The Importance ol Pafental Suppoft in the livesol Gay, Leshi.docx

The Importance ol Pafental Suppoft in the lives
ol Gay, Leshian, and Bisexual lodividuals
Marvin R. Goldfried
State University of New York at Stony Brook
T
Anita P. Goldfried
Private Practice, New York, New York
This article underscores the very important role that parental
acceptance
'aria'suppOi't plays in turthering the psychological well-being of
g
bian, and bisexual irTdiviauals. Parents, Families,
anaTrjerids_oLLesbians
—sTra Uays (KHAU), an organization dedicated to this goal,
has as its mis-
si o'n~tlTe]inpportJo71a^i]y~membersredU^^^ and ad^ra-
cacy for equal rights for lesbians,
gayrineri_andJ;usfi)iuals._By-lcomiRg-otjf-'
"themselves, strai^Rt parents and relatives—including those in
the mental
health field—not only can extend the support they offer to their
gay/
lesbian/bisexual children and relatives but also play a
significant role in
reducing the stigma of being gay, lesbian, or bisexual and in
mainstream-
ing gay, lesbian, and bisexual issues. © 2 0 0 1 John Wiley &

Sons, Inc.
J Clin Psychol/ln Session 57; 6 8 1 - 6 9 3 , 2 0 0 1 .
Keywords; gay men; lesbians; bisexuality; family; parents
/ gather from your letter that your son is a homosexual. I am
most impressed by the fact that
you do not mention this term yourself in your information about
him. May I question you, why
do you avoid it? Homosexuality is assuredly no advantage, but
it is nothing to be ashamed of,
no vice, no degradation. It cannot be classified as an illness. . . .
It is a great injustice to
persecute homosexuality as a crime, and cruelty, too.
Letter to an American Mother
Sigmund Freud
April 9, 1935
This article is personal, empirical, professional, and political in
nature. One of our two
wonderful sons is gay; we are a psychologist and clinical social
worker, respectively; we
Correspondence and requests for reprints should be sent to:
Marvin R. Goldfried, Department of Psychology,
State University of New York at Stony Brook, Stony Brook, NY
11794-2500; e-mail: [email protected]
sunysb.edu.
JCLP/ln Session: Psychotherapy in Practice, Vol. 57(5), 681-
693 (2001)
© 2001 John Wiley & Sons. Inc.

682 JCLP/In Session, May 2001
know about the research on the relationship between parental
support and the psycholog-
ical well-being of gay, lesbian, and bisexual (GLB) individuals;
and we believe that our
clinical work with such clients always will be limited until the
stigma of being gay,
lesbian, or bisexual in our society is removed.
We suspected that our son, Michael, was gay when he was about
7 years of age. Our
knowledge of the research on the developmental histories of gay
men (Green, 1974)
called our attention to the cross-gender behavior patterns and
interests that have been
found to be somewhat predictive of homosexuality in males
(e.g., feminine play). As he
grew older, our belief strengthened, and was confirmed when
speaking informally with
gay mental health professionals. Their advice was to wait
patiently until he was ready to
come out and then give him our complete support.
It was a long wait. Because such a long time was involved from
our first awareness
that he was "different" until he finally came out to us, we were
able to work through our
feelings of guilt, fear for his welfare, and loss of what we saw
as joys of life such as
marriage and children. We did all we could to make our
attitudes of acceptance of GLB
individuals known during this period and were careful to
encourage Michael to attend a

college having liberal attitudes toward diversity. It was during
his freshman year in col-
lege that he finally came out to us. He sat us down at the dining
room table and told us
that he "was experimenting with his sexuality." After he
elaborated on what he meant by
that, we finally told him that we were not surprised and that, in
fact, had sensed that this
was so a long time ago. His initial reaction was negative—an
interesting role reversal.
Even though we were supportive of his self-disclosure, he
understandably felt the fact
that we knew even before he did was intrusive in the personal
struggle he had been
dealing with for some years. As one might expect, however, this
initial negative reaction
soon became positive.
Having had so many years to become accustomed to the idea
that our son was prob-
ably gay, we did not feel the need to become involved in a
parent's support group. Although
we knew of Parents, Families, and Friends of Lesbian and Gays
(PFLAG) and became
members of the national organization, we did not attend the
support sessions sponsored
by the local chapter. Then, a few years ago, while attending the
Gay Pride parade, we saw
several local PFLAG groups marching. In the desire to offer our
support, we joined them
and had a chance to witness firsthand the profound loss of
family support that so many
GLB individuals live with. The GLB onlookers' reactions to our
group and the banners
we carried ("We love our gay and lesbian children" and "You
will always have a home in

PFLAG") were powerful. The applause and cheers were
punctuated by shouts of "We
love you, too" and "We wish our parents would march." The
expressions on the faces of
the younger onlookers communicated happiness and longing;
the older men and women
looked sad and regretful, perhaps reflecting a never-to-be-
fulfilled longing. This experi-
ence made an indelible impact on us. A thought that
immediately came to mind was the
fact that GLB individuals often speak of their network of
friends as "family," no doubt
because of the loss of, or alienation from, their actual families
of origin.
One does not have to be a mental health professional to
recognize the devastating
effect that parental nonacceptance or outright rejection can have
on the psychological
well-being of individuals. In a society that continues to
stigmatize people for not being
heterosexual, those who are GLB emotionally need all the
support they can get.
As we noted earlier, we wish to touch on personal, empirical,
professional, and polit-
ical issues. We already have begun with the personal: our
realization of the importance of
parental support and acceptance. We now turn to considerations
of what we know empir-
ically about the importance of parental support, how parents can
be helped to move to
greater acceptance, and the role that straight family members
can play in reducing the

Parental Support 683
Stigma of being GLB and encouraging mainstream thinking to
become better aware of
tbose issues related to the lives of people who are GLB.
Need for Family Support
Despite important advances in the status of GLB individuals,
they nonetheless continue
to represent a stigmatized segment of our society—both inside
and outside the home.
Current surveys have shown that one of every three gay youth
experiences verbal abuse
from family members, one of every four has encountered
physical abuse from peers at
school, and one of three has made an actual attempt at taking
his or her own life (D'Augelli,
1998). The U.S. Department of Health and Human Services
reported that lesbian and gay
youth are more likely to attempt suicide than are straight youth,
and that a little under one
third of actual suicides were committed by someone who was
gay (Gibson, 1989). It is
important to note tbat one's sexual orientation, per se, does not
contribute to suicidality,
but rather the depression and hopelessness resulting from the
rejection of others does
(Safren & Heimberg, 1998). It was found that in the Los
Angeles area, approximately
18% of homeless youth and young adults are GLB (Unger,
Kipke, Simon, Montgomery,
& Johnson, 1997). The Hetrick-Martin Institute estimated that
25% of gay youth who
"come out" to their parents are ejected from the home, and that

a very large percent of
homeless youth in New York City are gay. Thus, even with the
recent societal advances
that have been made, GLB youth continue to be rejected by their
parents and to face the
possibility of humiliation, physical assault, and, as in some
instances, even death.
Role of Support
As one might expect, the presence—or absence—of support
from parents can have a
major impact on gay men, lesbians, and bisexuals. Hershberger
and D'Augelli (1995)
found that family support significantly reduced the
psychological stress and symptoms
resulting trom victimization experienced by gay teenagers. An
even more dramatic
-association—a negcitive tmiddtion of .87 was foun4-bet""'f'ri
psyr '̂"'"g" '̂̂ *J-p'"*^-
Tenis and the personal self-acceptance on the part of gav youth.
The less self-acceptance,
the greater the likelihood of psychological distress. This finding
is consistent witb a
larger body of evidence indicating that negative self-image
among people in general is
associated with a host of psychological difficulties, including
depression, anxiety, and
level of functioning. In a study on the relationship between self-
esteem and coming out to
parents among gay and lesbian youth, Savin-Williams (1989)
found that self-esteem among
lesbians was positively related to having a satisfactory
relationship with their mother.
Among gay men, self-esteem was associated with a positive

relationship with both their
mother and their father.
The term "self-loathing" has been used in the past within tbe
gay community to
describe oneself. Given the assumption that conceptions of self
are often based on the
reflected views of others, and coupled with the stigmatization of
homosexuality through-
out our society, it is no surprise that many GLB people receive
and internalize the mes-
sage that they are "not quite human" (cf. Goffman, 1963, p. 5).
Even before one develops
a sense of sexual identity, boys and girls assimilate the societal
message that there is
something wrong with homosexuality. In light of this, one
cannot consider the psycho-
logical well-being of GLB individuals without addressing the
social stigmatization to
which they have been subjected. Although there has been a
greater societal acceptance of
homosexuality, along with the development of a more positive
identity among those who
are gay (Savin-Williams, 1998), clearly more needs to be done.
GLB individuals repre-
sent one of the few minority groups that can be ridiculed by
mainstream society without
fear of criticism. As minorities, they also are somewhat unique
in that they represent a
marginalized segment of our society whose parents do not share
their minority status.

Consequently, they are confronted with the additional challenge
of not only being stig-
matized by society at large but also the prospect of being an
outcast in their own homes.
Coming Out to Parents and Family Acceptance
Upon learning that their daughter or son is gay, parents
typically react quite negatively
(D'Augelli, 1998). Family members experience the conflict
between their love for their
son or daughter on the one hand and their own negative biases
toward homosexuality and
desire for social acceptance on the other. They may feel anger
and resentment, blaming
their son or daughter for "doing this" to them—as if it was a
choice. They may blame
themselves, wondering how and where they went wrong. They
may fear for the social,
personal, and physical well-being of their child and what might
in store for him or her.
They may worry what friends, relatives, and neighbors will
think if they learned of this.
The process of coping with the realization that one's daughter or
son is gay is much
like that associated with mourning, a process in which the first
year or so may be partic-
ularly difficult. Upon learning that her daughter was a lesbian,
one 46-year-old mother
confessed: "I mourned her as if she had died. I felt like she had
died, though intellectually
I knew she was alive" (Robinson, Skeen, & Walters, 1989, pp.
67-68). Although there is
little in the way of well-controlled research on how parents
typically deal with the news

that their son or daughter is gay, Strommen (1989) described
certain stages that parents^
frequently experience:
1. Subliminal awareness. There exist some vague suspicions,
often based on behav-
ior patterns shown and the failure to fit typical gender role
characteristics. Indeed, it is not
at all unusual for such suspicions to exist.
2. Impact. This involves the actual discovery of the child's
identity, on their own or
through having the child actually come out to them. This phase
may be best characterized
as involving a "crisis," accompanied by such reactions as shock,
denial, confusion, blame,
anger, and guilt.
3. Adjustment. Next are attempts to deal with the crisis, which
might be to get their
son or daughter to change. Attempts are made to keep their
child's sexual identity a
secret, so as to maintain the social, religious, and professional
respectability ofthe family.
4. Resolution. There begins a working-through process,
mourning the wish to have a
heterosexual child and the dreams and plans associated with this
(e.g., marriage, having
grandchildren). This phase also involves learning more about
homosexuality and its ori-
gins, and modifying one's own stereotypes about what it means
for someone to be gay.
5. Integration. Having completed whatever mourning needed to
be done, and having

learned about what is involved in being gay in our society, one
may hope to integrate this
all into an acceptance of one's daughter and son for who they
are, and as they are.
To study parental reaction upon learning that their child was
gay, Muller (1987)
conducted a survey of 111 family relationships, interviewing
lesbians, gay men, and their
parents. The most frequent relationship (48%) could be
characterized as Loving Denial,
which involved a positive relationship between parent and child.
Although the partner
often was included in family contacts, the parents remained
closeted about their son's or
daughter's sexual orientation. The next most frequent
relationship was that of Resentful
Denial, comprising 36% ofthe sample, in which actual contact
with parents was limited
by their difficulty in accepting their offspring's sexuality. Only
a small percent (11%) of
the relationships could be characterized as Loving Open, where
parents were not only
accepting of the daughter/son and partner, but were open and
positive in presenting this
information to others. In the final type of relationship. Hostile
Recognition (5%), the
nonacceptance of the offspring's sexual orientation resulted in
total estrangement. As one
might expect, the degree of acceptance and openness varied as a
function of the families

religion, educational level, and political beliefs.
As we have suggested, the acceptance process is very much of a
process for family
members, and can vary in time as a function of different factors
and experiences. Even
when one thinks they have accepted their gay child, an event
may arise that tells them
further change is needed. For example, one father believed that
he had fully come to
accept his son being gay, and had routinely included his son's
partner and friends in
various family events. However, at one family dinner when his
son referred to his partner
as "hon," the father became so distracted that he started serving
the salad with his hands!
Quite often, difficult if not painful decisions must be made in
fully accepting the
sexual orientation of one's son or daughter. Borhek (1993) tells
of a widowed mother
whose straight children and their families had difficulty
accepting her gay son. She there-
fore chose to celebrate holidays with her son and his partner. As
she explained to her
other children who were not happy with her decision, they had
their own families with
whom they could celebrate, and she would be happy to have the
entire family get together
whenever they were ready.
Borhek also tells of a mother who related her process of
acceptance at a meeting of
Dignity, the national gay/lesbian Catholic organization,
resulting from a recent experi-
ence with her gay son on Mother's Day:

For a long time Thomas has been wanting me to meet some of
his friends. I told him, "1 accept
you. I love you just as much as I did before, but I want no part
of your gay life, I don't want
to meet your gay friends, and if you have a lover, don't tell me
about it."
This past Mother's Day I had one of the most beautiful Mother's
Days anyone could have. My
son had wanted to take me to the Sheraton-Ritz, but the workers
there were on strike, and he
told me instead that one of his friends had invited me to his
home for brunch.
I'm happy that I went. I loved each and every one of them.
They're beautiful people! I was
ashamed of the feelings that I'd had. And I'm sorry to say this to
the heterosexual world, but
I saw more love in this church tonight than I've seen in a long
time. (Borhek, 1993, pp. 269-270)
The acceptance process takes time and corrective experiences,
and many of these
experiences can occur by having contact with other supportive
parents—as is the case
with PFLAG
PFLAG
In 1972, three years after the Stonewall riots in New York City,
Jeanne Manford marched
in the New York City Gay Pride Day parade, carrying a sign
that read "PARENTS OF
GAYS UNITE IN SUPPORT OF OUR CHILDREN." Shortly
thereafter, a handful of
groups scattered throughout the United States were formed by
parents of gay men and

lesbians for the purpose of providing each other mutual support
and support for their
children. In 1981, representatives of the several groups came
together to form Parents,
Families, and Friends of Lesbians and Gays (PFLAG). In
addition to providing support,
it was recognized early on that more needed to be done at a
broader societal level.
v,jrhe current mission of PFLAG is threefold: To provide
support to family members,
to educate the publtc, ana to advocate for equal rights for
GLB/transgendered individu-
als. It is a rapidly growing organization, with chapters in over
430 communities through-
out the United States, reflecting the involvement of close to
80,000 households. In more
recent years, it has become international in scope. In a response
to the antigay "family
value" attacks by the radical right, PFLAG issued the following
policy statement: "We
love, respect and support our gay, lesbian, bisexual and
transgendered children. We
denounce and will strongly resist any effort to label them as
less than responsible citizens
and caring family members we know them to be" (adopted by
the Board of Directors,
1999).'
Based in Washington, D.C., PFLAG is governed by a 21-
member board of directors.

It holds yearly national conferences, in which representatives
from various local affiliates
convene to provide mutual support and to attend training
workshops to learn how to
foster PFLAG's educational and advocacy agendas. Among the
various activities associ-
ated with national PFLAG are its involvement in providing a
clearinghouse for informa-
tion about issues and publications related to GLB/transgendered
issues, publishing
informational brochures, providing speakers for public
education, supporting local edu-
cational initiatives lobbying against discriminatory legislation,
organizing interfaith dia-
logues, and responding to antigay media campaigns.
At a national PFLAG conference we attended, one mother
related an experience she
had with her son, whom she believed to be gay but had not yet
come out to her. She had
been concerned about his psychological well-being for some
time, but was reluctant to
broach the topic of his sexual orientation directly. What she did
instead was to comment
on some brochures she had recently received from PFLAG and
passed them on to her son
in the event that he had any friends who might find them of
interest. Shortly thereafter,
her son came out to her, expressing how devastated he had been
feeling upon realizing
that he was gay. In fact, he confessed that right before receiving
the brochures from her,
he was seriously contemplating suicide.
At that same meeting, we heard numerous other heart-rendering
accounts from par-

ents. One Mormon couple from Salt Lake City had been
informed by their church that
they needed to choose between their gay son and the
congregation. Their lifestyle and
social contacts were intricately tied up with the Mormon
Church, making this a particu-
larly painful choice. They finally decided in favor of their son,
and indicated that involve-
ment in PFLAG made this major life change possible.
As clinicians, we often are inclined to recommend therapy as
the preferred method of
intervention. Indeed, Saltzberg (1996) suggested that family
therapy is the intervention of
choice for facilitating parental acceptance of their gay and
lesbian children. Although we
are certainly strong advocates of psychotherapy, our experience
convinces us that the
type of groups offered by PFLAG can be a much more powerful
alternative.
As a case in point, we attended a local PFLAG support group at
which a very angry
and distressed mother reported that her son has just come out to
her. Even at the coffee
hour before the actual group began, she had difficulty in
containing herself. She indeed
was in the midst of a crisis. She began the group discussion by
tearfully expressing her
anger upon hearing the news, questioning: "How could he do
this to me?" and "Doesn't
he know he's ruining my life?" Approximated halfway into the
meeting, after she had the
opportunity to describe what had happened and how she felt, a
young woman in her early
20s described her own current dilemma. Although she had come

out to some of her
friends, she had not done so to her family. With great anguish,
she described her fears
' Further information may be obtained from PFLAG, 1101 14th
Street NW, Suite 1030, Washington, DC 20005.
Telephone: 202-638-4200. Fax: 202-638-0243; e-mail:
[email protected]; website: www.pflag.org
associated with her parents learning that she was a lesbian. She
was torn between openly
being who she was and risking the possibility of being disowned
by her parents, whom
she loved dearly. As she spoke and received support from other
group members—
consisting mostly of parents—we watched the expression on the
face of the mother who
had spoken earlier. She appeared stunned in hearing what it was
like from the child's
point of view, and her face softened to reveal the sadness and
sympathy she felt for this
young woman. This experience, as well as others we have
witnessed, led us to conclude
that referral to PFLAG should be the intervention of choice in
foster parental acceptance.
For example, the parents of a 19-year-old college student
recently consulted one of
us (APG) after having been informed by her that she was a
lesbian. They were upper
middle class people, owned a successful business, and were
very active in their commu-

nity. Their daughter, Fran, was the model teenage girl—bright,
pretty, and popular in
school. Since Fran came out to them two weeks earlier, both
parents were markedly
distressed and were having difficulty working and sleeping.
They no longer had the
"ideal daughter." They were totally in shock, especially because
she "always seemed
normal in other ways." However, as Fran recently told them, she
had dated boys because
she felt she should, not because she really wanted to.
In our session, I pointed out that Fran was still the same
daughter they had known
and that their close relationship could grow even closer now
that she didn't need to keep
this a secret from them. However, they would need to mourn
their fantasies and images
about her future. I told them that their shock and grief reactions
were normal, and that
there was an organization of parents designed to help them deal
precisely with what they
were going through. I gave them some PFLAG literature,
together with the local PFLAG
telephone number from the directory. They very much wanted to
set up another appoint-
ment, which we did.
Before the next appointment, the mother called to indicate that
they had attended
their first PFLAG meeting. She thanked me for putting them in
touch with PFLAG and
indicated that it was just what they were looking for. Although
she acknowledged that
they realized that they had lots to deal with, they felt that much
better. In fact, she felt that

an additional appointment would not be needed. It was one of
those cancellations that a
therapist could feel good about.
Expanding Parental Support: Coming Out
Several years ago, one of us (MRG) attended a behavior therapy
conference at which
there was a panel discussion on the place of psychotherapy in
the lives of gay men and
lesbians. Inasmuch as one of the topics was whether
psychotherapy should attempt to
convert people in their sexual orientation, the room was
extremely crowded. One of the
panelists, a former colleague of mine, indicated that he believed
that under no circum-
stance should a therapist ever attempt to alter the sexual
orientation of a patient. Although
I found myself in agreement with this general statement, I
recalled a bisexual client with
whom I had worked many years earlier who wanted to increase
his sexual attraction to his
fiancee, whom he loved very much. However, I was somewhat
reluctant to raise this issue
during the question and answer period. I finally decided that I
had to say something and,
out of concern for the possible negative audience reaction, I
prefaced my comment by
indicating that one of my two favorite sons was gay and that I
was a dues-paying member
of PFLAG. I then went on to describe a case of a bisexual man I
had seen who wanted to
become more sexually attracted to his fiancee. At the end of the
meeting, this former
colleague approached me and commented that he thought it was
brave of me to say what

I said. I thought he was referring to my comment about the
particular case, but instead he
688 JCLP/ln Session, May 2001
referred to something I had not fully realized that I had done,
namely that I had "come
out."
In their experiences with parents and family members, PFLAG
has observed a curi-
ous phenomenon: When GLB/transgendered individuals come
out of the closet, their
parents and relatives go in. A minister from Pittsburgh admitted
that this happened with
him as his gay son David became more open about his sexual
orientation.
I did not realize that I had slipped into a closet. As David grew
older, I spoke less and less
about him to members of my congregation. To my shame and
horror, I began to realize why—I
didn't want anyone to ask what I considered an embarrassing
question about whom David was
dating, what he was involved in on campus, etc., which would
cause me to lie or admit he was
gay. I had accepted David, but I had not affirmed him. I was
still embarrassed and ashamed to
admit to others that I had a gay son. (PFLAG, 1996, p. 3)
Parents of lesbian, gay, and bisexual children do not have to go
very far from home
to learn about the difficulty in coming out; all they need do is
ask their children. For GLB

individuals, the coming-out process generally involves the
follow steps: (a) self-'
recognition as being gay, (b) disclosure to others, (c)
socialization with oth"erga5' indi-
viduals, (d) positive self-identification, and (e) integration and
acceptance (Mattison &
McWhirter, 1995). For parents to come out themselves, they
similarly need to recognize
and accept the fact that their son or daughter is gay. As
indicated earlier, this is a process
that requires time and corrective experiences as well as a total
reorganization of one's
expectations and values. Having finally reached this point,
parents—and other family
members—can take the next step of sharing this information
with family members and
close friends. It also involves a socialization process, which is
where involvement in
PFLAG and other related organizations can be particularly
relevant. Having reached a
positive self-identification, the family members need to deal
with any guilt and resent-
ment over the fact that their relative is gay, that they have not
had any part—except
perhaps genetically—in contributing to this, and that they can
accept the situation the
way it is. These various actions, thoughts, and feelings
hopefully can eventually be orga-
nized and integrated into their view of themselves, and the
attitude is that of "taking it for
granted" the way it is.
In their book Beyond Acceptance, Griffin, Wirth, and Wirth
(1986) reported on the
experiences that parents of gay and lesbian children have had in
this coming-out process.

They emphasize that the process of acceptance is very much an
ongoing one, and involves
various levels:
Whenever a parent is able to day, "I have a gay or lesbian child"
to anyone outside the imme-
diate family, there is an underlying message: "As his or her
parent, whatever befalls my child
befalls me. I will fight for my child, for we are intertwined in
our history and in our love for
each other. My child is not alone. I stand for him or her. (p.
101)
When parents remain in the closet, they send a different
message to their son or daughter,
namely, "We think you're okay, but let's keep it a secret."
Everything said before the
"but" gets negated. It also has a negative impact on the parents
themselves, as they …
Social Transition: Supporting Our
Youngest Transgender Children
Ilana Sherer, MD
Those of us who work with
transgender children frequently face
decisions based on evidence that is
conflicted or lacking and encounter
opponents who are rightfully wary

about what they see as experimental
treatments without well-examined
outcomes. However, in a transgender
population where nearly one half
experience suicidal ideation, the risk
of nonintervention is quite high.1
In this issue of Pediatrics, Olson
and colleagues2 provide evidence
in support of social transition, a
completely reversible intervention
associated with lower rates of
depression and anxiety in transgender
prepubescent children. Socially
transitioned children, or those who
have adopted the name, hairstyle,
clothing, and pronoun associated
with their affirmed, rather than
birth gender, have become more
visible in the media over the last

several years. Although to date there
has been no published evidence to
support providers in suggesting social
transition as a beneficial intervention,
many families, often guided by
mental health professionals, make
that decision based on observational
evidence in response to seeing how
suffering can be alleviated by allowing
the child to express their own sense of
gender.
Much of the research that is available
on transgender youth and adults
points to the dismal psychosocial
outcomes faced by this population.
Homelessness, substance abuse, HIV
infection, depression, anxiety, self-
harm, and suicidality are much higher

than in the general population, and
are thought to result from family
and community rejection.3, 4 In the
last decade, we have learned that
medical interventions, including
hormone blockers and later
phenotypic transition with feminizing
or masculinizing hormones, can
improve these outcomes in youth.4, 5
We have also learned the key role that
family acceptance plays in improving
outcomes.6
Olson and colleagues report on
the mental health outcomes of
prepubescent, socially transitioned
transgender children, comparing their
depression and anxiety scores with
those of age-matched controls. They

interpret these scores in light of the
findings of previous studies of children
with the diagnosis of gender identity
disorder (GID; a diagnosis that has now
been replaced by gender dysphoria in
the Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition) who
had not socially transitioned. Children
in the Olson sample who had socially
transitioned had depression scores
equal to their cis-gender peers and
anxiety scores dramatically lower than
the GID study sample (although anxiety
scores were higher than age-matched
peers and siblings). The authors use
social transition as a proxy for family
acceptance. Although families can be
accepting without allowing a social
transition, social transition can be an

incredibly affirming process for the
child, showing the child that their
identity is supported.
The rationale cited by those who
oppose social transition are that
children cannot possibly know their
gender at such an early age and that
social transition could encourage
Palo Alto Medical Foundation, Dublin, California; and Child
and Adolescent Gender Center, Benioff Children's Hospital,
University of California, San Fransisco, California
Opinions expressed in these commentaries are
those of the author and not necessarily those of the
American Academy of Pediatrics or its Committees.
DOI: 10.1542/peds.2015-4358
Accepted for publication Dec 8, 2015
Address correspondence to Ilana Sherer, MD, Palo
Alto Medical Foundation, 4050 Dublin Blvd, 2nd Floor,

Dublin, CA 94568. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
1098-4275).
Copyright © 2016 by the American Academy of
Pediatrics
FINANCIAL DISCLOSURES: The author has indicated
she has no fi nancial relationships relevant to this
article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has
indicated she has no potential confl icts of interest
to report.
COMPANION PAPER: A companion to this article
can be found online at www. pediatrics. org/ cgi/ doi/
10. 1542/ peds. 2015- 3223.
PEDIATRICS Volume 137 , number 3 , March 2016 :e
20154358 COMMENTARY
To cite: Sherer I. Social Transition: Supporting
Our Youngest Transgender Children. Pediatrics.
2016;137(3):e20154358
by guest on April 6,

2020www.aappublications.org/newsDownloaded from
SHERER
children to later seek out treatment
of medical transition.7 A 2013
study by Steensma and colleagues8
looked at factors associated with
“persistence”, that is eventual
pursuance of medical treatment, and
“desistance” of gender dysphoria.
Among the factors associated
with persistence was early social
transition. This set up a “chicken
or egg” question: is it early social
transition that leads to later
transgender identification or are the
children most likely to identify as
transgender later on also more likely

to socially transition? Those most
likely to seek out later transition are
also those with the strongest sense
of dysphoria, an older age at the time
of the study, and those most likely to
describe their identity in declarative,
rather than affective form (ie, “I am
a boy, ” as opposed to “I feel like a
boy.” Thus, the “persisters” may be a
qualitatively different group than the
“desisters, ” and further research may
be able to distinguish them at earlier
ages.
Proponents have argued that social
transition is useful both in improving
function in those children who are
intensely gender dysphoric and
in helping to test the waters so

to speak; that is, giving the child
a completely reversible way to
explore life in the other gender
before committing to any medical
interventions.9 Observational
evidence has shown that once they
have socially transitioned, children
with intense gender dysphoria
often settle down and show marked
improvement in behavior and mood.
If the child or family later realizes the
need to transition back to the birth
gender, that can also happen, with
the appropriate social supports and
without any irreversible changes.9
Olson and colleagues give supporters
of social transition evidence that
shows what we have suspected all

along: that socially transitioned
children are doing fine, or at least as
well as their age-matched peers and
siblings. This finding is truly stunning
in light of the numerous studies
that show depression and anxiety
internalizing psychopathology scores
up to 3 times higher for non–socially
transitioned children; although, as
pointed out by the authors, there
are some differences in the patient
population of those studies and in the
methods used to rate internalizing
psychopathology. Although it does
not establish a causal relationship,
this finding is crucially important to
professionals who work with these
children, as well as their families,

in showing us that they are not
likely to suffer any additional harm
and may benefit from early social
transition. While there is obviously
more research needed to determine
if providers should recommend
social transition as a beneficial
intervention, for families who have
already chosen this avenue for their
children, professionals should have
no concern over supporting the
family’s (or mental health team’s)
decision, and reassuring the parents
that social transition should have
little negative impact on their child’s
mental health.
ACKNOWLEDGMENTS
I thank Drs. Stephen Rosenthal and

Diane Ehrensaft for their review of
this commentary.
ABBREVIATION
GID: gender identity disorder
REFERENCES
1. Grossman AH, D’Augelli AR.
Transgender youth and life-threatening
behaviors. Suicide Life Threat Behav.
2007;37(5):527–537
2. Olson KR, Durwood L, DeMeules
M, McLaughlin KA. Mental health
of transgender children who are
supported in their identities.
Pediatrics. 2016;137(3):e20153223
3. Grant JM, Mottet LA, Tanis JE, Harrison
J, Herman JL, Keisling M. Injustice at
Every Turn: A Report of the National
Transgender Discrimination Survey.

Washington, D.C.: National Center for
Transgender Equality; 2011
4. Spack NP, Edwards-Leeper L, Feldman
HA, et al. Children and adolescents
with gender identity disorder
referred to a pediatric medical center.
Pediatrics. 2012;129(3):418–425
5. de Vries AL, Steensma TD, Doreleijers
TA, Cohen-Kettenis PT. Puberty
suppression in adolescents
with gender identity disorder: A
prospective follow-up study. J Sex Med.
2011;8(8):2276–2283
6. Ryan C, Russell ST, Huebner D, Diaz
R, Sanchez J. Family acceptance in
adolescence and the health of LGBT
young adults. J Child Adolesc Psychiatr
Nurs. 2010;23(4):205–213

7. Vilain E, Bailey JM. What should you
do if your son says he’s a girl? Los
Angeles Times. May 21, 2015. Available
at: www. latimes. com/ opinion/ op- ed/
la- oe- vilain- transgender- parents-
20150521- story. html. Accessed
November 19, 2015
8. Steensma TD, McGuire JK, Kreukels
BP, Beekman AJ, Cohen-Kettenis PT.
Factors associated with desistence
and persistence of childhood gender
dysphoria: a quantitative follow-up
study. J Am Acad Child Adolesc
Psychiatry. 2013;52(6):582–590
9. Ehrensaft D. Found in transition: Our
littlest transgender people. Contemp
Psychoanal. 2014;50(4):571–592
2

DOI: 10.1542/peds.2015-4358 originally published online
February 26, 2016;
2016;137;Pediatrics
Ilana Sherer
Social Transition: Supporting Our Youngest Transgender
Children
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DOI: 10.1542/peds.2015-4358 originally published online
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2016;137;Pediatrics
Ilana Sherer
Social Transition: Supporting Our Youngest Transgender
Children
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CP12CH18-Russell ARI 12 February 2016 18:2
Mental Health in Lesbian, Gay,
Bisexual, and Transgender
(LGBT) Youth

Stephen T. Russell1 and Jessica N. Fish2
1 Department of Human Development and Family Sciences, 2
Population Research Center,
University of Texas at Austin, Austin, Texas 78712; email:
[email protected],
[email protected]
Annu. Rev. Clin. Psychol. 2016. 12:465–87
First published online as a Review in Advance on
January 14, 2016
The Annual Review of Clinical Psychology is online at
clinpsy.annualreviews.org
This article’s doi:
10.1146/annurev-clinpsy-021815-093153
Copyright c© 2016 by Annual Reviews.
All rights reserved
Keywords
LGBT, sexual orientation, gender identity, youth
Abstract
Today’s lesbian, gay, bisexual, and transgender (LGBT) youth
come out
at younger ages, and public support for LGBT issues has
dramatically in-
creased, so why do LGBT youth continue to be at high risk for
compro-
mised mental health? We provide an overview of the
contemporary context
for LGBT youth, followed by a review of current science on
LGBT youth

mental health. Research in the past decade has identified risk
and protective
factors for mental health, which point to promising directions
for preven-
tion, intervention, and treatment. Legal and policy successes
have set the
stage for advances in programs and practices that may foster
LGBT youth
mental health. Implications for clinical care are discussed, and
important
areas for new research and practice are identified.
465
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ANNUAL
REVIEWS Further
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http://www.annualreviews.org/doi/full/10.1146/annurev-
clinpsy-021815-093153
LGBT: lesbian, gay,
bisexual, and
transgender; some
scholars include Q to
refer to queer or
questioning
Mental health:
broadly defined to
include mental health
indicators (i.e.,
depression, anxiety,
suicidality) and
behavioral health
correlates (i.e.,
substance use)
Gender identity:
one’s sense and
subjective experience
of gender
(maleness/femaleness),
which may or may not
be consistent with
birth sex
Contents

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466
UNDERSTANDING CONTEMPORARY LGBT YOUTH . . . . . .
. . . . . . . . . . . . . . . . . 467
MENTAL HEALTH IN LGBT YOUTH . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 468
Prevalence of Mental Health Problems Among LGBT Youth . . .
. . . . . . . . . . . . . . . . . . 469
Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
Protective Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 474
IMPLICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476
Law and Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476
School and Community Programs and Practice . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . 477
Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
CONCLUSIONS AND NEXT STEPS . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 479
INTRODUCTION
In the period of only two decades, there has been dramatic
emergence of public and scientific
awareness of lesbian, gay, bisexual, and transgender (LGBT)
lives and issues. This awareness can
be traced to larger sociocultural shifts in understandings of
sexual and gender identities, including
the emergence of the “gay rights” movement in the 1970s and
the advent of HIV/AIDS in the

1980s. Yet the first public and research attention to young
LGBTs focused explicitly on mental
health: A small number of studies in the 1980s began to identify
concerning rates of reported
suicidal behavior among “gay” youth, and a US federal report
on “gay youth suicide” (Gibson
1989) became controversial in both politics and research
(Russell 2003). During the past two
decades there have been not only dramatic shifts in public
attitudes toward LGBT people and
issues (Gallup 2015), but also an emergence of research from
multiple and diverse fields that has
created what is now a solid foundation of knowledge regarding
mental health in LGBT youth.
LGBT is an acronym used to refer to people who select those
sexual or gender identity labels
as personally meaningful for them, and sexual and gender
identities are complex and historically
situated (Diamond 2003, Rosario et al. 1996, Russell et al.
2009). Throughout this article, we use
the acronym LGBT unless in reference to studies of
subpopulations. Most of the knowledge base
has focused on sexual identities (and historically mostly on gay
and lesbian identities), with much
less empirical study of mental health among transgender or
gender-nonconforming youth. Sexual
identities are informed by individuals’ romantic, sexual, or
emotional attractions and behaviors,
which may vary within persons (Rosario et al. 2006, Saewyc et
al. 2004). Further, the meanings
of LGBT and the experiences of LGBT people must be
understood as intersecting with other
salient personal, ethnic, cultural, and social identities
(Consolacion et al. 2004, Kuper et al. 2014).
An important caveat at the outset of this article is that much of

the current knowledge base will
be extended in coming decades to illuminate how general
patterns of LGBT youth mental health
identified to date are intersectionally situated, that is, how
patterns of mental health may vary
across not only sexual and gender identities, but also across
racial and ethnic, cultural, and social
class identities as well.
In this article, we review mental health in LGBT youth,
focusing on both theoretical and
empirical foundations of this body of research. We consider the
state of knowledge of risk and
protective factors, focusing on those factors that are specific to
LGBT youth and their experiences
as well as on those that are amenable to change through
prevention or intervention. The conclusion
466 Russell · Fish
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considers legal, policy, and clinical implications of the current

state of research. First, we provide
context for understanding the lives of contemporary LGBT
youth.
UNDERSTANDING CONTEMPORARY LGBT YOUTH
We begin by acknowledging a paradox or tension that underlies
public discourse of LGBT youth
and mental health. On the one hand there have been dramatic
social changes regarding societal
acceptance of LGBT people and issues, and yet on the other
hand there has been unprecedented
concern regarding LGBT youth mental health. If things are so
much “better,” why are mental
health concerns for LGBT youth urgent?
Historical trends in social acceptance in the United States show,
for example, that 43% of
US adults agreed that “gay or lesbian relations between
consenting adults should be legal” in
1977; by 2013 that number had grown to 66% (Gallup 2015).
The pace of change in the United
States and around the world has been dramatic: The first
country to recognize marriage between
same-sex couples was the Netherlands in 2001; as of this
writing, 22 countries recognize marriage
for same-sex couples. The pink shaded area in Figure 1 (along
the x-axis) illustrates this change
in the increasing social acceptance of LGBT people across
historical time. Seemingly orthogonal
to this trend is the decreasing average age at which LGBT youth
“come out” or disclose their
sexual or gender identities to others (Floyd & Bakeman 2006).
This is illustrated with data on
the average ages of first disclosure or coming out (the y-axis in
Figure 1) taken from empirical

studies of samples of LGB persons. Data from samples collected
since 2000 show an average age
S O C I E T A L A C C E P T A N C E O F L G B T I S S U
E S
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12
14
16
18
22
20
1980

Troiden 1979
McDonald 1982
Savin-Williams 1998
Herdt & Boxer 1993
1990 2000
Calendar year
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2010
Rosario et al. 1996
D’Augelli et al. 2010
Baams et al. 2015
Figure 1
Historical trends in societal attitudes, age trends in peer
attitudes, and the decline in ages at which lesbian, gay, and
bisexual (LGB)

youth come out. Circles (with associated publication references)
indicate approximate average ages of first disclosure in samples
of LGB
youth at the associated historical time when the studies were
conducted.
www.annualreviews.org • Mental Health in LGBT Youth 467
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of coming out at around 14 (D’Augelli et al. 2010), whereas a
decade before, the average age of
coming out was approximately 16 (Rosario et al. 1996, Savin-
Williams 1998), and a study from
the 1970s recorded coming out at an average age of 20 (Troiden
1979). Although they appear
orthogonal, the trends are complementary: Societal acceptance
has provided the opportunity for
youth to understand themselves in relation to the growing public
visibility of LGBT people.
Contrast these trends with developmental patterns in child and
adolescent interpersonal rela-

tions and social regulation, represented by blue shading in
Figure 1. The early adolescent years are
characterized by heightened self- and peer regulation regarding
(especially) gender and sexuality
norms (Mulvey & Killen 2015, Pasco 2011). During
adolescence, youth in general report stronger
prejudicial attitudes and more frequent homophobic behavior at
younger ages (Poteat & Anderson
2012). Young adolescents may be developmentally susceptible
to social exclusion behavior and
attitudes, whereas older youth are able to make more
sophisticated evaluative judgments regarding
human rights, fairness, and prejudice (e.g., Horn 2006, Nesdale
2001). Therefore, today’s LGBT
youth typically come out during a developmental period
characterized by strong peer influence
and opinion (Brechwald & Prinstein 2011, Steinberg &
Monahan 2007) and are more likely to
face peer victimization when they come out (D’Augelli et al.
2002, Pilkington & D’Augelli 1995).
Such victimization has well-documented psychological
consequences (Birkett et al. 2009, Poteat
& Espelage 2007, Russell et al. 2014).
In sum, changes in societal acceptance of LGBT people have
made coming out possible for
contemporary youth, yet the age of coming out now intersects
with the developmental period
characterized by potentially intense interpersonal and social
regulation of gender and sexuality,
including homophobia. Given this social/historical context, and
despite increasing social accep-
tance, mental health is a particularly important concern for
LGBT youth.
MENTAL HEALTH IN LGBT YOUTH

To organize our review, we start by briefly presenting the
historical and theoretical contexts of
LGBT mental health. Next, we provide an overview of the
prevalence of mental health disorders
among LGBT youth in comparison to the general population,
and various psychosocial charac-
teristics (i.e., structural, interpersonal, and intrapersonal) that
place LGBT youth at risk for poor
mental health. We then highlight studies that focus on factors
that protect and foster resilience
among LGBT youth.
Prior to the 1970s, the American Psychiatric Association’s
(APA’s) Diagnostic and Statistical
Manual of Mental Disorders (DSM) listed homosexuality as a
“sociopathic personality disturbance”
(Am. Psychiatr. Assoc. 1952). Pioneering studies on the
prevalence of same-sex sexuality (Ford &
Beach 1951; Kinsey et al. 1948, 1953) and psychological
comparisons between heterosexual and
gay men (Hooker 1957) fostered a change in attitudes from the
psychological community and mo-
tivated the APA’s removal of homosexuality as a mental
disorder in 1973 (although all conditions
related to same-sex attraction were not removed until 1987).
Over the past 50 years, the psycho-
logical discourse regarding same-sex sexuality shifted from an
understanding that homosexuality
was intrinsically linked with poor mental health toward
understanding the social determinants of
LGBT mental health. Recent years have seen similar debates
about the diagnoses related to gender
identity that currently remain in the DSM (see sidebar Changes
in Gender Identity Diagnoses in
the Diagnostic and Statistical Manual of Mental Disorders).

Minority stress theory (Meyer 1995, 2003) has provided a
foundational framework for under-
standing sexual minority mental health disparities (Inst. Med.
2011). It posits that sexual minorities
experience distinct, chronic stressors related to their
stigmatized identities, including victimiza-
tion, prejudice, and discrimination. These distinct experiences,
in addition to everyday or universal
468 Russell · Fish
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CHANGES IN GENDER IDENTITY DIAGNOSES IN THE
DIAGNOSTIC
AND STATISTICAL MANUAL OF MENTAL DISORDERS
The psychiatric categorization of gender-variant behavior and
identity has evolved since the introduction of gender
identity disorder (GID) of children (GIDC) and transsexualism
in the third edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III) (Am. Psychiatr. Assoc.

1980). The DSM-IV (Am. Psychiatr. Assoc. 1994)
eliminated the nontranssexual type subcategory of GID [added
to the DSM-III-R (Am. Psychiatr. Assoc. 1987)]
and combined diagnoses of GIDC and transsexualism into GID.
Because of critiques regarding the limitations and
stigmatization of GID (see Cohen-Kettenis & Pfäfflin 2010), the
DSM-5 (Am. Psychiatr. Assoc. 2013) introduced
gender dysphoria in its place (with separate criteria for children
and adolescents/adults).
Among other improvements, the adoption of gender dysphoria
reflected (a) a shift away from inherently pathol-
ogizing the incongruence between one’s natal sex and gender
identity toward a focus on the distress associated with
this discordance, and (b) recognition of a gender spectrum with
many gender identities and expressions (see Zucker
2014). Despite advances, many argue that diagnoses unduly
label and pathologize legitimate and natural gender
expressions (Drescher 2014). Others voice concerns that the
loss of a gender identity diagnosis altogether might
restrict or eliminate insurance coverage of affirming medical
services, including body modification and hormone
treatment.
stressors, disproportionately compromise the mental health and
well-being of LGBT people.
Generally, Meyer (2003) posits three stress processes from
distal to proximal: (a) objective
or external stressors, which include structural or
institutionalized discrimination and direct
interpersonal interactions of victimization or prejudice; (b)
one’s expectations that victimization
or rejection will occur and the vigilance related to these
expectations; and (c) the internalization of
negative social attitudes (often referred to as internalized
homophobia). Extensions of this work

also focus on how intrapersonal psychological processes (e.g.,
appraisals, coping, and emotional
regulation) mediate the link between experiences of minority
stress and psychopathology (see
Hatzenbuehler 2009). Thus, it is important to recognize the
structural circumstances within
which youth are embedded and that their interpersonal
experiences and intrapersonal resources
should be considered as potential sources of both risk and
resilience.
We illustrate multilevel ecological contexts in Figure 2. The
young person appears as the
focus, situated in the center and defined by intrapersonal
characteristics. This is surrounded by
interpersonal contexts (which, for example, include daily
interactions with family and peers) that
exist within social and cultural contexts. The arrow along the
bottom of the figure suggests the his-
torically changing nature of the contexts of youth’s lives.
Diagonal arrows that transverse the figure
acknowledge interactions across contexts, and thus implications
for promoting LGBT youth men-
tal health at the levels of policy, community, and clinical
practice, which we consider at the end of
the manuscript. We use this model to organize the following
review of LGBT youth mental health.
Prevalence of Mental Health Problems Among LGBT Youth
Adolescence is a critical period for mental health because many
mental disorders show onset during
and directly following this developmental period (Kessler et al.
2005, 2007). Recent US estimates
of adolescent past-year mental health diagnoses indicate that
10% demonstrate a mood disorder,

25% an anxiety disorder, and 8.3% a substance use disorder
(Kessler et al. 2012). Further, suicide
is the third leading cause of death for youth ages 10 to 14 and
the second leading cause of death
for those ages 15 to 24 (CDC 2012).
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T I M E
C l i n i c a l p r a c t i c eC l i n i c a l p r a c t i c eC l i n i c
a l p r a c t i c e
S c h o o l a n d c o m m u n i t y p r o g r a m sS c h o o l a n
d c o m m u n i t y p r o g r a m sS c h o o l a n d c o m m u n
i t y p r o g r a m s
L a w a n d p o l i c i e sL a w a n d p o l i c i e sL a w a n d
p o l i c i e s
S o c i a l / c u l t u r a lS o c i a l / c u l t u r a lS o c i a l / c u l

t u r a l
I n t e r p e r s o n a lI n t e r p e r s o n a lI n t e r p e r s o n a l
C O N T E X T SC O N T E X T SC O N T E X T S
I M P L I C AT I O N SI M P L I C AT I O N SI M P L I C AT I
O N S
I n t r a p e r s o n a lI n t r a p e r s o n a lI n t r a p e r s o n a l
Y O U N G
P E R S O N
Figure 2
Conceptual model of contextual influences on lesbian, gay,
bisexual, and transgender (LGBT) youth mental health and
associated
implications for policies, programs, and practice. The arrow
along the bottom of the figure indicates the historically
changing nature of
the contexts of youth’s lives. Diagonal arrows acknowledge
interactions across contexts, thus recognizing opportunities for
promoting
LGBT youth mental health at policy, community, and clinical
practice levels.
Sexual orientation:
enduring sense of
emotional, sexual
attraction to others
based on their
sex/gender
The inclusion of sexual attraction, behavior, and identity
measures in population-based studies

(e.g., the National Longitudinal Study of Adolescent to Adult
Health and the CDC’s Youth Risk
Behavior Surveillance System) has greatly improved knowledge
of the prevalence of LGB mental
health disparities and the mechanisms that contribute to these
inequalities for both youth and
adults; there remains, however, a critical need for the
development and inclusion of measures
to identify transgender people, which thwarts more complete
understanding of mental health
among transgender youth. Such data illustrate overwhelming
evidence that LGB persons are
at greater risk for poor mental health across developmental
stages. Studies using adult samples
indicate elevated rates of depression and mood disorders
(Bostwick et al. 2010, Cochran et al.
2007), anxiety disorders (Cochran et al. 2003, Gilman et al.
2001), posttraumatic stress disorder
(PTSD) (Hatzenbuehler et al. 2009a), alcohol use and abuse
(Burgard et al. 2005), and suicide
ideation and attempts, as well as psychiatric comorbidity
(Cochran et al. 2003, Gilman et al.
2001). Studies of adolescents trace the origins of these adult
sexual orientation mental health
disparities to the adolescent years: Multiple studies demonstrate
that disproportionate rates of
distress, symptomatology, and behaviors related to these
disorders are present among LGBT
youth prior to adulthood (Fish & Pasley 2015, Needham 2012,
Ueno 2010).
US and international studies consistently conclude that LGBT
youth report elevated rates of
emotional distress, symptoms related to mood and anxiety
disorders, self-harm, suicidal ideation,
and suicidal behavior when compared to heterosexual youth

(Eskin et al. 2005, Fergusson et al.
2005, Fleming et al. 2007, Marshal et al. 2011), and that
compromised mental health is a fun-
damental predictor of a host of behavioral health disparities
evident among LGBT youth (e.g.,
substance use, abuse, and dependence; Marshal et al. 2008). In a
recent meta-analysis, Marshal
et al. (2011) reported that sexual minority youth were almost
three times as likely to report
470 Russell · Fish
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suicidality; these investigators also noted a statistically
moderate difference in depressive symp-
toms compared to heterosexual youth.
Despite the breadth of literature highlighting disparities in
symptoms and distress, relatively
lacking are studies that explore the presence and prevalence of
mental health disorders or di-
agnoses among LGBT youth. Using a birth cohort sample of

Australian youth 14 to 21 years
old, Fergusson and colleagues (1999) found that LGB youth
were more likely to report suici-
dal thoughts or attempts, and experienced more major
depression, generalized anxiety disorders,
substance abuse/dependence, and comorbid diagnoses, compared
to heterosexual youth. Results
from a more recent US study that interviewed a community
sample of LGBT youth ages 16 to
20 indicated that nearly one-third of participants met the
diagnostic criteria for a mental disorder
and/or reported a suicide attempt in their lifetime (Mustanski et
al. 2010). When comparing these
findings to mental health diagnosis rates in the general
population, the difference is stark: Almost
18% of lesbian and gay youth participants met the criteria for
major depression and 11.3% for
PTSD in the previous 12 months, and 31% of the LGBT sample
reported suicidal behavior at
some point in their life. National rates for these diagnoses and
behaviors among youth are 8.2%,
3.9%, and 4.1%, respectively (Kessler et al. 2012, Nock et al.
2013).
Studies also show differences among LGB youth. For example,
studies on LGB youth suicide
have found stronger associations between sexual orientation and
suicide attempts for sexual mi-
nority males comparative to sexual minority females (Fergusson
et al. 2005, Garofalo et al. 1999),
including a meta-analysis using youth and adult samples (King
et al. 2008). Conversely, lesbian
and bisexual female youth are more likely to exhibit substance
use problems when compared to
heterosexual females (Needham 2012, Ziyadeh et al. 2007) and
sexual minority males (Marshal

et al. 2008); however, some reports on longitudinal trends
indicate that these differences in dispar-
ities diminish over time because sexual minority males “catch
up” and exhibit faster accelerations
of substance use in the transition to early adulthood
(Hatzenbuehler et al. 2008a).
Although not explicitly tested in all studies, results often
indicate that bisexual youth (or those
attracted to both men and women) are at greater risk for poor
mental health when compared to
heterosexual and solely same-sex-attracted counterparts
(Marshal et al. 2011, Saewyc et al. 2008,
Talley et al. 2014). In their meta-analysis, Marshal and
colleagues (2011) found that bisexual
youth reported more suicidality than lesbian and gay youth.
Preliminary research also suggests
that youth questioning their sexuality report greater levels of
depression than those reporting other
sexual identities (heterosexual as well as LGB; Birkett et al.
2009) and show worse psychological
adjustment in response to bullying and victimization than
heterosexual or LGB-identified students
(Poteat et al. 2009).
Relatively lacking is research that explicitly tests racial/ethnic
differences in LGBT youth men-
tal health. As with general population studies, researchers have
observed mental health disparities
across sexual orientation within specific racial/ethnic groups
(e.g., Borowsky et al. 2001). Conso-
lacion and colleagues (2004) found that among African
American youth, those who were same-sex
attracted had higher rates of suicidal thoughts and depressive
symptoms and lower levels of self-
esteem than their African American heterosexual peers, and

Latino same-sex-attracted youth were
more likely to report depressive symptoms than Latino
heterosexual youth.
Even fewer are studies that simultaneously assess the
interaction between sexual orientation and
racial/ethnic identities (Inst. Med. 2011), especially among
youth. One study assessed differences
between white and Latino LGBQ youth (Ryan et al. 2009) and
found that Latino males reported
more depression and suicidal ideation compared to white males,
whereas rates were higher for
white females compared to Latinas. Although not always in
relation to mental health outcomes, re-
searchers discuss the possibility of cumulative risk as the result
of managing multiple marginalized
identities (Dı́az et al. 2006, Meyer et al. 2008). However, some
empirical evidence suggests the
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y
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al
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ve

rs
it
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SOGI: sexual
orientation and gender
identity
GSA: Gay-Straight
Alliance school club
contrary: that black sexual minority male youth report better
psychological health (fewer major
depressive episodes and less suicidal ideation and alcohol abuse
or dependence) than their white
sexual minority male counterparts (Burns et al. 2015). Still
other studies find no racial/ethnic
differences in the prevalence of mental health disorders and
symptoms within sexual minority
samples (Kertzner et al. 2009, Mustanski et al. 2010).
In summary, clear and consistent evidence indicates that global
mental health problems are
elevated among LGB youth, and similar results are found for the
smaller number of studies that
use diagnostic criteria to measure mental health. Among sexual
minorities, there are preliminary
but consistent indications that bisexual youth are among those
at higher risk for mental health
problems. The general dearth of empirical research on gender
and racial/ethnic differences in
mental health status among LGBT youth, as well as
contradictory findings, indicates the need for
more research. Specific research questions and hypotheses
aimed at understanding the intersection
of multiple (minority) identities are necessary to better
understand diversity in the lived experiences
of LGBT youth and their potentials for risk and resilience in
regard to mental health and well-
being (Russell 2003, Saewyc 2011).

Risk Factors
Two approaches are often used to frame and explore
mechanisms that exacerbate risk for LGBT
youth (Russell 2005, Saewyc 2011). First is to examine the
greater likelihood of previously identi-
fied universal risk factors (those that are risk factors for all
youth), such as family conflict or child
maltreatment; LGBT youth score higher on many of the critical
universal risk factors for com-
promised mental health, such as conflict with parents and
substance use and abuse (Russell 2003).
The second approach explores LGBT-specific factors such as
stigma and discrimination and how
these compound everyday stressors to exacerbate poor
outcomes. Here we focus on the latter
and discuss prominent risk factors identified in the field—the
absence of institutionalized protec-
tions, biased-based bullying, and family rejection—as well as
emerging research on …
Shannon D. Snapp University of Arizona
Ryan J. Watson University of British Columbia∗
Stephen T. Russell University of Arizona∗ ∗
Rafael M. Diaz San Francisco State University∗ ∗ ∗
Caitlin Ryan Marian Wright Edelman Institute∗ ∗ ∗ ∗
Social Support Networks for LGBT Young Adults:

Low Cost Strategies for Positive Adjustment
Lesbian, gay, bisexual, and transgender (LGBT)
youth and young adults are known to have com-
promised physical and mental health, and family
rejection has been found to be an important risk
factor. Yet few studies have examined the posi-
tive role that support from parents, friends, and
the community have for LGBT young adults. In
a cross-sectional study of 245 LGBT non-Latino
White and Latino young adults (ages 21–25) in
Norton School of Family and Consumer Sciences, Frances
McClelland Institute of Children, Youth, and Families, Uni-
versity of Arizona, PO Box 210078, 650 N. Park Ave, Tuc-
son, AZ 85721 ([email protected]).
∗ School of Nursing, Stigma and Resilience Among Vulner-
able Youth Centre, University of British Columbia, Vancou-
ver, Canada, T222-2211 Wesbrook Mall, Vancouver, B.C.
V6T 2B5, CANADA
∗ ∗ Norton School of Family and Consumer Sciences, Univer-
sity of Arizona, PO Box 210078, 650 N. Park Ave, Tucson,
AZ 85721.
∗ ∗ ∗ San Francisco State University, 3004 16th Street, Suite
203, San Francisco, CA 94103.
∗ ∗ ∗ ∗ Marian Wright Edelman Institute, San Francisco State
University, 3004 16th Street, Suite 203, San Francisco, CA
94103.
Key Words: family acceptance, gender identity, homosexual-
ity, LGBT adolescent, protective factors, sexual orientation,
social support.
the United States, sexuality-related social sup-
port was examined in association with mea-
sures of adjustment in young adulthood. Fam-
ily, friend, and community support were strong

predictors of positive outcomes, including life
situation, self-esteem, and LGBT esteem. How-
ever, family acceptance had the strongest overall
influence when other forms of support were con-
sidered. Implications for the unique and concur-
rent forms of social support for LGBT youth and
young adult adjustment are discussed.
Prior studies have clearly established physical
and mental health disparities for lesbian, gay,
bisexual, and transgender (LGBT) youth and
adults (physical health may include but is not
limited to weight, chronic health concerns, sex-
ual risk taking, and substance use; mental health
may include but is not limited to psychologi-
cal concerns, diagnosed disorders, and suicidal-
ity; Conron, Mimiaga, & Landers, 2010; Insti-
tute of Medicine, 2011; Ryan, Huebner, Diaz, &
Sanchez, 2009; Ryan, Russell, Huebner, Diaz, &
Sanchez, 2010). However, less is known about
positive development for LGBT young people.
Several existing studies have documented a pos-
itive association between family acceptance and
well-being for LGBT youth (Doty & Brian,
420 Family Relations 64 (July 2015): 420–430
DOI:10.1111/fare.12124
Social Support Networks for LGBT Young Adults 421
2010; Elizur & Ziv, 2001; Shilo & Savaya,
2011); fewer have examined the implications
of family acceptance beyond the teenage years
(Rosario, Schrimshaw, & Hunter, 2009) or in

conjunction with other salient forms of social
support. As youth move from adolescence into
young adulthood they are likely to encounter
additional supports from friends, peers, and their
community which may enable their positive
adjustment. This support may operate as general
support or it may be sexuality-related social sup-
port, a term used to describe social support that
is specific to young people’s sexuality-related
stress and life experiences (Doty, Willoughby,
Lindahl, & Malik, 2010). In the present study
we aimed to understand how family acceptance,
along with additional forms of sexuality-related
social support, may predict healthy adjustment
in young adulthood.
We approached this research from the foun-
dations of the minority stress model (Meyer,
2003). This framework suggests that the estab-
lished negative relation between minority
stressors (e.g., harassment due to sexual ori-
entation, internalized homophobia) and mental
health can in part be buffered by coping mecha-
nisms. For example, interpersonal relationships
(e.g., supportive parents), policies (e.g.,
anti-discrimination school codes), and organi-
zations (e.g., LGBT clubs, gay–straight alliance
networks) might provide protections against the
deleterious effects of minority-specific pres-
sures. Protective factors may attenuate the effect
of stressors on the negative health outcomes for
LGBT persons. In this study we conceptualized
support from family, friends, and the commu-
nity as potential coping mechanisms, and thus
protective factors, for LGBT young adults.

Family Acceptance and LGBT Youth
and Young Adults
When LGBT teenagers disclose their sexual
and/or gender identities (a process known
as “coming out”) they may face a range of
responses that either affirm or reject their iden-
tities (D’Augelli, Grossman, & Starks, 2005).
LGBT young adults who reported high levels of
parental rejection during adolescence were 8.4
times more likely to attempt suicide, 5.9 times
more likely to report high levels of depression,
and 3.4 times more likely to use illegal drugs
and to engage in risky sexual behavior com-
pared with peers from families who reported no
or low levels of family rejection (Ryan et al.,
2009). Similarly, lesbian, gay, and bisexual
(LGB) adults who thought their parents did not
provide emotional and social support after they
disclosed their sexual orientation had higher
odds of depression and substance use (Rothman,
Sullivan, Keyes, & Boehmer, 2012).
In contrast, perceived acceptance from family
and friends buffers the negative impact of per-
ceived rejection on youths’ subsequent alcohol
use (Rosario et al., 2009). In a study with 461
LGB adolescents and young adults in the United
States, family acceptance and support had a sig-
nificant positive effect on one’s self-acceptance
of sexual orientation, the strongest (as compared
to friend support) positive effect on well-being,
and the strongest negative effect on mental dis-
tress (Shilo & Savaya, 2011). Finally, a study
of 245 LGBT young adults in the United States

(Ryan et al., 2010) found that family acceptance
in adolescence predicted greater self-esteem,
social support, and better general health status
(including lower rates of depression, substance
abuse, and suicidal ideation and attempts) in
young adulthood (Ryan et al., 2010). Thus, fam-
ily acceptance of one’s LGBT status has been
conceptualized as fundamental to social support
for LGBT individuals. However, although the
association between family acceptance and posi-
tive health among LGBT youth has been demon-
strated, less is known about the co-influence of
other types of social support on positive adjust-
ment in young adulthood.
Extrafamilial Social Support for Positive
LGBT Adjustment
Recent research has explored the benefits of
supportive friends and peers during adolescence
within the context of supportive families. In
a sample of lesbian and bisexual girls, youth
reported better mental health if they had both
parental support and did not lose friends as
a result of disclosing their sexual orientation
(D’Augelli, 2003). Similarly, a study of bisexual
college students found that support from friends
and family was predictive of both positive and
negative measures of adjustment, including
depression and life satisfaction (Sheets & Mohr,
2009). Doty and colleagues (2010) assessed
sexuality-related social support from fam-
ily, sexual minority friends, and heterosexual
friends. As expected, sexual minority friends
provided the most sexuality-related support, and

422 Family Relations
heterosexual friends and family members were
more likely to provide general support than
support for sexuality-related stress. Together,
higher levels of all forms of sexuality-related
support predicted lower levels of emotional
distress and sexuality stress (Doty et al., 2010).
Other research has delineated the effect of
friend and family support on LGB youths’
well-being. For example, friend support had
the strongest positive effect on one’s disclosure
of his or her sexual orientation, and family
support was the strongest predictor of one’s
self-acceptance of his or her sexual orien-
tation. Both family and friend support were
the strongest predictors of well-being (Shilo
& Savaya, 2011), indicating both unique and
overlapping effects on youths’ adjustment.
Although less research has examined the
effect of community support on LGBT health
and well-being, some previous research has
noted the ways in which LGBT youth and
adults define support, including support at the
community level. One qualitative study with
LGBT youth in the United States found that
youth viewed community support as related
to socializing, having access to LGBT-related
information, and being introduced into the
LGBT community (Nesmith, Burton, & Cos-
grove, 1999). Similar to the findings that
implicate LGBT community support as essen-

tial to outcomes for sexual minorities, access
to a supportive community, social events, and
sexuality-related information was found to be
related to LGBT young people’s self-esteem
and well-being (e.g., D’Augelli & Hart, 1987).
On a related note, access to supportive commu-
nities is associated with disclosing one’s sexual
orientation (D’Augelli et al., 2005; Elizur &
Ziv, 2001); LGBT youth and young adults who
are not “out” may find it difficult to access
supportive communities.
In sum, having supportive family, friends,
and communities appears to be related to the
health and well-being of LGBT youth in distinct
and perhaps overlapping ways. Although family
acceptance has clear implications for LGBT
well-being, less is known about the unique
and concurrent roles of sexuality-related friend
and community support. Minimal attention
has been paid to the influence of personal
characteristics (e.g., race/ethnicity) as relevant
factors that may create variability in social
support (Ryan et al., 2010). To this end, we
assessed the co-occurring forms of social
support and personal characteristics on young
adult adjustment for LGBT youth.
The Current Study and Hypotheses
In this study we aimed to explore the protec-
tive function of three forms of sexuality-related
social support from family, friends, and com-
munity on salient measures of positive ado-
lescent development. The following two ques-

tions guided our analyses: Does family, friend,
and community support (considered individ-
ually) have positive associations with LGBT
young adult adjustment? Does each form of sup-
port remain a significant protective factor when
all forms of support are considered jointly? We
also assessed the possible mediating effects of
gender nonconformity and level of outness to
young adults’ support networks. Finally, we con-
sidered whether there are variations in young
adult adjustment due to race/ethnicity, gender,
gender identity, and immigrant status.
Given the previous links found between fam-
ily rejection and negative health consequences
(Ryan et al., 2009) and family acceptance and
lower health risk in adolescence for sexual
minorities (Ryan et al., 2010; Shilo & Savaya,
2011), we expected that family acceptance
would be related to positive adjustment in
young adulthood. Similarly, we expected social
support from friends to have positive impli-
cations for young adult adjustment (Sheets &
Mohr, 2009; Shilo & Savaya, 2011) that extends
beyond the influence of family acceptance (Doty
et al., 2010). Despite the little research that has
explored the association between LGBT com-
munity support, we expected a positive relation
with young adult adjustment, as found in early
research (e.g., D’Augelli & Hart, 1987; Nesmith
et al., 1999).
Each of our central constructs—family accep-
tance and sexuality-related support from friends
and community—may depend in part on the
degree to which the LGBT person is out in his

or her social network: We expected that being
out to family, friends, and others will be pos-
itively related to well-being (D’Augelli et al.,
2005; Elizur & Ziv, 2001). Family acceptance,
however, may mediate the negative impact of
being outed by someone else on young adult
adjustment given that youth who were outed
to their families experienced worse parental
relationships (D’Augelli, Grossman, Starks, &
Sinclair, 2010). Furthermore, sexuality-related
social support may vary to some degree on the
basis of one’s gender nonconformity (Landolt,
Bartholomew, Saffrey, Oram, & Perlman, 2004).
Finally, our analyses also accounted for eth-
nicity (White or Latino), immigrant status, and
sexual/gender identity because there may be dif-
ferences in the experiences of sexuality-related
social support based on these statuses (Breg-
man, Malik, Page, Makynen, & Lindahl, 2013;
Pearson & Wilkinson, 2013). The current evi-
dence indicates that White young adults report
higher levels of family acceptance, on average,
compared to Latinos, and immigrants report
lower levels than those born in the United States
(Ryan et al., 2010). LGBT immigrants may
also downplay their ethnic and sexual identity
characteristics that identify them as part of
marginalized groups; these are struggles that
challenge LGBT individuals daily (Heller, 2009;
Yoshino, 2006), which may hinder their access

to support. Furthermore, research that has exam-
ined family acceptance of transgender women
of color found that although most women had
one ally in their support group, most experi-
enced rejection and hostility (Koken, Bimbi, &
Parsons, 2009). As a result, we expected to find
similar trends in our data, with Latino, immi-
grant, and transgender young adults reporting
lower levels of young adult adjustment, although
the influence of these personal characteristics
may diminish when sexuality-related social
support is also considered.
Method
Sampling and Participants
Our data were drawn from a cross-sectional
study entitled the Family Acceptance Project
(FAP) that included 245 LGBT Latino and
non-Latino White young adults in the United
States. Participants were recruited in the San
Francisco Bay Area from 249 LGBT-serving
organizations within 100 miles of the FAP. Half
of the participants were from community, social,
and recreational organizations, and half were
recruited from area-wide clubs/bars. Prelimi-
nary screening procedures through venue-based
recruitment and outreach were used to select
participants who matched the following five
inclusion criteria: (a) were between the ages of
21 and 25; (b) ethnicity identity as Latino, Latino
mixed, or non-Latino White; (c) self-identified
as LGBT, homosexual, or non-heterosexual
(i.e., queer) during adolescence; (d) out to at

least one parent/guardian during adolescence;
and (e) resided with at least one parent/guardian
during adolescence (at least for part of the time).
Among the young adults in the study, 46.5%
identified as male, 44.9% as female, and 8.6%
as transgender. The study was designed to
include an equal number of Latino (51.4%) and
non-Latino White (46.8%) young adults. The
mean age was 22.8 years (SD = 1.4 years); 70%
of participants identified as gay or lesbian, 13%
as bisexual, and 17% as an alternative sexual
identity (e.g., queer). Participants were given
the option to complete the survey online or in
person on paper. Survey completion took less
than 1 hour, and all procedures were approved
by the university’s institutional review board
(for more information about the FAP, see Ryan
et al., 2010).
Measures
Family Acceptance/Support. The Family
Acceptance Scale is calculated as the sum
of positive family experiences for each item
(0 = never, 1 = one or more times), for a maxi-
mum possible total of 55 (see Ryan et al., 2009,
2010). Sample items include the following:
• How often did any of your parents/caregivers
talk openly about your sexual orientation?
• How often were your openly LGBT friends
invited to join family activities?

celebrate or appreciate your clothing or
hairstyle, even though it might not have been
typical for your gender?
bring you to an LGBT youth organization or
event?
In addition to this scale, we calculated a cat-
egorical indicator of family acceptance for illus-
trative purposes, dividing the distribution into
even thirds.
Friend Support. Participants were asked to ret-
rospectively report about their lives between the
ages of 13 and 19, including friendships, qual-
ity, and support. Participants reported their total
number of close friends and the number of those
friends who knew that they were LGBT (per-
centage of friends who knew that the participant
was LGBT is calculated as number of friends
who knew divided by total number of friends).
Participants also reported whether they had a gay
friend (1 = yes). A scale that measured support
from friends who knew that the participant was
LGBT was calculated on the basis of three items:
(a) “How many of those who knew accepted or
supported your being LGBT?” (b) “With how
many of those who knew could you communi-
cate frankly about your LGBT-related problems
and concerns?” and (c) “How many of those who

knew could you trust with your secrets or pri-
vate information?” (response range: 0 = none to
3 = all of them; � = .90).
Community Support. Participants answered a
series of questions about their current level of
community support. They responded to three
questions about their involvement in LGBT
events and activities, including their frequency
of attending social events, dance clubs, bars,
discos, meetings, or educational events at a com-
munity center or other place in their community,
and reading LGBT magazines, newspapers,
websites, books, or other publications or
watched LGBT videos or movies (response
range: 0 = never to 6 = more than once a week).
These three items were not strongly correlated
and thus were examined independently.
Young Adult Adjustment and Well-Being. Partic-
ipants were asked to report their feelings about
their current life situation, general self-esteem,
and LGBT self-esteem as a way to measure pos-
itive adjustment in young adulthood.
Life Situation. Current life situation was
assessed with a 10-item scale that included
questions about the present: (a) “Do you have
the education you need to do the kind of work
you want?” (b) “Are you able to save money
for your future?” and (c) “Do you have a sta-
ble job?” (response range: 0 = definitely no to
3 = definitely yes; � = .79).
Self-Esteem and LGBT Esteem. Self-esteem
was measured with the 10-item Rosenberg

Self-Esteem Scale (Rosenberg, 1965; � = .88).
Also included was a measure of LGBT
self-esteem based on the average of three
items modified from Shidlo’s (1994) scale: (a)
“Whenever I think a lot about being LGBT, I
feel critical of myself (reverse coded)”; (b) “I
am proud to be a part of the LGBT community”;
and (c) “I wish I were heterosexual” (reverse
coded; response range: 1 = strongly disagree to
5 = strongly agree; � = .72).
Personal Characteristics. Participants self-
identified as Latino or non-Latino White (coded
1 and 0, respectively), and we also assessed
immigrant status (1 = born outside the United
States, 0 = born in the United States) and trans-
gender status (1 = identified as transgender,
0 = did not identify as transgender). We com-
pared youth who identified as bisexual (coded 1
and 0, respectively) or other non-heterosexual
identity (including “homosexual” or “other,”
also coded 1 and 0); the reference group were
youth who identified as gay or lesbian. Adoles-
cent gender nonconformity was measured with
a single item: “On a scale from 1 to 9, where 1
is extremely feminine and 9 is extremely mas-
culine, how would you describe yourself when
you were a teenager (age 13–19)?” The item
was reverse coded for males, such that a high
score represents gender nonconformity (mas-
culinity for females and femininity for males;
see Toomey, Ryan, Diaz, Card, & Russell,
2011). Sexual orientation disclosure status was
measured with a four-item scale: Respondents
were asked how many people currently know
about their sexual orientation for each of the

following groups: (a) family, (b) LGBT friends,
(c) heterosexual friends, and (d) coworkers
or other students (response range: 0 = none to
4 = all; � = .82).
Plan of Analysis
We tested ordinary least squares regression mod-
els in which (a) family acceptance, (b) friend
support, (c) community support, and (d) per-
sonal characteristics were individually regressed
onto measures of well-being in young adult-
hood and then combined into a joint model in
which all were simultaneously regressed onto
well-being measures.
Results
Means, standard deviations, and correlations of
measures of sources of support and young adult
well-being are shown in Table 1. Regression
analyses predicting young adult well-being are
presented in Table 2. Column 1 of Table 2
includes models for each group of variables sep-
arately: family, friend, and community support,
and personal characteristics; column 2 of the
table represents full models that include all study
variables.
Table 1. Descriptive Statistics and Correlations of Study
Variables

Variable 1 2 3 4 5 6 7 8 9
1. Life situation —
2. Self-esteem .29* —
3. LGBT esteem .38* .41* —
4. Percentage of friends knew .18* .09 .20* —
5. Had gay friend .05 .11 .12 .20* —
6. Support from friends about LGBT .11 .17* .19* .05 .36* —
7. LGBT events .11 −.05 .03 .05 −.07 .05 —
8. LGBT books and magazines .05 .07 .16* .09 .09 .10 .27* —
9. LGBT bars .12 −.04 −.05 −.10 −.13* −.10 .41* .04 —
M 1.82 2.80 3.44 5.87 0.62 1.95 3.90 3.49 2.36
SD 0.57 0.38 0.57 4.8 0.49 1.01 1.90 1.81 1.44
Note: LGBT = lesbian, gay, bisexual, and transgender.
A number of notable patterns emerged in the
associations between personal characteristics
and young adult well-being. Males reported
higher general self-esteem, but there were no
gender differences in satisfaction with current
life situation. Males reported higher LGBT
esteem (Model 1), but this association was
largely explained (in the full model) by social
support. Although transgender study partici-
pants reported comparable levels of general
self-esteem, they reported significantly lower
satisfaction with their life situation and lower
LGBT-specific self-esteem. There is some evi-
dence that Latino respondents reported lower
general self-esteem, but only after controlling
for sources of sexuality-specific support. Con-
versely, Latino youth reported higher LGBT
esteem (Model 1), but when social support
(Model 2) was considered the positive asso-
ciation between Latino identity and LGBT

esteem was no longer significant. Contrary to
our hypothesis and previous research, we did
not find differences in adjustment based on
immigrant status. Although gender nonconfor-
mity was not strongly associated with these
indicators of positive young adult well-being
(with the exception of LGBT esteem), being
out to more people in one’s social network was
one of the strongest associations with a positive
current life situation and LGBT esteem.
Regarding sexuality-specific sources of sup-
port, family acceptance during adolescence
has consistently been shown to have strong
associations with each indicator of young
adult well-being; it typically is the strongest
association in comparison to other forms of
sexuality-related social support. We found that
family acceptance was independently linked to
higher levels of life situation, LGBT esteem, and
self-esteem for LGBT young adults. In addi-
tion, family acceptance remained significantly
associated with adjustment when we included
friend and community support variables such as
having a high percentage of friends who knew
about LGBT status.
Participants who had higher percentages of
friends who knew about their sexual orientation
or gender identity during adolescence reported
higher scores on the life situation and LGBT
esteem measures. The strengths of these associa-
tions were partly mediated by family acceptance
and personal characteristics. Although having a
gay friend did not have implications for positive

young adult adjustment in this sample, feeling
supported by friends related to being LGBT was
associated with positive adjustment across all
indicators, although this association was medi-
ated in the full model.
Finally, attending LGBT events and going
to LGBT bars was unassociated with young
adult well-being; reading LGBT-themed books
was, however, associated with positive LGBT
esteem (until the full model was taken into
consideration).
Discussion
Our study provides further evidence that social
support is an important protective factor for the
well-being of LGBT youth. Sexuality-related
support from family, friends, and the community
often has unique and overlapping contributions
for young adult adjustment. Whereas most
prior studies of LGBT health have focused on
Table 2. Social Support and Personal Characteristics Predicting
Lesbian, Gay, Bisexual, and Transgender (LGBT)
Adjustment
Life situation Self-esteem LGBT esteem
Predictor 1 2 1 2 1 2
Family acceptance .29∗ ∗ ∗ .23∗ ∗ ∗ .38∗ ∗ ∗ .34∗ ∗ ∗

.36∗ ∗ ∗ .20∗ ∗
Adjusted R2 .08 .14 .13
Friend support
Percentage of friends who knew .18∗ ∗ .14∗ .07 .05 .19∗ ∗
.10†
Had a gay friend −.05 −.03 .03 −.01 .01 −.00
Support from friends about LGBT .13∗ .06 .15∗ .11† .17∗ .06
Adjusted R2 .03 .02 .06
Community support
LGBT events .07 .03 −.06 −.08 .01 −.03
LGBT books and magazines .01 −.03 .08 .05 .16∗ .08
LGBT bars .08 .11 −.02 .06 −.07 −.01
Adjusted R2 .01 −.00 .02
Personal characteristics
Male .07 .10 .19∗ ∗ .17∗ ∗ .13∗ .11†
Transgender −.20∗ ∗ −.17∗ .03 .06 −.23∗ ∗ ∗ −.22∗ ∗
Bisexual .06 .04 −.02 −.07 .09 .06
Other sexual identity −.04 −.06 −.08 −.10 .04 .01
Latino −.02 −.04 −.11 −.15∗ .13∗ .09
Immigrant .10 .10 −.10 −.07 −.09 −.07
Gender nonconformity −.09 −.04 −.03 .02 −.13∗ −.09
Out to most family, friends, others .34∗ ∗ ∗ .24∗ ∗ ∗ .15∗ .05
.31∗ ∗ ∗ .24∗ ∗ ∗
Adjusted R2 .14 .19 .05 .12 .24 .29
Note: Table values are ordinary least squares regression
standardized estimates. Column 1 includes models for each
group

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