In this article, we address theories of attachment and parental acceptance and rejection, and their implications for lesbian, gay, bisexual, and transgender (LGBT) youths’ identity and health. We also provide two clinical cases to illustrate the process of family acceptance of a transgender youth and a gender nonconforming youth who was neither a sexual minority nor transgender. Clinical implications of family acceptance and rejection of LGBT youth are discussed.
In this article, we discuss sexual minority, i.e., lesbian, gay, and bisexual (LGB) and transgender (LGBT) youth. Sexual orientation refers to the individual’s object of sexual or romantic attraction or desire, whether of the same or other sex relative to the individual’s sex,1 with sexual minority individuals having a sexual orientation that is partly or exclusively focused on the same sex. Transgender refers to individuals for whom current gender identity and sex assigned at birth are not concordant, whereas cisgender refers to individuals for whom current gender identity is congruent with sex assigned at birth.1,2 Sexual orientation and gender identity are distinct aspects of the self. Transgender individuals may or may not be sexual minorities, and vice versa. Little is known about transgender youth, although some of the psychosocial experiences of cisgender sexual minority youth may generalize to this population.
The Institute of Medicine recently concluded that LGBT youth are at elevated risk for poor mental and physical health compared with heterosexual and cisgender peers.2 Indeed, representative samples of youth have found disparities by sexual orientation in health-related risk behaviors, symptomatology, and diagnoses, 3–8 with disparities persisting over time.9–11 Furthermore, sexual orientation disparities exist regardless how sexual orientation is defined, whether by sexual or romantic attractions; sexual behaviors; self-identification as heterosexual, bisexual, lesbian/gay or other identities; or, any combination thereof. Disparities by gender identity have also been found, with transgender youth experiencing poorer mental health than cisgender youth.12
Attempts have been made to understand sexual orientation and gender identity-related health disparities among youth. It has been argued that sexual minority youth experience stress associated with society’s stigmatization of homosexuality and of anyone perceived to be homosexual [see Ch. 5]. This “gay-related”13 or “minority” stress14 is experienced at the hands of others as victimization. It is also internalized, such that sexual minorities victimize the self by means, for example, of possessing negative attitudes toward homosexuality, known as internalized homonegativity or homophobia. In addition to interpersonal stigma and internalized stigma, the main focus of this article, structural stigma reflected in societal level norms, policies and laws also plays a significant role in sexual minority stress, and is discussed in Mark Hatzenbeuhler’s article, “Clinical Implications of Stigma, Minority Stress, and Resilience as Predictors of Health and Mental Health Outcomes,” in this issue. Meta-analytic reviews find that sexual minorities experience more stress relative to heterosexuals, as well as unique stressors.6,15,16 Research also indicates that transgender individuals experience substantial amounts of prejudice, discrimination, and victimization17 and are thought to experience a similar process of minority stress as experienced by sexual minorities,18 although minority stress for transgender individuals is based on stigma related to gender identity rather than stigma related to having a minority sexual orientation. Stigma related to gender expression affects those with gender non-conforming behavior, a group that includes both transgender and cisgender individuals. This includes many cisgender youth growing up with LGB orientations.
Actual or anticipated family acceptance or rejection of LGBT youth is important in understanding the youth’s experience of minority stress, how the youth is likely to cope with the stress, and consequently, the impact of minority stress on the youth’s health.19 This article addresses the role of family, in particular parental acceptance and rejection in LGBT youths’ identity and health. Literature reviewed in this article focuses on the experiences of sexual minority cisgender youth due to a lack of research on transgender youth. However, we include findings and implications for transgender youth whenever possible.