that nearly 30% of responding clinicians felt that treating homosexuality per se as pathological constituted ethical practice (Pope, Tabachnick, & Keith-Spiegel, 1987). A study of heterosexual bias in counselor trainees determined that 83% of participants assumed client heterosexuality when given ambiguous conditions (Glenn & Russell, 1986).

What do counselors need to know in order to work effectively with sexual minority adolescents? Pederson (1988) identifies a tripartite approach to diversity training which begins with awareness of the counselor's own attitudes and beliefs, moves into the acquisition of knowledge, and then toward the final stage of skill acquisition. Effective counseling with homosexually oriented youth or those questioning their sexual identity cannot happen if the provider has not first come to terms with his or her own feelings and attitudes about homosexuality. While not addressed in this article, we believe it is incumbent upon the professional to address this issue.

This articles goes beyond Zera's (1992) efforts to outline the developmental struggles of gay and lesbian adolescents. Stages of identity development are presented along with suggested intervention strategies. Also included is a perspective on the components of sexual orientation in order to guide the practitioner in assisting adolescents to more completely address the struggle of exploring and clarifying their sexual orientation.

Identity Development for Lesbian and Gay Adolescents

Like their heterosexual counterparts, gay and lesbian adolescents share the same physical, cognitive, psychological, and social tasks of development, many of which are unaffected by issues of sexual orientation. However, since one of the major psychological tasks of adolescence is that of identity formulation and consolidation, the gay, lesbian or bisexual adolescent faces myriad challenges that the heterosexual adolescent does not.

The various components of any individual's identity include the sense of who one is as a sexual being, i.e., a sexual identity. Several processes by which an adolescent clarifies and consolidates this particular sense of self are cohort comparisons, societal confirmation, and peer affirmation. Environmental systems such as school, family, neighborhood, and work setting assist in this process. For the adolescent struggling with a sense of undefined "differentness" regarding the focus of his or her sexual attractions, these typical avenues and resources for sexual identity clarification and healthy formation are frequently unavailable at best. More likely, however, they present a negative and stigmatizing backdrop against which the adolescent must explore feelings and thoughts about this highly personal and integral aspect of personal identity. In schools, it is commonplace for students to routinely apply the words "faggot," "gay," "dyke," or "queer" to anyone they dislike for any reason, highlighting the devaluing of anything associated with being gay. Nor can support be expected from family and friends since it is likely that they have expressed antagonistic attitudes toward homosexuality at some point in the past.

The cost of this stigmatization becomes all too apparent in statistics which reflect disproportionate frequencies of psychological disturbance among gay and lesbian teens. Runaways, substance abuse, depression, anxiety, suicide attempts, and prostitution have been evidenced by this group in higher proportions than by nonhomosexual youth (Jay & Young, 1979; Bell & Weinberg, 1978; Hetrick & Martin, 1987; Remafedi, 1987a). Gibson (1989), in a project funded by the U.S. Department of Health and Human Services, found that 30% of completed teen suicides were committed by youth dealing with sexual identity issues.

Estimates are that 10% of the population may be gay and lesbian which means one of every five families has a gay or lesbian child (Dahlheimer & Feigal, 1991). Hence, the population directly affected by the issues of gay and lesbian teens becomes geometrically larger, including parents, siblings, and other relatives who may experience the emotional consequences of maintaining family secrecy over having a homosexual family member.

Gay, Lesbian, and Bisexual Identity Formation

It is apparent that gay men and lesbians do not suddenly "appear" in adulthood. Many more adolescents will question their sexual identity than will actually come to define themselves as gay, lesbian or bisexual. The task of differentiating and providing meaning to sexual feelings and experiences during adolescence becomes a confusing one. Compared to the "development" of a heterosexual identity, a norm requiring little conscious thought or effort, the attempt to develop a healthy and viable bi- or homosexual identity is a draining, secretive, anxiety-producing, and lonely task for adolescents. Hetrick and Martin (1987) found that the primary presenting problem for gay and lesbian adolescents was one of both social and emotional isolation and loneliness which, at times, initiated sexual involvement with same sex adults simply from a need for some type of social contact.

It is highly likely that the process of claiming a gay or lesbian identity may not be completed during adolescence. This process also may not be attached to demonstrative homosexual behavior for many youth. At the same time, due to the lack of a supportive discernment process, many gay and lesbian youth believe they have to directly experience a same-sex encounter to prove to themselves that they are gay. Such beliefs put lesbian and gay teens at considerable risk for inappropriate sexual contact.

Evidence supports both gender and age differences in how males and females come to know they are gay (Bell, Weinberg, & Hammersmith, 1981; Gorsiorek, 1988; Remafedi, 1987b). For both, however, the self-identification occurs over a long period characterized by extreme emotional turmoil. There are several models of this process of sexual identity formation which can assist the clinician in understanding the sequence of this self-labeling or coming-out process (Cass, 1979; Lewis, 1984; Troiden, 1989). All share the commonality that each stage moves toward an increasing level of acceptance of a homosexual identity. A progression from confusion, through exploration, to synthesis or integration is outlined in all three.

In the most well known of these models, Cass (1979) identifies six stages of identity formation: Confusion, comparison, tolerance, acceptance, pride, and synthesis. In Stage 1, identity confusion, heterosexual identity is called into question and the teen wonders "Could I be homosexual?" Gay and lesbian information or awareness becomes personally relevant, and the heterosexual assumption begins to be undermined. At this stage, confusion is great and the adolescent may seek information on homosexuality, a difficult task given the inaccessibility of such information. For example, school librarians often report that, if permitted, books on gays and lesbians in their libraries often "disappear" from the shelves without being checked out.

Counseling interventions at this stage could assist the teen to redefine differentness, discourage premature labeling, and attempt to normalize feelings. Denial is a primary defense at this stage. The teen may attempt to prematurely foreclose on the development process if not provided an accepting environment in which to explore the possibility of gay, lesbian or bisexual identity.

Identity comparison, Stage 2, begins with accepting the potential that homosexual feelings are a part of the self. The realization that "I might be homosexual" may cross the teen's mind. Alternately, a re-framing of same-gender sexual attractions as a special case (it just happens to be this one person I am attracted to and he/she happens to be the same sex) may occur. The idea that "I may be bisexual" (which permits the potential for heterosexuality) can also be a manifestation of Stage 2 identity development. It is also at this level that "This is a 'phase' I'm going through" may surface. For some youth, there is a personal responsibility void where the cognitive stance is just "being born" that way (Cass, 1979). These strategies are developed to reduce the incongruence between same-sex attractions and a view of one's self as heterosexual.

The task at this stage of identity comparison, according to Cass, is to deal with social alienation as the teen becomes aware of his or her difference from larger society, experiences a sense of not belonging and the isolation of perceiving himself or herself as an isolated case; that is, the only one "like this." Hersch (1991) presents a poignant interview with a 14-year-old girl at this stage of development which underlines the emotional turmoil. She quotes Sarah, "I don't understand what is going on with me . . . I want to kill myself. I'm scared of who I am. There is no one else like me. It's not normal to be gay" (p. 38). Counselors dealing with clients at this developmental level can explore their fears and anxieties, attempt to identify role models and, where possible, locate healthy and appropriate support systems such as peer support groups or drop-in centers.

Identity tolerance, Stage 3, is marked by such statements as "I probably am homosexual." The individual has moved further from a heterosexual identity and more toward a homosexual one. This may include seeking out the company of homosexuals to meet psychosocial needs. This movement helps dispel the sense of confusion and turmoil of prior stages, but creates a greater gulf in the comparison between self and others. For the adolescent who experiences a heightened need for peer approval and acceptance, this can be a dramatically trying period. At the time when merely failing to acquire an opposite-gender girlfriend or boyfriend or wearing the wrong kind of clothing can be decisive in falling from heterosexual grace, the homosexual teen is forced to scrutinize every action to maintain his or her secret. Adolescents attempting to dissipate the dissonance of identities may adopt an asexual role or practice covert homosexual behavior, which is particularly dangerous given the impulsive nature of sexual contacts and the high incidence of HIV infection among adolescent males. Positive gay experiences are crucial to developing a degree of self-acceptance (vs. self-hatred) during this period. Contacting other gay, lesbian, and/or bisexual people becomes a more pressing issue to alleviate a sense of isolation and alienation. Counseling interventions at this stage can assist in interpreting negative experiences, developing interpersonal skills, addressing fears of exposure, facilitating decision making on coming out, and offering insight on the identity formation process as well as resource information.

Stage 4, identity acceptance, involves increasing contact with other gays and lesbians and developing a more clearly delineated homosexual identity. Finding other gay and lesbian teens is difficult at best for many adolescents. Those in rural areas often find the social isolation nearly unbearable. Many of these young people feel a need to leave home and school and move to an urban area simply to make contact with other gay people. Those adolescents fortunate enough to have access to support groups and/or gay social events often heighten their dual lifestyle existence, being heterosexual publicly and bi- or homosexual privately as the fear of being "discovered" permeates their existence. The issues of "who am I?" and "how do I fit in?", however, have begun to be addressed.

Stages 5 and 6, identity pride and identity synthesis, move the individual from a "them and us" mentality into a realization and acceptance of the similarities between the heterosexual and homosexual worlds. Strong identification with the gay subculture and devaluation of heterosexuality and many of its institutions (Stage 5) gives way to less rigid, polarizing views and more inclusive and cooperative behavior (Stage 6). Table 1 provides an overview of these stages with suggested counseling interventions.

These latter two stages, pride and synthesis, are particularly difficult for school-aged adolescents to achieve, given the basic reality of their life circumstances. In this regard, lesbian and gay adolescents have the same needs for economic, physical, and emotional dependence and nurturance from parents as do heterosexual adolescents.

Placing a gay or lesbian identity into appropriate perspective, as a part of an overall total identity, is made particularly difficult for several reasons. Society's focus on the sexual behavior component of a homosexual orientation, excluding feelings of attraction, love, companionship, and subcultural mores, encourages the perpetuation of inaccurate sexual myths and stereotypes. For example, the myths that anonymous sexual liaisons are the only recourse for gay males, or that lesbians are a danger to children, derive from an exclusionary focus on the sexual behavior component of homosexual orientation. Adolescence in general is a time of natural heightened interest in sexuality - for both heterosexual and homosexual youth. The adolescent can easily be overwhelmed with an amplified version of sex as the primary component in a homosexual's life, versus one of the many aspects of identity.

Sexual Orientation: More than Sexual Behavior

Adolescent mental health workers and school guidance counselors have the opportunity to make a substantial positive impact in the lives of teens uncertain about their sexual orientation simply by conveying the reality that orientation goes beyond sexual impulse or behavior. For example, a confused adolescent may believe that a single sexual contact of any sort defines sexual identity. Appropriate counseling encourages the young person to consider the meaning of daydreams, affectional patterns, unexpressed physical attractions, and emotional responses in sorting through issues of sexual orientation.

As noted earlier, many adolescents who question their sexual orientation will not develop a gay or lesbian identity. This confusion may be initiated by such behaviors as deviation from traditional gender roles, the occurrence of same-gender sexual fantasies, and/or attractions and incidents of same-gender sexual contact. The subsequent homosexual "panic" these behaviors can generate needs to be assessed within the context of the behavioral precipitants and the identity stages outlined earlier. The apparent fact that same-sex sexual behavior is relatively common (Kinsey, Pomeroy, & Martin, 1948) should also be kept in mind.

Adolescent emotional liability and the very lack of accurate information about homosexuality often exacerbates an adolescent's fear. However, to dismiss the fantasies and the same-sex intimate behavior with an explanation that it is a "phase," or to prematurely foreclose on an adolescent's acceptance of his or her own gay or lesbian identity, are equally invalid and harmful courses of action. Again, assisting teens to explore their prior sexual attractions and fantasies, differentiating between sexual orientation and gender roles, and providing literature to assist in the exploration of these questions can normalize the process and diminish their reactive fear. Above all, counselors need to recognize that for many teens, sexuality is an area of flux, and the process of arriving at an established sexual orientation can take months or years.

Sexual orientation includes a complex set of components. Coleman (1990) utilizes a nine-item questionnaire to help clients gain an appreciation for the complexity of sexual orientation, as well as assess various aspects of their current status. Clients respond to items that question, for example, to whom one is attracted and which sex one fantasizes or dreams about, utilizing a five-point scale from male to female. Adolescents can also benefit from differentiating between such issues as sexual preference and gender role, since many believe that gay males are effeminate and lesbians masculine (Paroski, 1990).

Hindrances to Treatment

Because of the current stigma surrounding everything associated with homosexuality, it is unlikely that the majority of affected adolescents will present themselves for treatment with issues related to their sexual identity. Coleman and Remafedi (1989) believe that most teenagers, even those seriously questioning their sexual identity, will identify as heterosexual until there is compelling evidence to the contrary. One study found that 40% of homosexual adolescent males interviewed had sought prior psychiatric treatment, but did not necessarily disclose their sexual orientation at the time (Remafedi, 1987a). More likely, [TABULAR DATA FOR TABLE 1 OMITTED] gay and lesbian adolescents maintaining their "secret" will be mixed among those in treatment through two sources: Those mandated by legal or institutional authorities (e.g., runaways, substance abusers, truants), and those seeking services for more traditional psychological problems (e.g., depression, school phobia, suicide attempts). It is only with an awareness of sexual orientation as a possible precipitator of unacceptable or apparently pathological behavior that the sensitive service provider can choose to explore sexual orientation.

Hetrick and Martin (1987), in one of the few studies on the types of problems presented by self-identified gay and lesbian youth, found the major reason for seeking service was a sense of extensive isolation - from family, social networks, and peers. This isolation was magnified by the lack of access to accurate information about homosexuality. The problem may be compounded for adolescents of color, with the resurgence of belief in some segments of minority communities that all gay people are white. Indeed, the presentation of gay issues by activists within the gay community often highlights the concerns of Caucasian middle-class gay and lesbian adults. Young African-American, Native American, Asian American, Hispanic and other minority adolescents face identity barriers on many fronts simultaneously.

Family problems were the second most frequent area of concern cited by Hetrick and Martin. Difficulties ranged from parental rejection to violence and expulsion from the home. Coming out to parents is perhaps one of the more serious issues in the coming out process. Counselors should assist adolescents in fully exploring their reasons for coming out to parents before making a decision to act. Such questions as availability of alternative resources, parents' moral views, motivation for coming out at the time, and the current emotional climate at home, should be addressed. The adolescent will also need to be aware that patience may be required as many parents will have to undergo their own "coming out" process with the information shared by their child.

Drug use was evidenced by 5% of the Hetrick and Martin sample, emotional problems such as depression and anxiety in approximately 19%, and suicide attempts by 20% of those seeking advice. It is interesting to note that suicide completions and attempts by adolescents decrease with age (Bell & Weinberg, 1978; Saghir & Robins, 1973; Hetrick & Martin, 1987). This decrease is thought to be related to the increased freedom of movement and attendant diminished sense of isolation which occurs for older teens.

Coming Out Issues

For the adolescent coming to terms with the fact that he or she might be gay or lesbian, the process of accepting oneself is intertwined with the decision to inform others. Professionals should be thoughtful of the potential costs and consequences of an adolescent's decision to come out to others, particularly parents. There seem to be few teens for whom the decision to come out is not a major life disruption. Parents may have a range of reactions, with negative reactions common, but not a certainty in all families. Even when parents are apparently supportive, they may have little patience for the long periods of identity uncertainty and exploration of many adolescents, and may cut off avenues for the heart-to-heart conversations which their lesbian and gay children want. Some parents demonstrate what appears to be an almost obligatory initial negative reaction based on religious doctrine, only to become far more accepting later. Overall, the decision to come out to parents often provokes a family crisis of some sort.

Once a gay or lesbian teen has come out, even supportive parents are faced with a confusing array of choices about how to set appropriate limits. Toward which same-sex friends might their child be attracted? Are sleep-overs still okay? With whom will they allow their children to associate? Are dating rules the same as with other siblings?

When counseling lesbian and gay adolescents, an awareness of the typical stresses of homosexual identity formation is vital (Coleman & Remafedi, 1989; Gonsiorek, 1988; Slater, 1988). Without such awareness, behaviors that are normal within the "coming out" context can be viewed inaccurately as indicators of more serious problems or psychopathology. Conversely, counselors unfamiliar with typical issues of the coming out process may minimize or ignore the significance of behaviors or situations which create genuine danger for the young person. It is critical that the impact of adaptation processes to homosexual identity be differentiated from other presenting issues.

Other Counseling Issues

For many adolescents, the timing of sexual identity uncertainty occurs somewhat later in their school career. For example, progress through Stage 3 (identity tolerance) and Stage 4 (identity acceptance) often is forestalled until after leaving high school. College environments and/or the financial independence that employment permits provide an opportunity to more freely explore issues of sexual identity. While in school, however, "adaptation" to sexual orientation uncertainty may take more socially acceptable forms, such as academic or athletic overachievement, perfectionism, or overinvolvement in extra-curricular activities. As a reaction formation against unacceptable thoughts and attractions, adolescent females may exaggerate their heterosexuality and engage in promiscuous behavior, even becoming pregnant to establish a heterosexual identity to others and to ward off internal fears of a homosexual identity.

As a group, these adolescents comprise an invisible sexual minority, often not disclosing their sexual orientation to others. They are the silent teens who struggle in isolation and fear of discovery (to self or others), yet survive using societally acceptable methods. Their price is high, however, as the consequent emotional isolation inhibits the timely and successful progression of adolescent developmental tasks which are put on "hold" until a safer time. In this regard, teens denied the opportunity to develop the social and sexual experiences appropriate to their developmental stage, predictably become the adults who later must experience this social and sexual adolescence, with all its awkwardness, before moving on to adult mastery of social and sexual situations.

Since a silent and invisible population of sexual minority students is unidentifiable, providing service to them becomes difficult. School counselors are in the best position to address this group, as they have access to the entire student body. While it may not be possible to provide direct service, indirect methods can create a more hospitalable environment for teens questioning their sexual identity in the schools. These efforts might include publishing articles about gay and lesbian teens in the school newspaper, providing books on gay and lesbian issues for the school library, having homosexual literature available in the waiting area, inservicing teachers and administrators on gay and lesbian youth issues, and developing policies which support teachers in challenging homophobic remarks.

Such work begins the process of advocacy for these students. However, these behaviors are not without risk for the school counselor, since homophobic school boards and parents can apply pressure to prevent such "encouragement of the gay lifestyle" from occurring in their schools. It is our position that the needs of these at-risk adolescents far outweigh the costs of advocating on their behalf.

If not the counselor, then who?

CONCLUSIONS

Lesbian and gay teenagers, or any adolescents whose sexual identity is uncertain, face a challenging combination of barriers on their journey toward formation of a positive identity. For many, this journey may include an extended period in which sexual orientation is unclear. Under ideal circumstances, parents, counselors, and other important figures in the lives of these teenagers will not only tolerate, but encourage the young person in their exploration of sexual identity issues. Throughout this process, it is important to allow the teen to "try" on labels, rather than adopt them. When appropriate to provide adolescents with information about resources within the gay, lesbian, and bisexual communities, it is crucial that the counselor screen resources for safety and appropriateness. Token efforts to meet the needs of gay, lesbian or bisexual youth by offering a single support group or library book are insufficient. There is need for a variety of resources, including written materials, waiting room posters, library resources and, ideally, at least one identified "safe" school faculty or staff member who is available for discussions and whose expertise in this area is made known to students.

Because the majority of adolescents with sexual identity concerns will remain hidden throughout their school careers, systems advocacy on their behalf is critical. In this regard, mental health workers focusing on adolescent populations as well as school counselors can work in concert to develop and implement school policies which provide safety from physical and verbal threats and abuse, and acknowledge the existence and legitimacy of individuals with a homosexual or bisexual orientation. Although such measures often provoke controversy, the alternative is to perpetuate an environment which places lesbian, gay, and bisexual youth (as well as those uncertain about their orientation) at risk of mental health problems and school drop out.

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Nancy L. Hammond, Ph.D., Consulting Clinical Psychologist, Community University Health Care Center, University of Minnesota Hospital and Clinic, 2001 Bloomington Avenue South, Minneapolis, MN 55404.

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