In this article, we address theories of attachment and parental acceptance and rejection, and their implications for lesbian, gay, bisexual, and transgender (LGBT) youths’ identity and health. We also provide 2 clinical cases to illustrate the process of family acceptance of a transgender youth and a gender nonconforming youth who was neither a sexual minority nor transgender. Clinical implications of family acceptance and rejection of LGBT youth are discussed.
Key points
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Parent–child attachment has implications for developing healthy relationships later in life.
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LGBT youth may experience a disruption in parent–child attachment if they are rejected based on their sexual orientation or gender identity.
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Parental rejection of LGBT youth negatively affects youths’ identity and health.
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Parental acceptance of LGBT youth is crucial to ensure that youth develop a healthy sense of self.
Introduction
In this article, we discuss sexual minority, that is, lesbian, gay, and bisexual (LGB) and transgender (LGBT) youth. Sexual orientation refers to the individual’s object of sexual or romantic attraction or desire, whether of the same or other sex relative to the individual’s sex, with sexual minority individuals having a sexual orientation that is partly or exclusively focused on the same sex. Transgender refers to individuals for whom current gender identity and sex assigned at birth are not concordant, whereas cisgender refers to individuals for whom current gender identity is congruent with sex assigned at birth. Sexual orientation and gender identity are distinct aspects of the self. Transgender individuals may or may not be sexual minorities, and vice versa. Little is known about transgender youth, although some of the psychosocial experiences of cisgender sexual minority youth may generalize to this population.
The Institute of Medicine recently concluded that LGBT youth are at increased risk for poor mental and physical health compared with heterosexual and cisgender peers. Indeed, representative samples of youth have found disparities by sexual orientation in health-related risk behaviors, symptomatology, and diagnoses, with disparities persisting over time. Furthermore, sexual orientation disparities exist regardless how sexual orientation is defined, whether by sexual or romantic attractions; sexual behaviors; self-identification as heterosexual, bisexual, lesbian/gay or other identities; or any combination thereof. Disparities by gender identity have also been found, with transgender youth experiencing poorer mental health than cisgender youth.
Attempts have been made to understand sexual orientation and gender identity-related health disparities among youth. It has been argued that sexual minority youth experience stress associated with society’s stigmatization of homosexuality and of anyone perceived to be homosexual (see Mark L. Hatzenbuehler and John E. Pachankis’ article, “ Stigma and Minority Stress as Social Determinants of Health Among LGBT Youth: Research Evidence and Clinical Implications ,” in this issue). This “gay-related” or “minority” stress is experienced at the hands of others as victimization. It is also internalized, such that sexual minorities victimize the self by means, for example, of possessing negative attitudes toward homosexuality, known as internalized homonegativity or homophobia. In addition to interpersonal stigma and internalized stigma, the main focus of this article, structural stigma reflected in societal-level norms, policies, and laws also play a significant role in sexual minority stress, and is discussed in Mark L. Hatzenbuehler and John E. Pachankis’ article, “ Stigma and Minority Stress as Social Determinants of Health Among LGBT Youth: Research Evidence and Clinical Implications ,” in this issue. Meta-analytic reviews find that sexual minorities experience more stress relative to heterosexuals, as well as unique stressors. Research also indicates that transgender individuals experience substantial amounts of prejudice, discrimination, and victimization, and are thought to experience a similar process of minority stress as experienced by sexual minorities, although minority stress for transgender individuals is based primarily on stigma related to gender identity rather than stigma related to having a minority sexual orientation. Stigma related to gender expression affects those with gender nonconforming behavior, a group that includes both transgender and cisgender individuals. This includes many cisgender youth growing up with LGB orientations.
Actual or anticipated family acceptance or rejection of LGBT youth is important in understanding the youth’s experience of minority stress, how the youth is likely to cope with the stress, and, consequently, the impact of minority stress on the youth’s health. This article addresses the role of family, in particular parental acceptance and rejection in LGBT youths’ identity and health. Literature reviewed in this article focuses on the experiences of sexual minority cisgender youth owing to a lack of research on transgender youth. However, we include findings and implications for transgender youth whenever possible.
Introduction
In this article, we discuss sexual minority, that is, lesbian, gay, and bisexual (LGB) and transgender (LGBT) youth. Sexual orientation refers to the individual’s object of sexual or romantic attraction or desire, whether of the same or other sex relative to the individual’s sex, with sexual minority individuals having a sexual orientation that is partly or exclusively focused on the same sex. Transgender refers to individuals for whom current gender identity and sex assigned at birth are not concordant, whereas cisgender refers to individuals for whom current gender identity is congruent with sex assigned at birth. Sexual orientation and gender identity are distinct aspects of the self. Transgender individuals may or may not be sexual minorities, and vice versa. Little is known about transgender youth, although some of the psychosocial experiences of cisgender sexual minority youth may generalize to this population.
The Institute of Medicine recently concluded that LGBT youth are at increased risk for poor mental and physical health compared with heterosexual and cisgender peers. Indeed, representative samples of youth have found disparities by sexual orientation in health-related risk behaviors, symptomatology, and diagnoses, with disparities persisting over time. Furthermore, sexual orientation disparities exist regardless how sexual orientation is defined, whether by sexual or romantic attractions; sexual behaviors; self-identification as heterosexual, bisexual, lesbian/gay or other identities; or any combination thereof. Disparities by gender identity have also been found, with transgender youth experiencing poorer mental health than cisgender youth.
Attempts have been made to understand sexual orientation and gender identity-related health disparities among youth. It has been argued that sexual minority youth experience stress associated with society’s stigmatization of homosexuality and of anyone perceived to be homosexual (see Mark L. Hatzenbuehler and John E. Pachankis’ article, “ Stigma and Minority Stress as Social Determinants of Health Among LGBT Youth: Research Evidence and Clinical Implications ,” in this issue). This “gay-related” or “minority” stress is experienced at the hands of others as victimization. It is also internalized, such that sexual minorities victimize the self by means, for example, of possessing negative attitudes toward homosexuality, known as internalized homonegativity or homophobia. In addition to interpersonal stigma and internalized stigma, the main focus of this article, structural stigma reflected in societal-level norms, policies, and laws also play a significant role in sexual minority stress, and is discussed in Mark L. Hatzenbuehler and John E. Pachankis’ article, “ Stigma and Minority Stress as Social Determinants of Health Among LGBT Youth: Research Evidence and Clinical Implications ,” in this issue. Meta-analytic reviews find that sexual minorities experience more stress relative to heterosexuals, as well as unique stressors. Research also indicates that transgender individuals experience substantial amounts of prejudice, discrimination, and victimization, and are thought to experience a similar process of minority stress as experienced by sexual minorities, although minority stress for transgender individuals is based primarily on stigma related to gender identity rather than stigma related to having a minority sexual orientation. Stigma related to gender expression affects those with gender nonconforming behavior, a group that includes both transgender and cisgender individuals. This includes many cisgender youth growing up with LGB orientations.
Actual or anticipated family acceptance or rejection of LGBT youth is important in understanding the youth’s experience of minority stress, how the youth is likely to cope with the stress, and, consequently, the impact of minority stress on the youth’s health. This article addresses the role of family, in particular parental acceptance and rejection in LGBT youths’ identity and health. Literature reviewed in this article focuses on the experiences of sexual minority cisgender youth owing to a lack of research on transgender youth. However, we include findings and implications for transgender youth whenever possible.
Theories of parental acceptance and rejection
The continued importance of parents in the lives of youth is indisputable: beginning at birth, extending through adolescence, and even into emerging adulthood, affecting all relationships beyond those with the parents, and determining the individual’s own sense of self-worth. Attachment accounts for this vast reach and influence of parents.
According to Bowlby, attachment to the primary caretaker guarantees survival because the attachment system is activated during stress and concerns the accessibility and responsiveness of the attachment figure to the child’s distress and potential danger. The pattern or style of attachment that develops is based on repeated interactions or transactions with the primary caregiver during infancy and childhood. Those experiences, in interaction with constitutional factors like temperament, influence the internal working model (ie, mental representations of emotion, behavior, and thought) of beliefs about and expectations concerning the accessibility and responsiveness of the attachment figure. In time, this internal working model influences perceptions of others, significantly influencing patterns in relationships over time and across settings. The beliefs and expectations concerning the attachment figure also affect the internal working model of the self, meaning the individual’s sense of self-worth.
The 3 consistent patterns of attachment that arise in infancy and childhood are related to the internal working models of the self and other. The “secure” child has positive models of the self and other because the primary attachment figure has been accessible when needed and responsive in an attuned and sensitive manner to the child’s needs and capabilities. Consequently, the securely attached child is able to regulate emotion, explore the environment, and become self-reliant in an age-appropriate manner. The “insecure” child has an inaccessible and unresponsive primary caregiver, who is intrusive, erratic, or abusive. One of 2 insecure attachment patterns emerges. In the first pattern, the child dismisses or avoids the parent, becoming “compulsively” self-reliant and regulating emotion even when contraindicated. This child with “avoidant/dismissive” attachment depends on the self, possessing a positive internal working model of the self but a negative one of the other. In the second insecure attachment pattern, the child is anxiously preoccupied with the caregiver but in a resistant (ie, distressed or aroused) manner. The individual with “anxious/preoccupied/resistant/ambivalent” attachment has a negative working model of the self, but a positive model of the other.
Attachment patterns in childhood are partly related to character traits in adulthood, and have implications for emotion regulation from the perspective of coping with stress, as detailed elsewhere. Based on positive working models of the self and other, the securely attached individual approaches a stressful situation in an adaptive manner that allows for a realistic appraisal of the situation and a selection of coping strategies most likely to reduce or eliminate the stressor or, at minimum, render the stressor tolerable. By comparison, insecurely attached individuals may distort reality because they may be more likely to appraise a situation as stressful, even when it is not. They may also be maladaptive in their management of stress and use emotion-focused coping strategies, such as substance use, to improve mood and tolerate stress. These patterns of coping influenced by attachment are present by and common in adolescence. Coping is critical because sexual orientation and gender development are potentially stressful experiences for all youth, but especially for sexual and gender minorities, given the frequent stigmatization of homosexuality, gender nonconforming behavior, and gender-variant identities.
Implications for parent–child attachment
The vast majority of sexual minority youth are born to heterosexual parents. Those parents may not uncommonly possess implicit or explicit negative attitudes toward homosexuality and expect their children to be heterosexual. Parents may not only be surprised that their child may be or is a sexual minority, but they may also respond negatively to the child. Similarly, the vast majority of transgender and/or gender nonconforming youth are born to cisgender and/or gender conforming parents, who often possess negative attitudes toward those who violate societal expectations for gender identity, expression, and roles, and expect their children to be cisgender and gender conforming. Negative responses from parents to LGBT youth may range from anxious concerns about the child’s well-being and future to abuse and even banishment of the child from the home.
The range of possible parental responses to the child’s sexual orientation, gender-related behavior, or identity when these deviate from parental expectation is linked to the child’s attachment. The securely attached youth has parents who have encouraged age-appropriate exploration and value the child as a unique individual. Such parents may be surprised and concerned by the child’s sexual minority orientation, gender nonconformity, or transgender identity, but they are likely to work through their negative attitudes over time and continue to be accessible and responsive to their child. Thus, the attachment of the securely attached youth may be shaken when parents learn of these, but it is unlikely to be undone. This does not apply to insecurely attached youth, given their a priori inaccessible, unresponsive, and potentially abusive parents. Knowledge of these deviations from expectation, coupled with negative attitudes, may lead such parents to be less supportive of their child, or reject them. The latter may manifest in parental abuse of the youth, running away by the youth to escape maltreatment, or eviction of the youth from the home.
Representative samples of youth find that, relative to heterosexual peers, sexual minorities report lower levels of parental closeness and increased rates of parental abuse and homelessness. Transgender youth also report elevated rates of child abuse compared with their cisgender peers. More specifically, sexual minority youth relative to heterosexual peers and siblings report less secure attachment to their mothers and their mothers report less affection for them. It has also been found that maternal attachment mediates sexual orientation disparities in depressive symptomatology and substance use. These disparities in sexual and gender minority youth from their gender normative peers and siblings involving the degree of attachment underscore the importance of parental attitudes toward sexual minority orientations, gender-nonconforming behavior, and gender identity variance for secure attachment in youth. Pediatric clinicians should assess these and the quality of the parent–child attachment.
These attachment implications and findings take on added meaning when considered along with youth’s neurocognitive development and coping capabilities. It is known that development of the prefrontal cortex lags behind that of limbic regions during adolescence, ensuring less impulse control and greater risk taking. The findings extend to emotion regulation. Human imaging studies demonstrate that youth have a difficult time downregulating amygdala activation. Therefore, coping in youth is circumscribed by limited ability to rationally or logically plan, execute, evaluate, and readjust a problem-focused strategy to eliminate or reduce stress, while simultaneously controlling emotional reactivity.
Consequently, youth greatly depend on adults, especially parents, both to assist them with meeting developmental demands and to guide their personal experiences in various domains (eg, interpersonal, romantic) and settings (eg, school, work). LGBT youth with insecure attachment may have a difficult time navigating and coping with such challenges if their parents are inaccessible and unresponsive.
Nevertheless, attachment may change over time. This may happen if the attachment figure becomes more or less accessible and responsive, or if 1 attachment figure (eg, the mother) buffers the negative impact of another attachment figure (eg, the father). A nonparental individual may provide support, but whether she or he can provide the deep sense of security and the safe haven of an attachment figure is uncertain, particularly if social structures and cultural traditions do not foster these relationships.
Parental Reactions to Gender Nonconformity
Gender nonconformity, defined as having a gender expression that is perceived to be inconsistent with gender norms expected for an individual’s sex, is not uncommon in children. A study of gender atypical behavior (1 aspect of gender nonconformity) among elementary school children found that approximately 23% of boys and 39% of girls displayed multiple gender atypical behaviors. Gender nonconformity exists on a spectrum, with some children displaying less and some children displaying more gender nonconformity. This spectrum has implications for victimization, such that youth who are more gender nonconforming are at increased risk for abuse by caregivers, as well as peer victimization and bullying (see Valerie A. Earnshaw and colleagues’ article, “ Bullying among Lesbian, Gay, Bisexual, and Transgender Youth ,” in this issue) and an increased risk of depressive symptoms. Although a link exists between childhood gender nonconformity and later sexual minority orientation and/or transgender identity, not all children who are gender nonconforming are LGB or transgender in later adolescence or adulthood.
As with stigma attached to sexual minorities and transgender individuals, gender nonconformity is also stigmatized in and of itself, particularly among boys. Connell’s theory of hegemonic masculinity sheds light on this stigma; it suggests that 1 form of masculinity, with features such as aggression, limited emotionality, and heterosexuality, is culturally exalted above others. For this reason, variation from this level of masculinity among boys can be stigmatized. Similar to stigma related to sexual minorities and transgender individuals, stigma related to gender nonconformity is often enacted through prejudice, discrimination, and victimization. A study of early adolescents found that gender nonconformity was associated with increased victimization by peers. Youth who are sexual minorities may be bullied for gender nonconformity before they are aware of their sexual orientation. A recent study found that sexual minority youth were bullied as early as fifth grade, which is before the majority of sexual minority youth are aware of their sexual orientation or disclose it to others. Although the study did not assess the reason for bullying, it is possible that these youth were bullied based on gender nonconformity.
Negative societal views may include adverse parental reactions to a child’s gender nonconformity. A qualitative study found that parents welcomed gender nonconformity among their daughters, but had mixed reactions to their sons’ gender nonconformity; they accepted some level of nonconformity in their sons (eg, interest in cooking), but had negative reactions to higher levels of nonconformity (eg, wearing dresses). In addition to increased risk for bullying victimization from peers, previous research has found that gender nonconforming children have a high prevalence of childhood sexual abuse, physical abuse, and psychological abuse by caregivers, which may be indicative of negative parental reactions to their child’s gender nonconformity. Parents’ initial reactions to gender nonconformity in their children may extend to reactions to youth’s sexual orientation disclosure.
Parental reactions to youths’ lesbian, gay, bisexual, and transgender disclosure
Disclosure of sexual orientation to family members is common among sexual minority youth. One study found that 79% of sexual minority youth had disclosed their sexual orientation to at least 1 parent, and two-thirds of youth had disclosed their orientation to at least 1 sibling and 1 extended family member. Another study of sexual minority emerging adults found that 46% of men and 44% of women had disclosed their sexual orientation to their parents. In this study, participants were more likely to disclose their sexual orientation to their mothers than to their fathers, and disclosures typically occurred around age 19 years in a face-to-face encounter.
A number of theories have been proposed to conceptualize the reactions of parents to their children’s disclosure of sexual minority orientation, including mourning/loss paradigms based on Kubler-Ross’s stage model of grief and family stress theory. Willoughby and colleagues applied family stress theory to parental reactions to their children’s sexual orientation disclosure, proposing that reactions may depend on the availability of family-level resources (eg, relational competencies) to manage stress, meanings that parents attributed to the stressful event (eg, believing that sexual orientation is a choice), and cooccurring stressors (eg, divorce, major illness). Although these theories are useful for understanding parents’ reactions to their child’s sexual orientation disclosure, some researchers have proposed that these models are limited in that they may not describe the reaction of all parents, account for developmental change in reactions over time, or consider the experiences of the child.
Parents may experience a number of different responses when faced with a disclosure of sexual minority orientation from their child, ranging from accepting to rejecting. Research in this area has yielded mixed results regarding the positivity and negativity of parental reactions. One study found that sexual minority youth who had disclosed their sexual orientation to family members reported more verbal and physical abuse by family members and more suicidality compared with youth who had not disclosed their orientation. However, this study was published in 1998 and much has changed since then regarding societal acceptance of sexual minorities. Another study found that, among sexual minority youth who had disclosed their sexual orientation to their mother or father, the majority (89%–97%) received a positive reaction. However, these findings may be misleading, given they do not consider how many youth have not disclosed to parents owing to fear of negative reactions or rejection.
A review of the sexual minority literature finds that one-third of youth experience parental acceptance, another one-third experience parental rejection, and the remaining one-third do not disclose their sexual orientation, even by their late teenage years and early 20s. The review also finds that regardless of initial reactions, parents generally become more accepting of their child over time. For instance, 1 study found that, compared with sexual minority youth who had not disclosed their sexual orientation to parents, sexual minority youth who had disclosed their orientation reported more past sexual orientation-based verbal victimization from parents, but more current family support and less fear of future parental victimization, indicating greater acceptance over time. Whether such findings generalize to transgender youth is unknown. Our first case vignette in this article illustrates areas needing more empirical research regarding transgender youth’s disclosure of gender identity to parents ( Box 1 ).
