David M. Huebner, PhD, MPH
Lesbian, gay, and bisexual (LGB) youth are at higher risk for a number of poor health outcomes, relative to their heterosexual counterparts. In its comprehensive review of the literature on LGB health, the Institute of Medicine recently concluded that there was clear scientific evidence indicating that LGB adolescents are at greater risk for depression and attempting suicide, and emerging evidence that they are more likely to use alcohol and other substances (Institute of Medicine, 2011). These empirical findings are mirrored in the mainstream media, where reports of tragic suicides among LGB adolescents have become commonplace in recent years. Minority stress remains the most widely accepted theoretical explanation for these disparities (Meyer, 2003). Because of the stigma that homosexuality still carries in modern society, LGB youth are subjected to varied forms of mistreatment, all of which create a stressful experience with the potential to harm health. Consistent with this notion, empirical research has documented that school bullying (Birkett, Espelage, & Koenig, 2009; Espelage, Aragon, Birkett, & Koenig, 2008; Friedman, Koeske, Silvestre, Korr, & Sites, 2006), discrimination in the community (Thoma & Huebner, in press ), and rejection by friends (D'Augelli, 2002; Hershberger, Pilkington, & D'Augelli, 1997) are all associated with a variety of negative outcomes among LGB youth. In addition to these challenges, recent empirical work has begun to highlight the important role that family responses play in shaping the health of LGB adolescents (Bouris et al., 2010). In one study, researchers found that LGB young adults ages 21-25 who reported that their families were highly rejecting of their sexuality during their teenage years were roughly eight times more likely to report having attempted suicide, three times more likely to have tried illegal drugs, and twice as likely to have engaged in recent unprotected intercourse, relative to youth from families who were less rejecting (C. R. Ryan, Huebner, Diaz, & Sanches, 2009).
Despite the profound impact that parent responses have on a child’s health, we know relatively little about how parents themselves experience the news that they have an LGB child, and interventions to support and guide parents who have an LGB child are limited and currently lack empirical support. This article summarizes the literature on parents’ responses to having an LGB child, and describes the available interventions for these families. It also describes our team’s recent efforts to develop, disseminate, and evaluate Lead with Love, an online film-based intervention for parents of LGB youth (www.leadwithlovefilm.com).
How do parents respond to the news that they have an LGB child?
Research on parents of LGB youth is limited, comprised largely of a handful of qualitative studies. Recurrent themes in the qualitative literature show that initial reactions to the news are characterized by intense emotionality (shock, denial, fear, sadness, guilt, and confusion) that can last for months and possibly years (Beeler & DiProva, 1999; Bernstein, 1990; Goodrich, 2009; Phillips & Ancis, 2008; Saltzburg, 2004; Wakely & Tuason, 2011). In moments immediately after disclosure, parents often report being unable to think of anything else, and may disengage from their normal social networks, increasing their sense of isolation (Phillips & Ancis, 2008; Saltzburg, 2004). As the initial shock dissipates, many parents also report feelings of loss surrounding their hopes and dreams for their child’s future, including marriage and beliefs that children and grandchildren are no longer in their child’s future (Beeler & DiProva, 1999; Bernstein, 1990; Goodrich, 2009; Phillips & Ancis, 2008; Saltzburg, 2004; Wakely & Tuason, 2011). Feelings of guilt or regret are also common among parents who express concern that they did something wrong and somehow caused their child to become gay or lesbian (Beeler & DiProva, 1999; Bernstein, 1990; Phillips & Ancis, 2008). The qualitative literature also suggests that most parents do gradually adjust to the news. Successful coping during the early adjustment period is characterized largely by emotion regulation strategies, and then subsequently through the use of cognitive and behavioral strategies (Phillips & Ancis, 2008) that progressively increase parents’ comfort with their child’s sexuality. Initially, these strategies are focused on pursuing social support, sometimes among LGB related sources, including other parents of LGB children, formal or informal support groups, or LGB friends (Goodrich, 2009; Phillips & Ancis, 2008; Wakely & Tuason, 2011). Parents often experience increased stress or anxiety deciding how, and to whom, they should disclose their child’s sexuality, including to friends and family (Beeler & DiProva, 1999; Bernstein, 1990; Goodrich, 2009; Phillips & Ancis, 2008; Saltzburg, 2004; Wakely & Tuason, 2011). It is common for parents to report an increased desire to learn about homosexuality and LGB culture. Many read books, search online sources, and increase contact with LGB individuals and communities (Beeler & DiProva, 1999; Phillips & Ancis, 2008; Wakely & Tuason, 2011). Other parents describe developing an increased awareness of spiritual or political issues regarding homosexuality. Parents who ultimately come to support their child’s sexuality often report mild to moderate reconceptualization of political, moral, and spiritual beliefs about homosexuality (Beeler & DiProva, 1999; Phillips & Ancis, 2008; Wakely & Tuason, 2011). This sometimes results in a change in spiritual or political affiliation. Often, supportive parents became more vocal proponents of pro-LGB policies, and may publically challenge others who speak or act in a homophobic way (Beeler & DiProva, 1999; Phillips & Ancis, 2008; Wakely & Tuason, 2011).
As time continues to pass, parents enter into, what Phillips and Ancis (2008) describe as, the “later adjustment phase.” Parents often report strong commitment to their new values and often describe themselves as better people, with increased compassion and sensitivity (Phillips & Ancis, 2008; Wakely & Tuason, 2011). In general, supportive parents commonly state that post-disclosure, they are closer to their children and enjoy improved family functioning, including greater communication, understanding of roles, and deepened connection with family members (Beeler & DiProva, 1999; Goodrich, 2009; Phillips & Ancis, 2008; Wakely & Tuason, 2011).
While the results of the qualitative literature are encouraging, in that it suggests that most parents do gradually adjust to the news, findings from data our team has collected indicate that this process of adjustment can take a long time. We are currently analyzing data from approximately 1200 parents of LGB youth ages 10-25, who have known about their child’s sexual orientation for anywhere between a few weeks and 5 years (Huebner & Allen, 2013). On average, parents who have known for a full year do not report that having an LGB child is any easier than parents who have known for just a week or two. The improvement appears to be particularly slow for parents of girls. Although preliminary, these findings point to the need for interventions to support parents and families during this adjustment period and to provide guidance that might help reduce the occurrence of rejecting behaviors.
Resources for Parents
Parents, Families, and Friends of Lesbians and Gays (PFLAG)
PFLAG is the most well-known organization devoted to working with parents and families of lesbian, gay, bisexual and transgender (LGBT) individuals. PFLAG is a national not-for-profit organization with over 350 chapters spread across all 50 states. PFLAG chapters offer support to parents and families who might be struggling with the news that they have an LGBT child. They also provide education about LGBT issues to families and communities more broadly, and serve as a vehicle through which interested families and allies can engage in activism to promote LGBT rights. Anecdotally, many parents report great benefit from participation in their local PFLAG chapters. Unfortunately, at present there is no empirical evidence to confirm that participation in PFLAG activities results in improvement in parent well-being or in changes in parent behaviors that might confer benefits for their children. Challenges to evaluation exist, in part, because the activities and services offered by any local chapter are largely determined and run by local volunteer leadership, resulting in variable experiences in each locale. With that noted, the national PFLAG organizing body does disseminate a variety of high-quality self-help publications targeted to families, and also provides trainings to local chapter leadership to help develop appropriate capacity to carry out the organization’s mission. More information about the organization and local chapters can be found on their website (www.pflag.org).
The Family Acceptance Project (FAP)
The FAP is an initiative based at San Francisco State University that is seeking to develop evidence-based resources to help ethnically, socially, and religiously diverse families be more supportive of LGBT youth. While the ultimate goal is to disseminate an intervention model to healthcare providers around the country, this model is still currently under development. Presently, individuals in the San Francisco Bay Area can receive FAP support services through a collaborative venture with San Francisco General Hospital. For individuals outside of the Bay area, FAP has published a self-help booklet that was written to be accessible for parents, and that might also be useful to practitioners wishing to learn more about these issues. Although the resources do have a foundation in the empirical work that the team has conducted with families of LGBT individuals, actual efficacy data on the model have yet to be published. More information about the FAP, including downloads of their resources, can be found on their website (www.fap.org).
Lead with Love: A film-based intervention for families
Given the limited availability of widely disseminated, easily-accessible, evidence-based resources for families, it is unsurprising that most parents of LGB youth are not receiving services. In our study of 1200 parents, 86% of parents indicate that they have never sought out any type of formal support or therapy for having an LGB child (Huebner, Rullo, Thoma, McGarrity, & Mackenzie, 2013). These data are corroborated by a separate study we conducted with over 500 LGBT youth from 4 cities; 90% of these youth indicated that their parents had never attended any type of support group for families (unpublished data). Because of this unmet need, we developed an intervention format more consistent with public health approaches to reaching large numbers of individuals with lower-dose preventive interventions. Specifically, we created a 35-minute documentary film entitled Lead with Love, which we made available for anyone to view free online (www.leadwithlovefilm.com). We combined this with a media and social networking campaign to draw attention to the film. Evidence suggests that film-based interventions can change individual behaviors across a variety of domains (Chiasson, Shaw, Humberstone, Hirshfield, & Hartel, 2009; Downs et al., 2004; Janda, Stanek, Newman, Obermair, & Trimmel, 2002; Singhal & Rogers, 2002; Wilkin et al., 2007). Moreover, in the instance of this particular target population, a film accessible online has the potential to reach large numbers of parents, including those who wish to remain anonymous, or who do not have the time or resources to access more intensive interventions.
The objectives of the film are to provide comfort, information, and behavioral guidance to parents of LGB adolescents and young adults (age 25 and under), with the goal of reducing rejecting behaviors and increasing positive family interaction. Because sexual orientation and gender identity are distinct (though related), and because the issues parents of transgender children face are unique (e.g., decisions about medical intervention), we opted to focus specifically on the experience of having an LGB child rather than attempting to cover both sexual orientation and gender identity in one brief film. The film’s content was informed by focus groups with parents of LGB youth, as well as previous research on the process whereby parents come to accept the news that they have an LGB child (Phillips & Ancis, 2008; Saltzburg, 2004). This research suggests that coming to accept an LGB child is indeed a process, characterized by some common stages, and thus we sought to create a film that would offer something for parents at any point in that process (e.g., some parents new to the news are still in shock and simply need to know that they are not alone, whereas have moved beyond that intense emotionality, but have no idea what steps they should take next). We also drew from motivational interviewing approaches which highlight the importance of rolling with resistance and emphasizing clients’ motivations that are consonant with behavior change goals, even when behavior change itself is daunting (Miller & Rollnick, 2002). Although the film was infused with theory-based intervention content, we also ensured the documentary had high production value, was entertaining, and emotionally engaging. Four ethnically diverse families comprise the primary characters in the film. Each family shares elements of their story of coming to understand their LGB son or daughter, as a way of bringing the intervention material to life. Perspectives of both parents and LGB youth themselves are offered. In addition to the families depicted in the film, several experts share relevant commentary and guidance. These include: two psychologists, two clergy, and a high school teacher.
The central behavioral guidance in the film is summarized by the acronym L.E.A.D., which stands for (1) Let your affection show, (2) Express your pain away from your child, (3) Avoid rejecting behaviors, and (4) Do good before you feel good. Each of these recommendations is grounded in empirical work on families and behavior change. Let your affection show aims simply to increase positive family interactions, a key ingredient of many evidence-based family interventions (Beardslee, 2003; Kumpfer, 2003; Sanders, 2000; Taylor, 1998). Express your pain away from your child, was modeled after interventions targeting divorcing and bereaved families, which recommend that parents minimize children’s exposure to parental conflict and stress (Cookston, Braver, Griffin, De Lusé, & Miles, 2007; Haine, Ayers, Sandler, & Wolchik, 2008), as well as on research indicating that LGB youth feel rejected when they witness their parents’ expressions of sadness surrounding their sexual orientation (C. Ryan, Huebner, Diaz, & Sanchez, 2009). We recommend that parents Avoid rejecting behaviors because of the strong associations between parental rejection and LGB health risks (C. Ryan et al., 2009). Finally, Do good before you feel good was based on behavioral approaches to intervention (Watson, 1924; Watson, Tolman, Titchener, Lashley, & Thorndike, 2009), which suggest that it is possible for an individual to initiate behavior change regardless of their current feelings, and that behavioral changes can be an effective starting point for initiating subsequent emotional changes (Dimidjian et al., 2006; Jacobson, Martell, & Dimidjian, 2001). This may be particularly important for parents of LGB youth, given the work by our team and others that suggests parents’ negative emotional reactions to coming out can last from months to years (Beeler & DiProva, 1999; Bernstein, 1990; Goodrich, 2009; Phillips & Ancis, 2008; Saltzburg, 2004; Wakeley & Tuason, 2011).
Promoting and disseminating the film
In order to let people know about the availability of the film as a resource, we embarked on a multi-level promotional campaign that included national media, online search optimization, social networking, and outreach to professional health organizations. The film and our website received national media coverage in outlets such as USA Today, The New York Times, ABC’s The View, and National Public Radio. We increased our online presence by obtaining a Google Grant, so that when individuals use Google to search for relevant terms such as “my child is gay,” an ad for our website is prominently displayed in the search results. These efforts resulted in a large online viewership for the film in the first year after its release. During 2011 the film was viewed at least once by 10,949 individuals, 1865 of whom were members of our primary target population (i.e., parents of LGB youth under the age of 25). Although the film was created for parents, rather than youth themselves, considerable numbers of LGB youth were a part of the viewership (n = 2509). In addition to online dissemination, orders for DVD copies of the film have come from all over the world. The Los Angeles Unified School District purchased copies to put in approximately 250 high schools in its district.
Our team is currently in the process of summarizing and publishing the results of pilot data collected from online viewers in the first year after the film’s release (Huebner et al., 2013). Parents overwhelmingly report that they find the film helpful in both quantitative and qualitative feedback. Moreover, after watching the film, parents report increases in their self-efficacy for being a good parent to an LGB child. The most common suggestion we receive is a request to cover additional topics not currently addressed in the film (e.g., to provide guidance about how to talk to siblings about their LGB brother or sister).
The future of evidence-based intervention for families of LGB youth
While the work that our team and others are conducting represents some important first steps, it is clear that the field has a long way to go in expanding the range of evidence-based interventions available for families with an LGB child. In particular, future work must concentrate on developing guidance for appropriate assessment of families with an LGB child, creating evidence based interventions for these families, and expanding the methods of delivering interventions in order to circumvent the multiple barriers these families experience in accessing care.
Appropriate assessment of the family situation
As with any challenge a family confronts, having an LGB child is not a uniform experience, and therefore appropriate intervention to support the child and family must be guided by a thorough assessment of the family system and the ways in which a child’s coming out is experienced by the family. As we gain a greater understanding of the varied ways in which families respond to having an LGB child, and how those responses impact various members of the family, we will be able to make more concrete recommendations regarding the ways in which standard family assessments should be expanded and tailored to gather information about the most critical issues facing families with an LGB child. For example, the work Ryan and colleagues did documenting strong associations between family rejection and child well-being suggests that a thorough assessment of parent rejection is essential (C. R. Ryan et al., 2009). Building on this work, our team has further begun to explore the impact of more subtle forms of rejection (e.g., asking that a child keep his or her sexual orientation a secret from extended family), and we have found that these behaviors are associated with child outcomes above and beyond the effects of more obviously rejecting behaviors, such as name calling or physical abuse. Additionally, our work suggests that rejecting behaviors and accepting behaviors can co-exist in the same family, and therefore, the presence of one should not imply that assessment of the other is unnecessary. Thus, assessment of a broad spectrum of parent behaviors is necessary if we want to adequately understand the risks to an LGB child. Undoubtedly as empirical work on the topic grows, so too will guidance about other important areas of inquiry during family assessment.
Developing and testing evidence-based techniques to address family concerns
As researchers and clinicians continue to uncover the specific challenges that families face, developing appropriate techniques to address those challenges will be a priority. To the degree that families with LGB youth present with issues similar to other families, adopting and adapting other techniques from the cannon of evidence-based family intervention is possible. However, it is also likely that these families face unique challenges that require novel approaches. For example, one topic that many parents of gay or bisexual boys raise is concern about HIV risk. Although concerns about sexuality and its consequences are not unique to parents of a gay child, the prevalence of HIV among gay men raises the stakes for these boys. And our work suggests that conversations about sex in a family with a gay son are complicated by a variety of factors: parents have limited personal experience and knowledge from which to draw in providing education, and sons often experience their parents’ highly emotional tone in talking about HIV as an implicit (or explicit) rejection of their sexuality. In one study we have in progress, we see that the kinds of parent behaviors that are typically associated with less sexual risk among heterosexual kids (i.e., parental monitoring and parent communication about sex) are not protective for gay boys, and might actually be associated with greater risk (Thoma & Huebner, 2013). Thus, we must develop novel approaches to appropriately intervene with families to address sexuality, as well as the other unique issues that families of LGB youth bring to treatment.
Recognition of the limitations of traditional mental health services
Across the broad spectrum of mental health concerns, access to quality treatment is limited by a host of factors – the number of available mental health providers, access to insurance or other ability to pay, and stigma, to name just a few (Kazdin & Blase, 2011). In the case of families with an LGB child, the barriers to obtaining treatment may be even greater. As we have discussed, many parents report great hesitancy talking openly about the fact that they have an LGB child. For those who might be open to seeking services, finding a provider who is knowledgeable about these issues can be difficult. Thus, as a field, we need to identify new means of delivering quality services to families that acknowledge these realities. Applying innovations in telehealth and internet-based interventions to this population might be promising options. Additionally, research shows that LGB individuals are healthier when raised in settings with a climate more favorable to LGB rights (Hatzenbuehler, McLaughlin, Keyes, & Hasin, 2009; Hatzenbuehler, Pachankis, & Wolff, 2012). This suggests that structural interventions designed to change social norms around LGB issues could be a powerful intervention strategy. Indeed, by becoming an advocate locally or nationally for laws and policies that promote LGB equality, every psychologist has the potential to intervene to improve the social climate in which LGB youth are raised.
David M. Huebner, PhD, MPH is an Associate Professor of Psychology at the University of Utah. He has been conducting research on lesbian, gay, and bisexual health for the past 15 years with funding from the National Institutes of Mental Health and the Centers for Disease Control and Prevention. Dr. Huebner serves on the National Board of Directors of the Gay, Lesbian, Straight Education Network (GLSEN).
Portions of this article are adapted from a paper currently under review at the Journal of Primary Prevention. This research was supported by grant MH072381 from the National Institute of Mental Health. The author would like to acknowledge the contributions of multiple graduate students to this body of work, including Kendrick Allen, Larissa McGarrity, Jordan Rullo, and Brian Thoma.
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