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).

Sexual minority youth face similar and different developmental tasks than their heterosexual peers as they try to assimilate this aspect of their identity into their lives and their social and emotional relationships. Adolescents who are raised in families and communities where heterosexuality is considered normative often hide or deny their same-sex feelings and interests. The implications of this for identity development are unknown. Since many of these teens are being raised in families where the parents have a different sexual orientation, it is difficult to make use of parental identifications to help with the process of self-exploration (15).

Increased homosexual and bisexual role models are a result of a shifting culture, with greater tolerance for homosexuality. A virtual community now exists where youth can explore the notion that distinct and rigidly defined categories of sexual arousal, attractions, fantasies, and behaviors are not necessarily concordant with individual feelings and experiences. Teens have more access to discourse about sexuality through TV, books, magazines, school and community support groups, and the Internet. The deconstruction of the heterosexual paradigm as uniquely normative has allowed the possibility for more youths to begin to experience both the social and emotional incorporation of a sexual minority identity. D’Augelli found that even though society has become more accepting, “youths spent one-third of their lives aware of same-sex feelings but not revealing this to others (7).” But simultaneously, increasing numbers of high school students today personally know someone who is in a sexual minority. A recent Washington Post/Henry J. Kaiser Family Foundation/Harvard University sponsored survey noted that 57% of Washington, DC–area teens had a friend who is gay or lesbian (16).

In his study, D’Augelli found that half of the sexual minority males and three-quarters of the females had had heterosexual experiences, with more females having had heterosexual sex prior to having a same-sex experience. More males (84%) than females (60%) in this study were aware of their same-sex feelings prior to engaging in heterosexual sex (7). Sexual identity, sexual behavior, and sexual orientation are not stable or necessarily congruent for many adolescents during this period of development. This is particularly relevant for the mental health clinician who relies on the description of sexual behavior to define a patient’s sexual orientation or sexual identity.

Kinsey first described a nonbinary understanding of sexual orientation as a spectrum with exclusive homosexuality (0) on one end of a continuum and exclusive heterosexuality (6) on the other. He found that for both men and women sexual behavior could be very fluid over time (17,18). Sexual behavior in adolescence does not necessarily predict future patterns of sexual arousal, emotional and romantic feelings, or fantasies.

Contributions made by Troiden, Cass, and others helped to begin a dialogue in the field about “normal” development for sexual minorities. The literature on heterosexual identity development is sparse as it is has been considered “normative development” and little research has been done to understand it. Troiden, Cass, and others described a linear stage model of sexual identity development that depicts a pathway to a full integration of one’s sexual identity. Troiden used retrospective data from predominantly openly identified gay men with same-sex attractions. Troiden’s model begins with a stage of Sensitization. It is described in the literature as a sense of being different from peers (21), with this sense of difference often stemming from nonconforming gender roles. The correlation of early feelings of “being different,” and later same-sex orientations, correlates more strongly for men than for women (5,22,23).

The second Troiden stage is called Identity Confusion. Beginning in adolescence the youngster wonders if he is homosexual, based on his same-sex sexual interests, and feels threatened by the social mandate for heterosexual identity. This is qualitatively distinct from heterosexual youth who may have transient same-gender sexual interests and experimentation. Such youngsters cope by trying to pass as heterosexual, and may immerse themselves in heterosexual sex to prove to self and others that they are heterosexual.

Troiden’s third stage is called Identity Assumption. There is gradual acceptance of one’s homosexual identity through contact with gay and lesbian individuals and a supportive homosexual culture, if that is available in the community. Selective self-disclosure occurs first to other openly homosexual youth and adults and then to selected heterosexual peers and adults. Rural and minority youth have a much harder time, the former due to lack of available role models and the latter due to double discrimination or stronger cultural bias against homosexuality within their minority community.

Troiden and Cass expanded on the work of Goffman (24) to describe the impact of stigma on gay and lesbian youth who are consolidating their identities. Such youth tend to use “impression management” skills, as described in the work of Goffman in reference to members of other stigmatized groups who use “covering” defenses, in order to minimize the impact of stigma and the risk of rejection. They do this by selectively disclosing to those most likely to be accepting, while minimizing to others aspects of their identity which they fear might lead to rejection. Goffman also described the process of “spoiled identities,” as identity becomes reduced to the stigmatized aspects, denying membership in other aspects of the self, such as ethnicity and religious affiliation. This concept has been extended to sexual minority youth by authors such as Martin in his article Learning to Hide: The Socialization of the Gay Adolescent, and has been revisited by many others, including Yoshino’s recent book on “covering (25,26,27).”

Troiden’s fourth stage is called Commitment. Homosexual identity is internalized with more acceptance “with the fusion of sexuality and emotionality into a significant whole.” There is increasing disclosure to peers and family. Management of stigma shifts from the personal to political and educational efforts in the broader community. Cass adds two additional stages. Stage five is called Identity Pride. This represents a stage where the individual is self-accepting and more involved with the community. Stage six is Synthesis. In this stage identity is fully incorporated into their lives, both socially and professionally (28).

Diamond, Garnets, Savin Williams, Klein, and others have challenged these models of linear progression, and have introduced a concept of a multidimensional approach to sexual identity development (8,29,30). Fritz Klein developed an alternative multidimensional model of sexuality, which includes a grid of seven variables: sexual attraction, sexual behavior, sexual fantasies, emotional preference, social preference, self identification, and hetero/homosexual lifestyle, all plotted along a time course (8,17,18,19,20).

Galatzer-Levy addressing clinical aspects of treatment stated, “In non-linear systems models, like epigenetic models, the fact that processes share initial and end points does not indicate that the paths joining these points are the same. Instead it leaves us free, in each case to explore the path taken by the individual and suggests that there will often be multiple paths between various developmental points (31).” Other critiques of earlier linear models include using male retrospective experiences as the norm, and not taking cultural factors into account (30,32). At the time the linear models were constructed there was little data on the development of sexual identity in women.

Diamond has written extensively on the development of female same-sex orientation. “Women appear more likely to exhibit situational and environmental plasticity in sexual attractions, behavior, and identifications (33).” She argues that thinking about sexual identity development in women as an evolving process may be more helpful in understanding their development with regard to both emotional and sexual attractions. In this study some women maintain a stable same-sex attraction and behaviors over their lifespan and others are more fluid. In another study Lisa Diamond conducted, women with same-sex attractions did not have the same childhood profiles as men. Men were found to have an early age of same-sex attractions, gender atypicality, and an early age of first same-sex contact (5). The sexual minority women she studied were more likely to have had a late and abrupt development of same-sex attractions.

Rosario et al. looked at ethnic and racial differences in the coming-out process. They looked at a sample of black, Latino, and white youths and found that there were no significant differences in the sexual developmental milestones, sexual orientation, sexual behavior, or sexual identity between groups. They found that cultural factors did not impede the formation of identity but might cause a delay in identity integration due to familial and cultural factors. Cultural factors (which include religious beliefs) may delay integration of a gay identity, as manifested by limiting involvement in gay-related social activities, due to the impact of stigma. They reported that black sexual minority youth were involved in fewer gay-related social activities, and also reported less comfort with others knowing about their sexual orientation, and disclosed less frequently to others, than did white youth. Latino youths also disclosed to fewer people than white youth. Black youth reported greater increases in positive attitudes regarding their sexual identity than did white youths over time. Negotiating multiple identities impacted in sexual minority identity formation in males and females of varied ethnic backgrounds (34,35,36,37).