Patricia Shelby. The Canadian Nurse. Volume 95, Issue 4. April 1999.

A 14-year-old boy confides that he feels he does not fit in with the other boys and does not understand why. Would you consider that he might be questioning his sexual orientation? Would you be able to explore these feelings without bias? Do you have an understanding of the developmental process for gays and lesbians? Can you dispel myths and give accurate information?

Recently, some gay youth dared to speak out to a public health nurse about their feelings of being isolated and invisible. When the nurse did a bit more exploring, she discovered that the problems facing these youth were far greater than she expected and deserved further attention. Her investigation led to a report for the regional health board.

The issues surrounding gay, lesbian and bisexual youth affect not only the young people themselves but also their parents and siblings. Heterosexual youth who have same-sex parents face many of the same issues. Transgendered youth are also profoundly affected by the same issues, but it is beyond the scope of this article to address the complexity and diversity of gender identity and gender roles. To offer support to gay, lesbian and bisexual youth, nurses must be aware of the issues and know how to devise helpful strategies.

Gays (homosexual males) and lesbians (homosexual females) are emotionally and physically attracted to individuals of the same sex. Bisexuals are attracted to either sex. The gay, lesbian and bisexual communities are individual, diverse and complex groups with distinct issues. Nonetheless, for the sake of brevity, this article will refer to gay, lesbian and bisexual youth collectively as a group and discuss issues that affect all of them. Most research in this area has been with gays.

Some believe that people choose their sexual orientation and that a homosexual can be converted to a heterosexual through counselling (such as a currently popular program called reparative therapy). On the contrary, it is probable that sexual orientation has a biological, genetic determination and cannot be changed with counselling. The American Psychological Association states that there is no scientific evidence supporting the effectiveness of conversion therapies and opposes “all portrayals of lesbian, gay and bisexual people as mentally ill and in need of treatment due to their sexual orientation.”

Sexual orientation is usually considered an adult orientation, but awareness of a “difference” starts in childhood. Self-acknowledgment of same-sex sexual orientation often occurs around 14 to 16 years of age. For most gay, lesbian and bisexual youth, acknowledging their sexual orientation is a long process that takes many years.

It is often assumed that gay, lesbian and bisexual individuals are easily identified by mannerisms, speech and gender-role behavior, but this assumption is a myth. Many live invisibly within the community. In addition, gay, lesbian and bisexual youth come from all ethnic communities.

The prevalence of gay, lesbian and bisexual people within the population is controversial. Although statistics vary widely, most researchers report that at least five to 10 per cent of the general population would describe themselves as part of this group.(f.6) However, as long as discrimination against this group exists, the exact prevalence will be almost impossible to ascertain.

Health Issues

There are definite health risks to being gay, lesbian or bisexual. The literature agrees that most of these risks are not inherent in the sexual orientation but instead lie in society’s negative response to these individuals. The risks include depression and suicide, verbal and physical assaults, homelessness, school dropout and low socio-economic status, substance abuse and HIV infection.

Depression and suicide. Gay, lesbian and bisexual youth experience more depression than the general youth population. The incidence of suicide in this group varies according to the study, but gay and lesbian youth have been found to be two to seven times more likely to attempt suicide than their heterosexual counter-parts. Gay, lesbian and bisexual youth account for nearly 30 per cent of completed youth suicides. These high rates of depression and suicide are related to the discrimination and isolation these youth face from family, friends and society in general.

Verbal and physical assaults. Although other marginalized groups can get support from their family or peers, gay youth are often alone, and many are subjected to frequent verbal and physical abuse. The abuse can lead to lower selfesteem, self-hatred and despair. The youth eventually become socialized to hate themselves. Selfhatred lends itself to drug and alcohol abuse, risky behaviors (sexual and other) and suicide. Even gay, lesbian and bisexual youth who have kept their sexual identity a secret do not escape unharmed; they must listen in silence to derogatory comments. Trying to pass as heterosexual requires constant vigilance and deception, which can lead to chronic anxiety, diminished self-esteem and depression.

Alcohol and drug use. Gay, lesbian and bisexual youth are more at risk for alcoholism and drug use than their heterosexual counterparts. Alcohol and drug abuse can lead to many other health problems, such as depression, suicide, accidental injury, malnutrition and cirrhosis. It has also been found that adult lesbians smoke more cigarettes than their heterosexual counterparts, putting them at greater risk for lung and heart disease. Smoking, along with other drug use, usually starts in adolescence.

HIV infection. Gay, lesbian and bisexual youth have a higher risk of HIV infection than the general youth population. Gay, lesbian and bisexual youth are unable to participate in mainstream dating, yet they experience the same needs as heterosexual youth. Social isolation, decreased self-esteem, decreased opportunities for safe development of relationships, lack of relevant safer sex information, homelessness and increased exposure to intravenous drug use all contribute to the increased HIV risk.

Homelessness. Gay, lesbian and bisexual youth are more likely than the general youth population to live on the streets. A British Columbia study found that youth living on the street are four to seven times more likely to describe themselves as gay, lesbian or bisexual than are youth attending school. One reason is that heterosexual parents of gay, lesbian and bisexual youth have the same prejudices and misperceptions as the general public; thus, many have difficulty accepting and supporting their children. A study found that only 21 per cent of mothers and 10 per cent of fathers were perceived to be supportive of their gay, lesbian or bisexual children. These youth often experience verbal and physical abuse from parents and siblings; this abuse can push them out of their homes and into the streets without the skills and resources to cope.

Gay youth often receive peer acceptance and support for the first time in their lives from other street youth, thus making it difficult to get them back off the streets.

School dropout and low socio-economic status. An American study found that the dropout rate for gay, lesbian and bisexual youth is 28 per cent compared to the U.S. national average of only nine per cent. This high dropout rate is caused primarily by the almost universal discrimination against gay, lesbian and bisexual young people by their peers. Gay, lesbian and bisexual youth face severe verbal harassment six times more often than their heterosexual counterparts and are three times more likely to be injured in a fight.

Dropping out of school and homelessness put gay, lesbian and bisexual youth at a high risk of low socio-economic status, which contributes to poorer health status.

Health care barriers. Health service providers rarely ask about sexual orientation; heterosexuality is generally assumed. Many health professionals are ignorant of the issues and some are even prejudiced against gay, lesbian and bisexual individuals.

Thus, gay, lesbian and bisexual youth face a dilemma when meeting with a health professional. If they keep their orientation a secret, they may not receive appropriate care (such as screening for diseases for which they are at higher risk). If they “come out,” they risk discrimination and having their sexual identity leaked to parents and others. The consequences of being “outed” to parents who are not supportive might include verbal and physical assault, forced “curative therapy,” forced religious involvement and other negative events. For these reasons, many gay, lesbian and bisexual youth delay or decline necessary health care.

Helpful Strategies

Widespread ignorance and discrimination are the primary causes of most of the health issues facing gay, lesbian and bisexual youth. To improve the health of this group in our community, the ignorance and discrimination need to be addressed directly. Nurses, by virtue of their respect in the community, are perfectly positioned to lead the way.

The most important thing that nurses can do is to become aware of the complex issues facing this group including stereotyping, same-sex family dynamics, psychosocial development, the coming out process, feelings of shame and isolation, parent supports and religious beliefs. Nurses should also know of any gay, lesbian and bisexual resources available in their community. In British Columbia, for example, Youthquest! is a gay, lesbian, bisexual, transgendered and questioning youth support service, offering resources, education, advocacy and drop-in centres at a variety of locations in the province. Check your local area for such groups. (A useful information web site is http://www.gaycanada.com, which, among other things, includes links to province-specific resources for gay, lesbian and bisexual youth.)

Nurses can also initiate actions within their communities. As valued role models, nurses can demonstrate acceptance of gay, lesbian and bisexual individuals. They can challenge name-calling and harassment. To broaden understanding and acceptance, nurses can engage families, friends and colleagues in discussions about gay, lesbian and bisexual issues. It is important not to assume that everyone is heterosexual; the use of inclusive language, such as “date” rather than “boyfriend,” helps lower barriers. Nurses can wear buttons or put up posters showing support for gay, lesbian and bisexual communities. They can ask gay, lesbian and bisexual friends and colleagues how to be an ally, or join a gay-straight alliance. Urging health agencies and local libraries to carry educational material and pamphlets on gay, lesbian and bisexual issues is another strategy for increasing local resources.

Finally, the nurse who is gay, lesbian or bisexual can come out, because youth need visible role models. Undeniably, coming out is fraught with risks and tensions, but hiding one’s sexual orientation is also stressful and can take a tremendous toll on personal health. Also, when a reputable professional comes out, colleagues are more likely to confront their own biases. The more gay, lesbian and bisexual people who are out in any given place, the more difficult it is to single out any individual for harassment.

Gay, lesbian and bisexual youth are largely unsupported by health professionals, educators and parents. Discrimination and prejudice stemming from a lack of accurate information is the norm, although small pockets of support are growing in number. Individual nurses can do much on their own to affect these issues and help these youth to negotiate through adolescence.