Within the framework of medical anthropology this group is of interest because of the health risks that this group faces compared to their peers. What causes the increased health risks that they suffer? What are their support networks and health behaviors? How do these youths function as a group, both inwardly with each other and outwardly with the larger culture? Do they have solid social networks based on their unique sexual identities or does that identity separate them from each other and the rest of their peers? Answers to questions like these can bring us a long way to understanding the unique health challenges faced by this population. While it had been hypothesized that structural heterosexism and homophobia is the root of these problems, much work needs to be done on this issue.
While the political face of each of these three issues is defined with the language of civil rights, I suggest that a deeper issue is the root of these battles. That issue is the worth that we, as a culture, give to individuals who do not hold positions of power. In the case of race, we see this dynamic in the treatment of Native Americans and African Americans, neither of whom had the ability to consistently ward off the attack of European aggressors, thus losing land, freedom and lives. In the case of women, they did not have the ability to consistently gain power over men, who used the tools of religion, politics and traditional family structures to maintain historically derived power structures in the control of men. In the case of GLB's, these same tools are used to prevent them from obtaining the rights granted to those citizens with traditional sexual orientations, such as legal marriage rights and responsibilities, protection from being fired, denied public housing and education, serving their country in the military, etc.
In each of these cases, the public manifestations of these civil rights struggles are in the denial of rights. However, the social expression is in how we perceive and treat people who fall outside of our cultural definitions of normalcy and decency. Churches taught that it was indecent for women to work outside of the home, for black people to be seen as equals to white people and for GLB people to express their sexuality. Science showed that women, blacks and GLB's were inferior to white heterosexual males. Communities set up laws, rituals and organizations that propagated the idea that white heterosexual males were spiritually, psychologically and morally more stable than anybody else. Cognitive social structures were therefore arranged such that women, blacks and gay people were seen as weak, dirty, perverted and mentally ill. Such techniques, while possibly not conscious attempts to subvert power and self-esteem in these three classes of people, were used consciously with brutal effectiveness by Nazi propagandists against Jews, racial minorities and GLB's under Hitler's Germany (Blumenfeld, 1996; Bytwerk).
It is within this larger context of general social oppression, structural abuse and destructive cognitive mapping that I place many of the maladaptive health behaviors of GLB youth. Studies of GLB adults and youth show that they suffer from numerous medical and mental problems at greater rates than those found among heterosexual populations. Further, studies have examined the causes of several of these problems, controlling for different variables and have reached the tentative conclusion that many of the health issues specific to the GLB community are related to issues of self-esteem and self-acceptance.
GLB youth have a greater incidence of homelessness than heterosexual youth. Several studies indicate the severity of this problem. Kruks (1991) indicates that the Los Angeles County Taks Force on Runaway and Homeless Youth reports that approximately 25-35% of their youth are GLB. Similarly, he indicates that the Seattle Commission on Children and Youth estimates that 40% of their homeless youth are GLB. These figures are much higher than the estimated population of homosexuality in the United States, probably about 2-5% (Diamond, 1993). Such youth suffer from health issues of poor living conditions, malnutrition, lack of medical care and increased rates of violence.
In San Diego County, a coalition for homeless youth exists between a number of social service agencies, including the local GLB Community Center. Part of the outreach to homeless youth in the urban San Diego area is a large bus that had been converted into a mobile medical unit in cooperation with the University of California, San Diego, Medical School, that runs two days a week. This coalition perceived a relatively greater risk of homelessness in their GLB youth so provides one day of weekly service to the mixed sexual orientation community of downtown and the second day in the primarily gay community of Hillcrest (data obtained from an internship I did in 1999 with the coalition and the GLB community center).
Many homeless youth are forced to engage in survival sex in exchange for food, money, shelter or safety. Kruks indicates that survival sex is particularly a problem with gay youth, citing an unpublished study from the Children's Hospital of Los Angeles, whose data shows that 72% of males involved in survival sex self-identify as gay or bisexual. Much of the social dynamic for this is a significant trend in prostitution for "Johns" (the person seeking to exchange money, goods or services for sex) to be older males seeking teens. Therefore the targets of preference are young females willing to engage in heterosexual sex or young males willing to engage in homosexual sex. The demand for such services makes it easy, though far from safe, for young runaways to obtain money in this way.
Different communities have different trends for homeless youth, depending on the context of the community. For example, one sub-group of homeless youth identified by the San Diego coalition is represented by male illegal immigrant youth (13-18 years old) from Mexico who experience gender confusion. Lacking a concept of homosexuality as a valid sexual identity, many of these youth interpret their same-gender sexual attraction as the belief that their soul is female even though they are biologically male. Therefore, in order to express their sexuality appropriately within the social and religious constructs of their home community, they believe that changing their biological sex is the only viable alternative. These youth, mostly from poor areas in Northwestern (Baja) Mexico, cross the border into San Diego County to prostitute themselves in order to make the money necessary to pay for such an operation.
Another trend in homelessness, one that is ubiquitous across the country, is throwaway or runaway GLB teens. Such teens are either forced to leave their homes by parents who are unable to deal with their teens, or teens who runaway because they are unable to deal with their parents. Reflecting the statistics given above, a significantly higher percentage of runaway and throwaway teens are GLB than heterosexual. The tension that arises in many households when an adolescent "comes out" (states to him/herself or to others that s/he is GLB) can add to the already stressful situation that often exists between parents and their children. The added stressor can push the already strained relationships beyond their capacity to cope, thus causing parents to force the adolescent from the home, or the teen to feel overwhelmed by the parent, thus running away from the stressful or violent situation.
Several studies have shown increased rates of suicide ideation and suicide attempts among the GLB population compared to the heterosexual population. These studies are broken up into two general categories: studies done strictly within GLB youth organizations and population-based studies. The former indicate rates of suicide ideation and attempts at much higher rates than other studies that have been done on whole populations, but are critiqued because of the lack of a control group. Such studies indicate that these populations are in desperate need of social support, but do not address rates of suicide for GLB youth who do not seek social services from GLB-related youth organizations.
Population-based studies tend to examine statewide data on youth populations that contain GLB youth together with heterosexuals. These studies provide comparison rates that seem to give an accurate portrayal of the suicidality of youth populations. The four largest studies are summarized in Table 1. The studies consistently demonstrate a significantly higher rate of suicide ideation and attempts by GLB youth compared to heterosexual youth.
|Author, Year||N||GLB-youth reporting suicide attempts||non-GLB-youth reporting suicide attempts|
|Faulkner, 1998||3054||41.7% (represents only sexually-active youth)||28.6% (represents only sexually-active youth)|
|Remafedi, 1998||36,254||28.1% male, 20.5% female||4.2% male, 14.5% female|
Remafedi (1998) and Garofalo (1999) found that GB male youth were especially susceptible to suicide ideation, but that LB female youth increases were eliminated when controlled for socioeconomic factors. Russell (in press), however, who controlled for family demographic background, still found a significant increase in both male and female GLB youth suicidality. Further, he looked at suicidality after having controlled for four variables frequently associated with suicidality: hopelessness, depression, alcohol abuse and the suicide attempt of a family member or friend. Russell also looked at the effects of recent victimization on suicidality. Each of these factors, except for recent victimization, are strong indicators for suicidality for GLB youth. Moreover, the different rates of suicidality between GLB and heterosexual youth drop to non-significance when hopelessness and depression alone are controlled, and the differences for females drop significantly when hopelessness is controlled.
Similarly, Safren (1999) found that environmental variables were adequate to explain not only suicidality in GLB youth, but also increases in depression and hopelessness. His data indicates that after the external factors of stress, social support and acceptance coping were controlled, the rates of suicidality, hopelessness and depression fell to non-significance. Finally, Hershberger (1997) found similar results, but contradicted Russell's finding about victimization. Hershberger found that suicide attempters all had a significantly greater incidence of verbal insults, property damage, physical and sexual assaults and physical abuse. Further, he found that relational problems, alcohol abuse and self-esteem were all highly correlated to suicide attempts.
All of this date coincides with the hypothesis that sexual orientation is not inherently related to suicidality. Rather, external factors such as stress, social isolation, feelings of hopelessness and victimization seem to be more useful predictors of suicidality among GLB youth. As will be shown, this population suffers significantly higher rates of victimization, violence and social stigma than demographically matched heterosexual youth.
C. Violence and Victimization
Many minority populations have higher rates of violence and victimizations. GLB youth face similar increased risks. Such factors can be measured directly, in questions that ask about being attacked or threatened, and indirectly in measures of missed days at school because of fear. Durant (1998) correlated the number of male sexual partners of gay youth with several of these factors. He found a significant correlation between the number of sexual partners and "the frequency of having been threatened or injured with a weapon at school, the number of days the students did not attend school because they felt unsafe, and the number of times theyhad been injured in a fight that required medical treatment" (p. 115).
Faulkner (1998) found similar results. His data indicates that GLB youth were almost eight times as likely to have missed four or more days of school because of feeling unsafe, that GLB youth are over seven times more likely to have been threatened or injured with a weapon, over five times more likely to have had property stolen or damaged at school and almost four times more likely to require medical treatment from peer physical abuse (fighting).
Not only are GLB youth more likely to face violence and victimization at their schools, but they are also more likely to engage in inappropriate methods of coping with violence, such as bringing weapons to school. Garofalo's data (1998) indicates similar victimization and violence rates as the previous studies, but also found that GLB youth are over twice as likely to carry a weapon, five times as likely to carry a gun and almost three times as likely to carry a weapon to school. Such studies indicate that school systems are not only doing a poor job at protecting students from interpersonal violence, but that there may be differential rates of protection in favor of heterosexual youth. Further, it appears that GLB youth are not made to feel as though they can utilize standard means of social and legal support to protect themselves against aggressive and homophobic peers, possibly due to blatant heterosexism/homophobia on the part of the administration.
D. Mental Health Risks, Substance Abuse and High Risk Sexual Behaviors GLB youth have higher rates of psychiatric disorders, substance abuse and high risk sexual behaviors. The reasons for this are complex, but do not seem to be related directly to sexual orientation issues. The primary factors related to these increased rates seem to be similar to those described above regarding suicidality. It is clear that this population suffers significantly more victimization and violence than their peers. Further, as will be seen below, they also suffer from social stigmatization and isolation to a degree not experienced by their heterosexual peers. These factors seem to combine to cause a multiplicity of problems within the GLB community, both youth and adults.
DuRant (1998) found higher rates of both alcohol and marijuana use in GLB teens. Garofalo (1998) found that GLB youth were almost twice as likely to have smoked or to have used alcohol prior to the age of thirteen, 1.4 times as likely to have used marijuana, almost five times as likely to have used cocaine and almost fourteen times more likely to have shared needles.
When controlled for family background and demographics, however, neither Fergusson (1999) and Safren (1999) found increases in substance abuse. It is possible, therefore, that the previous studies' apparent increases are due to a failure to take these factors into account. The DuRant and Garofalo studies were quite large (n=3886 students from Vermont High Schools and n=4159 students from Massachusetts High Schools respectively), the Safran study was small and non-random (n=104 youth from local community programs) and while the Fergusson study was both large and longitudinal (n=1007) the sample is a non-U. S. population (Christchurch, New Zealand). Therefore, neither study, while they control for demographics, do not necessarily show that U. S. GLB youth are not at higher risk for substance abuse than heterosexual youth. Studies have shown that self-acceptance/self-esteem and family history of substance abuse (Ghindia, 1996; Kus, 1989) are strong predictors of substance abuse among gay men, indicating a potential relationship among GLB youth.
A related issue is that of increased psychiatric disorders among GLB youth. Fergusson (1999) found higher overall rates of major depression (71% v. 38%), generalized anxiety disorder (29% v. 13%) and conduct disorder (32% v. 11%). Similarly, Lock (1999) found higher rates of mental health problems, eating disorders and general health problems in GLB youth. However, as mentioned above, Safren's (1999) analysis showed that once environmental factors such as stress, social support and acceptance coping were controlled, depression and hopelessness failed to achieve levels of significance. Several studies indicate that adult GLBT's are significantly more at risk than heterosexual adults, lending weight to the Fergusson and Lock studies. However, more work needs to be done in this area, especially controlling for variables such as victimization, violence and stigma.
Finally, GLB youth tend to engage in higher risk sexual behaviors than heterosexual youth. Garofalo (1998) found that GLB youth were almost twice as likely to have engaged in sexual intercourse and were almost three times as likely to have had three or more sexual partners. Stronski-Huwiler and Remafedi (1998) indicate that, regarding GLB youth, "about two thirds had at some time engaged in unprotected anal intercourse" and that "in about half of recent encounters, the partners were not well acquainted before having sex" (p. 126). Though no comparative data is presented with heterosexual youth, it is still clear that this represents a medical risk experienced by GLB youth.
McBee (1997) describes several sources of structural inequity other than State and Federal issues. One factor, described above, is the lack of a safe educational environment, shown in the fact that many youth miss school out of fear of abuse. Thus there is poor training of and/or enforcement by school administrators and teachers regarding sexual orientation issues, including peer abuse. Another factor is poor access to professional help. McBee notes that at least one study has indicated that 60% of child psychiatrists had no experience with GLB adolescents, indicating either a differential rate of help-seeking behavior from GLB youth, or the refusal to deal with sexual orientation issues by the psychiatrists. Either way, it leaves this population open to poorer access to mental health care. A third factor McBee mentions is religious oppression of GLB people. Given the power that religious beliefs hold in American culture and the pervasiveness of anti-gay attitudes among religious institutions, this represents a powerful structural risk factor for adolescents.
Another form of inequity is general social heterosexism. Wells (1999) describes some of these issues as they relate to social health.
Contributing factors include fear of disclosure, feelings of being the only gay teenager or actual discrimination and ostracizing by homophobic peers. These adolescents may believe themselves to be completely alone and unable to talk to anyone about their sexual identity. They may subsequently withdraw completely from family members and peers because they fear having their "secret" discovered and they fear rejection. ... Socialization of children occurs within the paradigm of heterosexuality and its presumed gender roles. ...The belief that one is different or abnormal is highly stressful to many gay teens. ... Gay teens may doubt themselves, lose self-esteem, or experience self-hatred.Issues such as family and peer rejection become powerful influences in shaping how GLB teens socialize and how they progress in identity formation. Many experience delays in solidifying their gender, relational and sexual identities that are often accomplished by heterosexuals as teenagers. Further, GLB youth may experience distortions in their perceptions of themselves, as described by Erwin (1993):
Homosexual people grow up in a homophobic society in which they learn that homosexuality is immoral and sick, concepts drawn from the religious and early medical psychological theories. At some point in their lives, varying from person to person, they come to realize that they are different from most people based on their erotic and emotional attractions to people of the same biological sex. By this time, however, they have already internalized society's homophobia. As role models, most gays and lesbians have only the media's negative stereotypes of sick, sinful, `effeminate' men or `masculine' women.One issue about which to be sensitive is the "coming out" process of GLB people. This often occurs in definable stages and can take place in the contexts of coming out to oneself and coming out to others. Understanding these processes can help teachers, counselors, physicians and parents to better understand a GLB youth as well as provide developmentally appropriate services. Troiden (1988) describes a four-stage model of the coming out process. This model is comprised of a general stage developmental process as well as "evasion of stigma" patterns that are common for each stage.
However, the medical anthropologist and other community health providers can play a role in initiating interventions that can help protect GLB youth (D'Augelli, 1993). One effort is the development of mental health services for GLB youth. This involves educating and sensitizing youth workers, therapists, physicians, etc, to issues of sexual orientation. This also involves making a conscious public relations effort to assure that a GLB youth will not only be safe from heterosexism/homophobia, but also that the youth will be affirmed in their identity and will not be judged, condemned, or, in some cases, outed.
Another effort is the development of "safe spaces". This involves public education to all students that abuse and harassment of GLB youth will not be tolerated, whether by adults or peers. Similar to the issue of mental health services, a proactive public relations effort must be made to let GLB youth know that their safety, health, presence and well-being is equally as valid as heterosexual youth. Their journey for identity formation needs to be vigorously affirmed, whatever path that might take. Having an administratively approved GLB organization available to students is a strong, positive step in affirming the identity of GLB youth and gives them a place to socialize with other youth who struggle with similar issues. Such an organization should be located at the school with easy student access. Additionally, schools should make their students aware of outside agencies that are set up to provide services to GLB youth.
A third area where health care providers can benefit GLB youth is in parental education programs. Organizations like P-FLAG (Parents and Friends of Lesbians and Gays) can help parents cope with having a GLB child. However, many parents assume that their child is going through a stage, or at worst, is mentally ill. Such families may experience severe relational distress as the child attempts to express his/her sexual or romantic feelings at the resistance of the parents. While such resistance is normal even for parents of heterosexual youth, when the resistance is rooted in an attack on the very identity of the youth, it can be severely traumatizing for normal social development as well as the trust between parents and children.
Parents often go through their own coming out process (Stronski-Huwiler, 1998). They must often go through a grieving period of the loss of the image and expectations associated with having an heterosexual child, having to redefine the relationship with their child, as well as learning a new identity for their child. Parents often experience guilt due to older psychoanalytical theories of etiology that blame inadequate parenting styles on the development of homosexuality in children. Further, social and religious issues may make the process of publicly and privately accepting their child's identity more difficult. These factors can make it even more difficult to actively affirm the child's identity. Both parents and youth "require comprehensive information about homosexuality to overcome myths, stereotypes and fears and to build a positive framework for understanding" (Stronski-Huwiler, 1998: 134). The health care provider and agency can assist this process by actively assuming this role.
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Wells, Susan. 1999 The Health Beliefs, Values and Practices of Gay Adolescents. Clinical Nurse Specialist 13: 69-73.
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|Jeramy Townsley; last updated April 18, 2001|