It is challenging to write a chapter on sexual minority youth and avoid the trap of further entrenching a dichotomous discussion about sexuality, rather than advance a discussion about the multidimensionality of an individual. Sexual minority youth is a term used to describe adolescents who are not exclusively heterosexual. In this chapter we will use this term to refer to youth with same sex attractions, relationships, or behaviors, regardless of their self-identification as lesbian, gay, or bisexual (1).

The youth of today are resisting the categorization of their emotional attachments as well as their intimate relations. Although the categorization of gay, lesbian, and bisexual has been helpful in the past to find community, in many parts of the world it no longer is necessary to segregate oneself with others who label themselves in a similar way in order to find acceptance. Schools and the media have played an important role in redefining community for youth who are sexual minorities. They have created role models that have supported the idea that it is possible to understand one’s sexual identity in a more complex manner. There is increasing visibility of adults who partner, have children, and create a home and a life outside of a heterosexual construct.

The variation in adolescent sexual identity development is as complicated as any aspect of identity development. It is not known what aspects of biological, environmental, psychological, and sociocultural influences are critical to a sexual minority identity, but relevant current research will be presented in this chapter, along with stressors adolescents may experience that might lead an adolescent and/or a family to seek psychiatric consultation. While the problems these adolescents face require the full empathy and support of a trained professional, it is important to acknowledge that not all sexual minority adolescents face these challenges with the same degree of severity. There are many recognized cases of individuals whom, for whatever reason, whether it is a solid support system, a loving environment, or their own abilities to maneuver the many complex challenges most adolescents in these stages of development face, are able to enter adulthood fully self-accepting and secure in their feelings regarding their sexual identity.

As child and adolescent clinicians we often see the most vulnerable youth. This vulnerability occurs secondary to complex interactions of the child within a family, culture, and society. Although research findings often find higher rates of mental health risk in adolescent sexual minority populations, it is difficult to isolate what is due to internalized homophobia and external stressors that sexual minority youth experience, versus other biological and psychosocial factors. The defenses used to cope with both internal and external stressors can lead to compartmentalization to protect this aspect of one’s identity from being known. Youth may consciously and unconsciously do this as a shelter from rejection, as well as from emotional and physical harm by family members, peers, communities, and religious affiliations.

Although in the literature and in clinical discussion definitions may vary, some core concepts are defined here and used within the chapter. Gender identity refers to the youngster’s internally perceived gender, regardless of chromosomal constitution, gonadal/hormonal secretions, or genitalia. Most children develop a stable gender identity that is concordant with their biology around the age of three. This process is likely driven by biologic determinants, but environmental psychosocial factors may also play a role. This chapter will not explore the experience of transsexual youth, as this is a distinct population and thus beyond the scope of this chapter.

Gender role refers to culturally underwritten masculine and feminine behaviors, attitudes, and personality traits, partly biologically driven, and partly shaped by environment. “Aspects of sex-typed behavior in childhood and adulthood are affected by hormones that were present very early in development, confirming findings in other mammalian species (2).” This is often noticeable as early as age two or three, although in some children there can be flexibility until age five or later. In younger children, gender role can be observed by stereotypic “feminine” affiliative, nurturant play involving dolls and feminine dressup and also in “masculine” rough and tumble play, with a greater interest in automotives and action toys. It includes play and work preferences, friendships, extracurricular interests, and courting patterns, and can variably shift over the course of one’s life. Children’s books and the media play a role in reinforcing stereotypes.

Gender roles are enforced by peers. Anxiety about atypical gender behavior may lead to peers teasing and ostracizing gender atypical youth, and to parents bringing their child for a mental health evaluation. For some, gender-variant roles in childhood may coincide with a later homosexual identity. The association between sexual orientation in adults and retrospective reports of gender nonconformity in children is substantially higher among men than among women (3).

Sexual orientation is the predominance of erotic feelings, thoughts, and fantasies one has for members of one sex, or both sexes. Some consider it to be biologically driven, immutable, stable over time, and resistant to conscious control (4). Diamond states that these beliefs are derived primarily from gay male populations and posits that women differ. She states, “In contrast to this premise, female same-sex orientations often exhibit late and abrupt development, and inconsistencies among women’s prior and current behavior, ideation and attractions have been extensively documented (5).” Freud stated in Analysis Terminable and Interminable, “We have come to learn, however, that every human being is bisexual in this sense and that his libido is distributed, either in a manifest or a latent fashion, over objects of both sexes (6).” Savin Williams believes that sexual identity—which refers
to one’s identity as a sexual being, and is distinct from gender identity—and behavior—not orientation—are most subject to conscious choice and thus fluid over time (4). Both Savin Williams and Diamond posit that sexual orientation exists along a continuum, with the possibility of a multitude of expressions over the lifespan of an individual. Sexual orientation may not be within conscious control but may shift along a bisexual continuum for some, and for others remain in a fixed position.

Sexual behavior and one’s identity as heterosexual, gay, lesbian, or bisexual can be malleable over time. “The fluidity of sexual desire, behavior and identity may be a fundamental characteristic of sexuality during the teenage years (7).” Complicated cultural and social identities will influence sexual identity as well. Savin Williams and Diamond compared the genders and looked at sexual identity trajectories among sexual minority youth. This research led them to conclude that differences among youths can not be explained by gender alone. “No singular sexual identity model is capable of representing the diverse trajectories of male and female sexual identity development.” They found that the context for sexual identity development was more likely to be emotionally oriented for female adolescents and sexually oriented for male adolescents (8).

Although the existence of divergent attractions and sexual behaviors is not a new phenomenon, public and professional discourse have changed over time. It was only in 1973 that homosexuality was deleted from the Diagnostic and Statistical Manual (DSM II) of the American Psychiatric Association, following the work of Evelyn Hooker that did not find increased rates of psychopathology among homosexuals (9). The Stonewall Rebellion in 1969, when the visibility of the gay, lesbian, bisexual, and transgendered community was increased in the media, had an influence as well. The social movement that began at that time has accelerated with the help of popular culture in the United States in recent years. Youth today are rejecting the labels that have served to help identify community in the past, and those who need or want to affix a label to themselves are sometimes choosing broader categories such as queer, polysexual, heteroflexible, and polyamorous.

In 1992, Gary Remefedi et al. conducted a survey of Minnesota junior and senior high school students. In this early study Remefedi found that 1.6% of males and 0.9% of females identified themselves as either bisexual or predominantly homosexual, and more than 10% were “not sure (10).” Of the 36,706 students, 52% reported having some heterosexual experience and 1% as having had a homosexual experience. Interestingly only 27.1% of the students with homosexual experience self-identified as homosexual or bisexual. He also found that even though a larger number of adolescent boys reported a homosexual identification, more adolescent girls reported same-sex attractions and fantasies (10).

This does not necessarily correlate with assuming a gay, lesbian, or bisexual identity. In a study sample of Massachusetts students, which asked about same-sex experiences rather than self-labels, 6.4% of sexually experienced students reported same-sex sexual contact. In addition, they found that an equal number of male and female adolescents had same-sex experiences (11).

More adolescents are self-identifying as lesbian, gay, and bisexual. D’Augelli collected data in the late ’80s and again in the late ’90s in social and recreational programs for gay, lesbian, and bisexual youth in America and Canada. His final sample included 542 youths, 62% male and 38% female. He found that 74% identified as gay or lesbian, and 20% reported being bisexual, but mostly gay or lesbian; and 6% said they were bisexual, but equally gay or lesbian and heterosexual. The bisexual group was significantly more represented by females. They also reported being aware of same-sex feelings around age ten for male youth and 11 for female youths. Self-labeling occurred on average five years after initial awareness. This is a significant decrease in the age that sexual minority youth are self-identifying from the literature of only a decade age. More sexual minority youth are self-identifying while they are still of high school age and living at home even if they are not sexually active (7).

Recent studies have shown that same-sex contact occurs a year or two prior to a boy’s gay identification, while a girl is more likely to have her first same-sex contact after identifying as lesbian. The context for first same-sex sexual contact and self-labeling were found to be more emotionally or relationship oriented for young women and sexually oriented for young men (8). Although the data on this has varied, it probably represents diverse trajectories that sexual minority youth take in their development (12,13,14). Many adolescence begin to explore their sexuality during this developmental period. While this is normative for heterosexual youth, sexual minority youth may not have this experience, due to stigma and internalized homophobia, which may delay the exploration of their sexuality (1).