The Role of Family in LGB Youth Wellbeing and Identity Formation
A term paper submitted for the capstone course PSYC-090: Field Placement in Clinical
Psychology in partial fulfillment of the degree
Bachelor Arts in Psychology
Swarthmore College
Rebekah Katz
Abstract
Using quantitative and qualitative sources, this paper seeks to investigate negative mental
health outcomes for LGB youths and adolescents that are a part of families where their parents
do not accept their sexual orientation. While those that do face rejection also face higher rates of
anxiety, depression, and suicidality, those that receive acceptance not only score lower on these
measures, but higher for signs of positive adjustment such as self-esteem and general health. This
paper later explores current family systems research and, as an extension, the state of therapies
that are available for LGB youths, adolescents, and their families. Finally, this paper concludes
with recommendations for Marriage and Family Therapy training programs and directions for
future research into underdeveloped concepts.
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Introduction and Considerations
It is no secret that LGB individuals in American society are still very much stigmatized
for their sexual orientation and/or gender representation. Despite sweeping nationwide reforms,
the LGB community still faces large-scale discrimination. However, the perils that this
marginalized community face begin long before workplace or housing discrimination. LGB
youths and adolescents risk drastic negative mental health outcomes when coming out to their
parents and families and during their maturation, including higher rates of anxiety, depression,
and suicidality due to parental rejection forcing disruption in identity formation and disrupting
the attachment between parent and child (Diamond and Shpiegel, 2014; Katz-Wise, Rosario, &
Tsappis, 2017; Ryan, Russell, Huebner, Diaz, & Sanchez, 2010). Since LGB youths and
adolescents are so at risk for these negative mental health outcomes, it is absolutely crucial that
we develop and maintain therapies and interventions appropriate to these issues.
This paper will explore the familial variables that affect LGB youth and adolescent’s
wellbeing in the face of parental rejection or acceptance, as well as the current state of familycentered therapies involving LGB adolescents and young adults. The investigation will
summarize three therapies: Narrative Pathways Therapy, Attachment-Based Family Therapy for
LGBT Youths and Adolescents, and Sexual and Gender Minorities Therapy. Finally, it will offer
recommendations for training future therapists and gaps in the literature that could be explored,
which include a need for affirmation-centered therapist training and more research into identity
development.
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Methods
This analysis includes a blend of qualitative and quantitative journal articles from a variety of
peer-reviewed sources. Keywords such as LGB, therapy, family, and coming-out were searched
on online databases such as Keywords on ProQuest, PubMed, and Google Scholar to yield a
rather limited number of resources on this topic. LGB mental health is a fairly under researched
area, and this led to two major limitations in this paper. It should be noted that since the research
is so slim, many literature reviews combine youths and adolescents into one category to span the
age group from 6-21 years old. As such, it is currently difficult to parse out family-centered
variables that may affect youths and adolescents differently. Furthermore, there is an extreme
dearth of information on nontraditional gender minorities and transgenderism not only in familycentered research, but in the field of mental health in general. For this reason, the remainder of
this paper does not explore this topic beyond the acknowledgement of the very clear research gap
written presently, while also offering the recommendation that future researchers develop this
area.
Definitions
LGB youth face a variety of negative mental health outcomes upon facing parental
rejection. Ryan et al. (2010) describes detriments to wellbeing across 4 sub-areas: depression,
substance abuse, sexual behavior risk, suicidal thoughts or behaviors. Young adults who reported
low levels of family acceptance had scores that were higher than those with accepting families
and showed measures that were “significantly worse for depression, substance abuse, and
suicidal ideation and attempts,” which not only are factors of wellbeing but are negative mental
health outcomes (Ryan et al. 2010: 208). On the opposite token, positive adjustment is defined
by Ryan et al. (2010) as high rates of self-esteem, social support, and general health. Not only
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were all measures reported higher for youths and adolescents that faced parental acceptance of
their sexual orientation, but these individuals also reported lower rates of negative mental health
outcomes (Ryan et al. 2010).
LGB Identity Formation
Sexual identity formation typically takes place in adolescence, and interruptions or delays in
identity development is associated with poor adjustment (Bregman, Malik, Page, Makynen, &
Lindahl, 2012). LGB adolescents differ from heteronormative adolescents in their identity
formation in that there is substantially more individual variation, and the process is not as
predictable or linear. Bregman et al., et al. (2012) outlines six different benchmarks of identity
development in LGB adolescents, which include the following:
“…internalized homonegativity (rejection of one’s LGB identity), concealment motivation
(concern with and motivation to protect one’ privacy as LGB person), acceptance concerns
(concern with the potential for stigmatization as an LGB person), identity uncertainty
(uncertainty about one’s sexual orientation identity), identity superiority (view favoring LGB
people over heterosexual people), and finding the experience of developing an LGB identity to
be a difficult process” (417).
The Role of the Family in LGB Identity Development and Mental Health
Parents relationships with their children and their acceptance or rejection of their
children’s coming out have a major impact on their children’s identity formation and general
wellbeing. Nonetheless, even parents who love and support their children to the fullest extent
may find it initially difficult to accept their child’s sexuality identity and to accommodate new
information (Saltzburg, 2004 in Saltzburg, 2007). In general, parents with even the most liberal
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of backgrounds have an increased sense of internalized homophobia, and consequently an
increased sense of needing to reorient and redefine their lives. Effectively, parents fear for their
children facing a world that they know propels homonegativity, and they feel that the
heteronormative narrative that they had built for their child is no longer viable.
Most youths that face parental rejection face the majority of the emotional dismissal upon
the initial moment of coming out. Before even broaching the conversation with their parents,
youths and adolescents suffer a slew of emotional worries, including feeling guilty that they’re
hiding something, and fearing potential violence and abuse, and the risk of losing emotional
support (Butler 2009, Diamond and Shpigel, 2014, Ryan et al. 2010). This rejection can have
significant impact on youths and their mental health due to a developmental component known
as symbolic interaction theory. According the theory, individuals in their early stages of
development form their identity vis a vis their interactions with others, and in particular based on
how they believe others perceive them (Cooley 1902, and Mead, 1934 in Bregman et al., 2012).
Specifically, studies show that adolescents and young adults in general that face parental
rejection develop lower self-esteem, while the converse is true for those that experience parental
acceptance (Berenson, Crawford, Cohen, & Brook, 2005; Robinson and Simons, 1989;
Robinson, 1995 in Bregman et al., 2012). This is especially applicable to children and how their
parents perceive them, and so children who face parental rejection not only are forced into
questioning their own identity based off their own fears and internal biases, but rather that
questioning is compounded with the stress that their parents perceive them as somehow wrong or
inadequate.
In terms of identity development and negative mental health outcomes, negative parental
interactions increase rates of homonegativity, identity confusion, and need for acceptance
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(Willoughby, Doty, & Malik, 2010 in Bregman et al., 2012). The process of coming out is
statistically the time period where youths and adolescents face the majority of the emotional
upheaval, and the consequences of initiating revealing their sexuality include “parental
distancing, rejection, or incidents of abuse sexual harassment, bullying, threats of violence, and
physical assaults by peers in the school environs, living on the street or in shelters, and truancy,
low academic achievement and school drop-out” (Saltzburg, 2007; 58). Ryan et al. (2010)
describe a study by Ryan and Diaz (2009) that revealed significant correlations between parental
rejection and drug use, depression, suicidality and attempted suicide, and risky sexual behavior
in LGB young adults. Furthermore, adolescents from highly accepting families indicated half as
many suicidal thoughts as those from non-accepting families- 18.5% versus 38.3%, and 30.9%
versus 56.8%, respectively (Ryan et al. 2010: 208).
It should not be surprising that youth and adolescents who reveal their sexual orientation
to parents who accept them face significantly fewer negative mental health outcomes, and in fact
demonstrate high correlations of positive adjustment in the form of self-esteem, social support,
and general health, as well as preventing all negative mental health outcomes as described by
Ryan et al. (2010), with the exception of deviant sexual behavior. Additionally, Savin-Williams
(1989) found that LGB youth with affirmative parental attitudes (i.e. attitudes that accept and
encourage, with intent, LGB behavior) demonstrate higher rates of comfortability with their
sexual orientation and self-esteem, as well as lower rates of self-critical thoughts and behavior.
Family Variables
Within the family system, there are three specific variables that contribute to
relationships and wellbeing: Individual, Dyadic, and Familial (Heatherington and Laver, 2008).
However, each variable possesses several sub-variables that increase the complexity of the
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situation. Individual Variables have to do with the variables that are personal to the
youth/adolescent themselves, such as gender, race, or religion. in the case of gender, there are
seemingly minor but realistically substantial differences that males and females1 face differently.
For example, fathers are more likely to be physically and emotionally abusive to their gay sons
than they are to their lesbian daughters, as are brothers to their gay brother than to their lesbian
sister. Though there is little research on race, Heatherington and Lavner (2008) make note that
non-Caucasian minorities are less likely to come out to their parents, and thus face mental health
challenges similar to but different from those that do come out and face negative reactions.
Furthermore, research shows that traditional values matter more than race; that is to say parents
with more firm beliefs around religion and marriage are less likely to be accepting than parents
of color who are not religious (Heatherington and Lavner, 2008).
While this may appear straightforward at first glance, the reality is that intersectionality
“[complicates] straightforward predictions” (Heatherington and Lavner, 2008; 333). These
individual variables are even more complicated when compounded with Dyadic variables, which
are variables that pertain to binary relationships. For example, for lesbians girls, the quality of
relationship with the mother was a predictor for comfort with sexual orientation, but not the
relationship with the father (Heatherington and Lavner). Additionally, for gay men, relationship
status with both the mother and father improved comfortability with sexuality if and only if “they
felt that their parents were important to their self-worth,” but this was not the case for lesbian
girls (Heatherington and Lavner, 2008; 334). In the case of relationships with one individual
parent and their child, it should not be surprising to learn that closer relationships usually yield
1
Due to the lack of literature available, is beyond the scope of this paper to explore mental health outcomes and
relationships with parents for gender non-conforming or non-binary individuals.
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less stressful disclosure and consequential relationship status. Furthermore, the “news” of their
child’s sexual identity is better received by parents when they find out from their child directly,
as opposed to from some external source (Heatherington and Lavner, 2008). Kids with selfreported secure attachment had better wellbeing outcomes and coming out experiences
(Diamond and Spiegel, 2014; Heatherington and Lavner, 2008).
Family variables speak to family cohesion, closeness, and support. Heatherington and
Lavner (2008) report that in some studies, family cohesion is not correlated with coming out, but
rather it is directly correlated with identity expression, which acts as a mediator to the process of
coming out. Contrary to what should seem logical, family cohesion was actually inversely
correlated with positive identity expression, arguably because children fear that their expression
will break family bonds and disrupt relationship (Waldner and Magruder, 1999 in Heatherington
and Lavner, 2008)
Family-Centered Therapies
Even before seeking out therapy, there are some variables that may soften parents’
reactions to their child revealing their sexual identity. For example, parents that have been
exposed to gay culture previously are more likely to have less homonegative attitudes and be
more accepting of their children upon initial disclosure (Heatherington and Lavner).
Furthermore, parents who pick up on early signs of gender fluctuations or assigned genderatypical behaviors and attitudes may work through the early stages of loss and grief early on
even before disclosure. Furthermore, parents reactions may often reflect their child’s; if the child
has a positive, non-nervous, homo-positive sense of their identity, it is likely that the parents will
strive to follow suit.
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According to Butler (2009; 350-351), there are four stages through which therapists
should assist parents who are struggling with accepting their child. First and foremost is the
Finding Out stage, where the therapist’s role is to help family members reflect on and interpret
their thoughts and feelings and learn how to talk to their child. Second, it is reported that along
with the sense of grief, parents also feel nervous about communicating their child’s sexual
orientation to peers or other family members. As such, the therapist’s role through the stage of
Communicating with Others is to work with the family on how to man age conversation if the
news leaks before they are able to disclose on their own terms. It may be helpful in this case as
well to refer the family to organizations like Parents and Friends of Lesbians and Gays (PFLAG)
to facilitate growing a network of support that may help mediate feelings of loss. The third stage
involves Changing Inner Perceptions, which works on changing feelings of loss and redefining
narratives believed to be lost. For example, one component contributing to grief is often the idea
that their child will not be able to have children. In a process called Narrative Therapy Pathways,
the therapist can assist the parents to deconstruct the traditional, heteronormative narratives that
they have had for their child, and rebuild those narratives with the new information in mind.
Finally, therapists can help parents Take a Stand and help them become advocates for LGB(T)
children and to change their narrative of their future.
Narrative Pathways Therapy (NPT), as previously noted, is a parent-focused therapy that
assists parents in coping with their perceived loss by deconstructing and reconstructing
previously held narratives of their child’s future; Butler (2009) writes that NPT “creates an
empathic and supportive therapeutic context for people to call forth other ways of knowing
themselves and their lives in order to bring about change” (59). Through a process called
situating, parents work with the therapist to figure out what the origins of their thoughts and
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feelings are. More often than not, it is discovered that the sense of anxiety that they feel for their
youth often comes from parallel narratives- the one of their child as (s)he has previously existed,
and the one of her/him being who they are in a largely unaccepting world. As such, the therapy is
grounded in the idea that “reality is subjective, multiple and fluid in nature, socially constructed
through language within communities of people, and maintained through storied trajectories”
(Butler, 2009; 59).
Another therapy that may be applied is Sexual and Gender Minority Therapy (SGM).
SGM is not a treatment plan in and of itself, but rather is a way of adapting existing methods of
practice to be “gay affirming” (Butler, 2009). It is a method that challenges therapists to be
conscious of their own privileges and biases in their interactions with their clients. For example,
it would be harmful for a therapist to assume that an LGB client is seeking therapy for LGBrelated issues. Nonetheless, one must recognize intersectionality and how issues might be
underlying things. As such, it is crucial that therapists strike a balance between challenging their
own assumptions and digging deeper to understand how and if the client’s sexuality, or it’s
interactions with the outside world, may be contributing to their distress. SGM relies on themes
of position, transparency, and self-disclosure, whereby the therapist practices radical honestly to
reveal their identity to their clients. It should be noted that this method is slightly complicated
when working with families, as some members might find that it crosses boundaries, and
sometimes it might privilege some members of families and exclude others. To remedy this, one
should allow the clients to ask their own questions about them before therapy initiates, so they
can decide if they want to work with the therapist in question, as well as only disclosing small
bits of information about themselves at a time and being aware of emotional responses. In some
cases, it may be advisable to use a co-therapist (Butler, 2009).
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The final therapy presented in this paper is Attachment-Based Family Therapy for
Lesbian and Gay Young Adults and Their Persistently Nonaccepting Parents (Diamond and
Shpigel, 2014). The therapy functions on the principle that secure attachment between the child
and their parents is associated with positive adjustment and a decrease in negative mental health
outcomes (Cooper, Shaver & Collins, 1998 in Diamond and Shpigel, 2014). It is composed of
five tasks over the course of 16-24 weeks. Task one, the relational reframe, changes the
expectation that the therapy’s purpose is to address challenges outside the family, such as school
issues or peer relationships, and focus the energy on the parent-child relationship. The next two
phases involve alliance building with the child and parent separately. Alliance building with the
adolescent focuses on mental health treatment and how to discuss feelings with the parent, while
alliance building with the parents evaluates their own attachment history and parental strategies.
The therapist also challenges parents to learn how to respond to the child’s expression of their
unmet attachment need. The attachment task, or the fourth task, is meant to allow the adolescent
to explore their new relationship with their parent, whereby they feel supported, connected, and
understood. The fifth task, the competency promoting task, assists the parents in providing that
aforementioned support as their child navigates the challenges of adolescence and identity
formation.
Implications for Couple and Family Therapy
With all the information taken above, it is clear that therapy should be centered around
building and maintaining healthy attachment, as well as being affirmative of the child’s identity
(Diamond and Shpigel, 2014; Needham and Austin, 2010). Therapists that are affirmative have
the best effect on parental acceptance (Diamond and Shpigel, 2014). Despite this information,
the most recent research indicates that couple & family therapy programs don’t prepare students
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to deliver “competent and affirmative services to LGB clients” (Carlson, McGeorge, & Toomey,
2013; Doherty & Simmons, 1996; and Rock, Carlson, & McGeorge, 2010 in McGeorge and
Carlson, 2015). Furthermore, Rock et al. (2010, cited by McGeorge and Carlson, 2015: 153)
reported that 60% of CFT/MFT students surveyed indicated that they did not receive adequate
(or any at all) LGB-affirmative training in graduate school. Needless to say, it is clear that there
is an extreme gap in where the research points and what actually takes effect in practice.
Future Directions for Research
Current literature examines identity formation across a single variable of identity
development, as opposed to considering other variables across the dimension. According to
Bregman et al., 2012, this “[limits] the assessment of identity to comfort and openness about
sexual orientation or internalized homonegativity, as a majority of studies have done, may not
portray the full spectrum of identity” (Bregman et al., 2012: 420). Furthermore, there is little
research done on the moment of coming out to families, but research does suggest that parental
responses can vary over time (Bregman et al., 2012). To continue, there are very few crisis
intervention plans, with ABFT representing the closest thing. Finally, there is very little
longitudinal data examining long-term effects on sense of identity other than anecdotal evidence
that it improves over time (Bregman et al., 2012)
Concluding Remarks and Limitations
This paper attempts to provide a small glimpse into the literature as it pertains to LGB
youth/adolescent wellbeing and mental health in the face of parental rejection or acceptance, as
well as to examine the state of family-centered therapies for the same. However, it would be
remiss to expect that this is an exhaustive account of all research and therapy. As noted
previously, this paper does not discuss transgender and non-binary youth, as there is a significant
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gap in the literature that hold enormous potential to be explored over the next several years.
Finally, as with any study, the research presented may be biased in the sense that individuals in
them potentially self-select into therapy because the parents are may be more open-minded and
hopeful than the general population. Nonetheless, it remains hopeful that this research may
contribute to a more well-rounded field of research, and consequently, more productive and
sensitive treatment for those who need it.
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