How Depressed and Suicidal Sexual Minority Adolescents Understand the Causes of Their Distress

Abstract

This study examined how lesbian, gay, and bisexual (LGB) adolescents reporting clinically significant depressive and suicidal symptoms understand the causes of their psychological distress. The role of the quality of the adolescent-parent relationship as a risk or protective factor was explored. Ten qualitative interviews were analyzed using the Consensual Qualitative Research method. Results showed that adolescents viewed family rejection of sexual orientation, extra-familial LGB related victimization, and non-LGB related negative family life events as the most common causes of their psychological distress. Most of the adolescents also reported experiencing support from at least one family member, and half reported experiencing significant extra-familial (e.g., peers, school counselor) support. Almost all of the adolescents reported wishing that their relationships with their parents were closer and characterized by more acceptance, as well as a willingness to participate in family therapy to improve their relationships with their parents. Clinical implications are discussed.

KEYWORDS:

• suicide
• depression
• gay
• lesbian
• bisexual
• adolescent
• parents
• family therapy

While the great majority of sexual minority adolescents are healthy, functioning, and resilient (Savin-Williams, 2005; Savin-Williams & Ream, 2003), 30 years of research suggest that, as a group, they evidence disproportionately higher rates of depressive symptoms, suicidal ideation, and suicide attempts than their heterosexual peers (Almeida, Johnson, Corliss, Molnar, & Azrael, 2009; Balsam, Beauchaine, Mickey, & Rothblum, 2005; Fergusson, Horwood, & Beautrais, 2005; Poteat, Aragon, Espelage, & Koenig, 2009; Remafedi, French, Story, Resnick, & Blum, 1998; Russell, 2003, 2006; Russell & Joyner, 2001; Zhao, Montoro, Igartua, & Thombs, 2010). Most researchers agree that there is probably nothing depressogenic or suicidal about same-gender sexual orientation. Instead, it is likely that environmental responses such as discrimination, victimization, and rejection (i.e., minority stress) lead to low self-esteem, depression, hopelessness, and social isolation which, in turn, place LGB adolescents at risk for contemplating suicide.

Research shows that sexual minority adolescents experience more frequent and more violent victimization than heterosexual adolescents (Almeida et al., 2009; Balsam, Rothblum, & Beauchaine, 2005; Bontempo & D’Augelli, 2002; D’Augelli, Pilkington, & Hershberger, 2002; Birkett, Espelage, & Koenig, 2009). Furthermore, data show that discrimination and victimization play an important role in suicidality among sexual minority youth (Almeida et al., 2009; Bontempo & D’Augelli, 2002; Hershberger, Pilkington, & D’Augelli, 1997; Rotheram-Borus, Hunter, & Rosario, 1994; Russell, 2003; Savin-Williams & Ream, 2003). For example, perceived discrimination has been found to mediate the relation between sexual minority status and depressive symptoms and suicidal ideation among boys but not girls (Almeida et al., 2009). In other studies, school victimization was found to moderate, and perhaps mediate, the association between LGB status and depressive symptoms and suicidality (Bontempo & D’Augelli, 2002).

There is also evidence that rejection by peers and loss of friends due to sexual orientation is a predictor of suicide attempts (Hershberger et al., 1997), as is youths’ harboring negative attitudes regarding homosexuality (i.e., internalized homophobia) (Rosario, Schrimshaw, Hunter, & Gwadz, 2002; Savin-Williams & Ream, 2003). Some have suggested that African-American LGB youth may be particularly vulnerable due to their status as both racial and sexual minorities (Boykin, 1996). However, findings from the Add Health study indicate that African-American sexual minority adolescents are at no greater risk for suicidal ideation and depression than their white counterparts (Consolacion, Russell, & Sue, 2004).

One prominent risk and protective factor associated with adolescent depression and suicidality is the quality of the adolescent-parent relationship. A substantial amount of research, including both prospective and cross-sectional studies using community and clinical samples, has linked parental criticism, emotional unresponsiveness, lack of care and support, and rejection and control to adolescent depression, suicidal ideation, and suicide attempts (Connor & Rueter, 2006; Kerr, Preuss, & Kind, 2006; see Wagner et al., 2003, for review). LGB adolescents may be particularly at risk for conflict with parents, parental criticism, and parental rejection due to their sexual minority status and/or atypical gender role behavior (D’Augelli et al., 2005; Floyd, Stein, Hartin, Allison, & Nye, 1999; Hammelman, 1993; Hunter & Schaecher, 1987; Savin-Williams, 1989, 1994). While many parents over time become more accepting and affirming of their child's minority sexual-orientation (Herdt & Koff, 2000; Holtzen & Agriesti, 1990; Robinson, Walters, & Skeen, 1989; Savin-Williams, 2001), up to 40% initially reject or are intolerant of their adolescent's same-sex attraction (D’Augelli, 2003; D’Augelli, Hershberger, & Pilkington, 1998), despite increasing social acceptance of lesbians, gay males, and bisexual people (Saad, 2010).

When parents reject, disengage from, invalidate, or otherwise express discomfort with their adolescent's sexual orientation, the message conveyed is that something is wrong with the adolescent (Goldfried & Goldfried, 2001). Such a message, delivered from the most important people in the adolescent's life, can exacerbate self-loathing, depression, and hopelessness, all correlates of suicide. Furthermore, negative parental responses teach adolescents that they have no one to turn to when they are victimized outside of their home due to their sexual orientation. Not surprisingly, parental psychological abuse and discouragement of childhood gender atypical behavior are associated with suicide attempts among LGB youth (D’Augelli et al., 2005). In one study of gay male adolescents, nearly half attributed their suicide attempts to “family problems” (Remafadi, Farrow, & Deisher, 1991).

In contrast, when parents accept their youth's lesbian, gay, or bisexual orientation as an integral and valued aspect of their child, they validate (Savin-Williams, 1989) and are positioned to support, guide, and advocate for their child as she or he negotiates the challenges of growing up with a minority sexual orientation. LGB adolescents who report high levels of parental support, good communication, and emotional closeness with their parents evidence fewer depressive symptoms and less suicidal ideation and attempts (Floyd et al., 1999). Furthermore, such parental support has been shown to moderate or buffer against the negative effects of gay-related victimization (D’Augelli, 2003; Evans, Hawton, & Rodham, 2004).

To date, most researchers have used cross-sectional, correlational data derived from closed-ended questionnaires or interviews to identify factors associated with depressive symptoms and suicidality among LGB adolescents. Such an approach has certain advantages. In particular, it allows researchers to gather data from large population-based samples, increasing the external validity of findings. One disadvantage, however, is that such methods do not capture how these adolescents themselves understand what has made them depressed and/or suicidal. Listening to the adolescents’ perspective can serve to validate previous findings from correlational studies, uncover unexpected yet salient factors or processes related to depressive and suicidal symptoms, shed light on the interactions between multiple factors and processes, and potentially identify important treatment targets.

The purpose of this study was to capture adolescents’ own perspectives regarding the factors implicated in their psychological distress. To that end, we conducted in-depth interviews with 10 sexual minority adolescents reporting clinically significant levels of depressive symptoms. Seven of the 10 adolescents also reported clinically significant levels of suicidal ideation. The primary goal was to better understand how these youth conceived the causes of their depression/suicidal ideation. The interviews were semi-structured and comprised a number of nondirective, open-ended questions such as, “What do you think makes you feel depressed or suicidal?” As family therapy researchers, and based on the literature highlighting the importance of the quality of adolescent-parent relationships in the context of depression and suicidal ideation, we were particularly interested in the quality of the relationships between these adolescents and their parents and the role these relationships played in the adolescents’ psychological distress or resilience. We were also interested in the attitudes of these youths regarding counseling in general, and family therapy in particular, in order to obtain information about barriers to treatment and how to make treatment more accessible and sensitive to the needs of these youth.

METHOD

Participants

Interviewees included 10 LGB adolescents reporting clinically significant depressive symptoms, seven of whom also reported clinically significant suicidal symptoms. Four of the adolescents self-identified as male and gay (3) or primarily attracted to other males (1), five identified as female and lesbian, and one identified as a pre-operative female to male gay trans man. Seven self-identified as African-American, one as Jamaican, one as Hispanic, and one as biracial. One adolescent was 15 years old, one was 17, seven were 18, and one was 19 years old. Nine of the 10 adolescents had disclosed their sexual orientation to at least one parent.

Their scores on the Beck Depression Inventory–second edition (BDI-II; Beck, Steer, & Brown, 1996) ranged from 20–45 (X = 28.7; SD = 8.14), placing them all in the moderate to severe range for depressive symptoms. Seven of the adolescents reported clinically significant levels of suicidal ideation, with scores on the Suicide Ideation Questionnaire (SIQ; Reynolds, 1988) ranging from 20–68 (X = 37.42, SD = 15.91). The remaining three adolescents had SIQ scores of less than 20.

Sampling

Adolescents were recruited through the Adolescent Medicine Department of a large, East Coast children's hospital and via area LGB agencies and signed consent forms before participating in the interview. The study was conducted with the approval of, and in accordance with, hospital IRB guidelines. Signs describing the study were posted in these settings. Youth who expressed interest in participating were screened using the BDI and SIQ. Three of the 13 adolescents responding to the advertisement did not meet study criteria (i.e., did not evidence clinically significant levels of depressive and/or suicidal symptoms). Those adolescents meeting criteria (n = 10) signed consent forms and underwent the interview.

Interview

The interview was semi-structured and included open-ended questions about five domains. The first domain referred to the adolescent's sexual orientation and included questions about attraction and self-labeling. The second domain included questions about family members’ responses to the adolescent's sexual orientation. For example, we asked, “How did the various people in your family react to discovering or hearing about your same sex orientation?” The third domain referred to how the adolescent understood the causes of his/her depressive symptoms/suicidal ideation. This section included questions such as, “What do you think has led you to feel depressed and suicidal currently and in the past?” In those cases in which the adolescent did not spontaneously mention her or his sexual orientation as a cause (n = 3), the interviewer followed up by specifically asking, “To what degree, if at all, do you think being LGB was/is related to your feeling depressed or having thoughts about hurting yourself?” The fourth domain addressed the potential role of parental support or rejection as a factor in the adolescent's psychological distress. For example, we asked questions such as, “To what degree, if at all, were you able to turn to your family members for support and comfort when you were feeling depressed and/or thought about death?” The fifth domain included questions about the adolescent's past experiences in counseling and current attitudes toward counseling, including family therapy.

The interviews were conducted by three interviewers. Two were female and one was male. Two were white and one was African-American. One interviewer was a Ph.D. student, another was an undergraduate, and the third was a faculty member. Interviews were conducted on-site (i.e., at the hospital or at the youth agency) in private rooms. The interviews lasted approximately one hour and were audio-recorded and subsequently transcribed.

Analytic Procedure

To analyze the transcripts, we utilized the Consensual Qualitative Research (CQR; Hill et al., 2005; Hill, Thompson, & Williams, 1997) approach. CQR is a method for organizing and making meaning of qualitative data. Typically, a small number of cases are analyzed to afford an in-depth understanding of each case. The method “incorporates elements from phenomenological (Giorgi, 1985), grounded theory (Strauss & Corbin, 1998), and comprehensive process analysis (Elliott, 1989)” (Hill et al., 2005, p. 196). Described as predominantly constructivist or interpretive in nature, with some postpositivist elements, CQR involves having judges identify core domains and specific ideas manifested in each participant's responses to open-ended questions and then develop categories to describe consistencies in core ideas across cases. Throughout this process, emphasis is placed on having judges reach consensus through discussion and reflection on the data. Such consensus contributes to the trustworthiness or validity of the data (Hill et al., 2005; Hill, Thompson, & Williams, 1997).

Developing of Domains

Domains are overarching clusters which provide a conceptual framework for organizing the large amount of data generated by open-ended interviews. The three primary members of our research team (i.e., judges) first generated five a priori domains (i.e., a “start list”) based on the structure of the interview protocol itself. Then they independently read through all of the interviews. During this process, each piece of potentially meaningful data appearing in the transcript, be it a phrase, sentence, or paragraph, was assigned to a given domain. In those cases in which data did not fit into one of the a priori domains, the judge proposed additional domains to reflect the emerging data and coded the data accordingly. Irrelevant information was placed into an “other” domain.

Once each of the judges had independently coded all 10 transcripts, the team met to discuss the coding. Through discussion, the team was able to reach consensus regarding an expanded list of domains that accounted for all relevant data found in all cases. Team members then went back and independently re-read the transcripts from all 10 cases. With the revised, expanded list of domains in mind, data were recoded and, when necessary, reassigned to other or new domains. The team then met again to discuss and resolve discrepancies regarding which data should be coded in which domain.

Constructing Core Ideas

Each judge independently read all of the data within each domain for each individual case separately. Each judge then identified what he or she considered as being the core idea associated with each unit of meaning (i.e., word, phrase, sentence, or paragraph).

Cross Analysis (Generating Categories)

Cross analysis involves looking across cases to determine whether there were core ideas which seemed to cluster into categories. Each judge independently examined all of the core ideas within a given domain across cases and organized the data into categories. The team then met to compare categories and reach agreement through consensus regarding which categories made the most sense and how to name them.

Auditing Data

Once the team had completed the tasks of generating domains, core ideas, and categories, the data were presented to an independent judge (i.e., auditor). The auditor had been involved with the planning of the study and interview process but had not participated in any of the earlier steps analyzing the data. So, despite being involved with the study, she was able to provide an independent perspective on the coding scheme. Feedback from the auditor was then discussed by team members and incorporated into the final list of categories. The final lists of categories appear under their respective domains in Table 1.

TABLE 1 Domains, Categories and Frequencies

Domain	Category/Subcategories	Frequency
Negative Life Events/Stressors
	Family nonacceptance, rejection, denial of adolescent's LGBT orientation/identity	General
	Nondisclosure related stress (i.e., fear of being discovered, hypervigilance)	Typical
	Religion/ethnicity/race/culture implicated in family rejection	Typical
	Societal homophobia (e.g., discrimination)	Typical
	Extra-familial (e.g., school, neighborhood) LGBT related victimization	Variant
	Lack of self-acceptance of sexual orientation/identity	Variant
	Non-LGBT related negative life events (e.g., poverty, loss of friends)	Variant
	Non-LGBT related lack of family support/protection	Variant
Explicitly stated causes of depressive/suicidal symptoms
	Family nonacceptance, rejection, denial and conflict associated with adolescents’	Typical
	LGBT orientation/identity
	Extra-familial (e.g., school, neighborhood) LGBT related discrimination and victimization	Typical
	Non-LGBT related negative family life events/processes.	Typical
Positive life events/strengths
	Positive family reactions to adolescent's LGBT orientation/identity (i.e., support, acceptance)	Typical
	Extra-familial (i.e., mother of friend, support group, friends) support.	Typical
	Stories of resilience (i.e., perseverance in the face of adversity)	Typical
	Self-acceptance/self-esteem	Variant
	Perspective taking/mentalization regarding parents’ experience and behavior.	Variant
Desire for change
	Wish or longing for greater closeness/acceptance regarding family relationships	Typical
	Hopelessness about change	Variant
Experience of and attitudes toward counseling
	Positive past or current experiences	Typical
	Negative past or current experiences	Variant
	Characteristics of counselor	Typical
	Interest in family therapy	Typical
	Lack of interest in family therapy	Variant

Determining Frequency (or Representativeness) of Each Category

In order to describe how representative each category was of the sample as a whole, we adapted Hill et al.'s (2005) convention of labeling categories as “general” (i.e., appearing in all or all but one of the cases), “typical” (i.e., appearing in at least half of the cases), and “variant” (i.e., appearing in less than half but at least two of the cases). Categories that appeared in fewer than two of the cases were dropped, in that they were considered idiosyncratic rather than representative of the sample. Frequency labels appear next to each category in Table 1.

Analyses were conducted by four judges, three of whom conducted the primary analyses and the fourth served as the auditor. Two of the judges were graduate students, one a psychology faculty member, and one a social work faculty member. Two identified as male and two as female. One judge identified as gay, one as lesbian, one as bisexual, and one as heterosexual. Three were white and one African-American.

RESULTS

Negative Life Events/Stressors

The adolescents in this study reported having experienced multiple life stressors, some of which were specifically related to their sexual orientation. For example, all but one of the adolescents reported experiencing family nonacceptance of his/her sexual orientation. In some cases the nonacceptance was blatant, explicit, and intentionally hurtful. For example one of the girls reported, “My biological father got upset and physically attacked me. My mother was like, ‘What do you do, bump cootchies all night?’” In other cases, the nonacceptance was less aggressive but had a dismissive tone, as when parents told their adolescents, “It is just a stage and you will grow out of it soon.” In yet other cases, the nonacceptance was more subtle and even unspoken, though evident nonetheless. For example, one girl reported, “My mom doesn't say anything negative, but I can see it in her face. When I bring up my girlfriend in conversation—me and my girlfriend have been going out for about a year and a half now and my mom, she knows—and she says that she doesn't really have any feelings about it but just in her face, if I bring it up you can just see this sadness come over her.”

More than half of the adolescents reported suffering from nondisclosure related stress—a fear of being discovered by those who did not yet know of their sexual orientation. For example, one adolescent said, “The fact that some people in my family don't know does causes me stress … Sometimes when I get upset I tend to say the wrong things and I’m afraid one day if I get upset that's just going to come out of my mouth and then they are going to be surprised and shocked and they’re going to say that they didn't know … I am afraid it might come out the wrong way at the wrong time. I am also worried that they might find out from somebody else, so I take precautions.”

In more than half of the cases, adolescents referred to their families’ religious beliefs or cultural backgrounds as contributing to the family's nonacceptance and their own nondisclosure. As one adolescent described, “They don't like it because they are Christians. Gay people go to hell and burn there forever and ever.” Another adolescent reported that her Muslim cousin told her, “Out of everything, that's the worst sin! It is a sin in all religions—you are going to hell.” Another described why he did not want certain members of his family to know he was gay. “I don't tell my Jamaican side of the family. They would kill me.”

Comments about societal homophobia/discrimination were also typical. One adolescent girl who joined her high school boys’ football team reported that the coaches at first told her that she couldn't try out for the team: “… once they realized they couldn't stop me, they would hide my uniform, send me to the other end of the field to practice kicking … it was humiliating.” Another adolescent girl described how “… it's just hard, everybody telling you it's [being lesbian] wrong and all.”

In four of the cases, homophobia manifested itself as victimization. One of the boys in the study described why he typically carried a knife with him. “I carry a knife because I've been bashed before … I carry a big knife. You know, the one with the square on the tip … a meat cleaver … I’m not getting bashed again … it was 2 or 3 years ago when I was in high school.” Another boy talked about his experience having to fight every day to protect himself. “When I was growing up I had to fight and stuff … I had to fight at school and in the neighborhood … I had to fight up and down the block … all through life.”

Two of the adolescents reported having trouble accepting themselves as being gay. As one teen put it, “Right now, I’m not really, I don't really accept it … it feels like there's a weight on me.” The other adolescent, speaking about the hardships of being gay, lamented, “I wouldn't choose to be gay. I’m not going to lie. I really did try to be straight because I don't really want to live my life worrying about this and that.”

Not all of the negative life events/stressors mentioned were related to adolescents’ sexual orientation. Four of the teens mentioned non-LGBT related negative life events such as the death of friends or family members, economic hardship, and rape as having affected them. Two of the adolescents noted non-LGBT related lack of family support/protection as particularly stressful for them. For example, one youngster described how her mother forced her to go to the funeral of the man who had raped her when she was younger. Another participant, who had been adopted by friends of the family shortly after her biological family had been killed in a fire, described how, as a stepchild, she felt uncared for and unprotected. She described how her step-siblings psychologically and emotionally abused her, including teasing her that her parents were “burned up.”

Explicitly Stated Causes of Depressive/Suicidal Symptoms

When asked specifically what they thought was causing their depressive/suicidal symptoms, six of the adolescents attributed their symptoms to lack of family acceptance and/or family conflict regarding their sexual orientation. For example, one of the lesbian participants reported, “My mother is not even willing to talk to me about it openly or go to a PFLAG [Parents, Families, and Friends of Lesbians and Gays] meeting with me. She's like ‘that's disgusting, nasty. If you were a boy, I would have killed you by now.’” Another participant described a more subtle form of nonacceptance and its impact on her welfare. “You know what's crazy, sometimes parents get sad when their kids are gay or lesbian because they worry that their kids are going to have a hard life but then they don't realize that their [parents’] being sad is what makes it hard for their kids.”

Five of the participants pointed to extra-familial LGB related discrimination and victimization as playing salient roles in their psychological symptoms. One participant described the impact of having a close friend killed because he was gay. “I found out I was gay at 17 and then I had a friend who was killed because he was gay … somebody didn't like it. They all thought he was straight and then somebody told them that he was gay and so they killed him … that made me feel depressed and I started seeing a therapist for it … I’m still seeing a therapist for it.” Another adolescent lamented, “I still sometimes get down because I just can't walk around and be myself. Everywhere you go somebody will say something … well, they don't really say it to me but they say it to my friends. They call them faggots and these other kinds of names, like sissy and this and that … People at school would say to me, ‘Oh, I knew you were a faggot’—It's really frustrating because you can fight some people, but after a while you just get tired of fighting every day and it just becomes so much you have to deal with on your own and then nobody understands.”

Five of the participants cited non-LGBT related negative family life events/processes as contributing to their psychological distress. One adolescent described the impact of the incarceration of her older brother on her mother and, in turn, on the rest of the family. “My brother being in jail has made my mother really sad, and it's bringing everybody else down. Like, when my mom gets depressed or down it impacts on us because we’ll ask her ‘what are we doing wrong’ and she’ll just scream ‘nothing’ … that makes me mad.” Another adolescent attributed his depressive symptoms to the death of his father. “The main thing is probably the loss of my father overall … that would probably be the main thing that caused it.” Another adolescent attributed her distress to the economic hardship she and her family were facing and the pressure to get a job. “My mom says, ‘you need to go get a job.’ Sometimes I wish that I was so rich that I could support me, my family and my friends … that would be a perfect world, but it's not going to happen, not yet.”

Positive Life Events/Strengths

Our analysis uncovered many examples of positive life events and personal strengths. For example, eight of the ten adolescents described experiencing at least some positive family reactions to their sexual orientation/identity. As one adolescent described, “My mom had a talk with me and let me know good things … that she supported me. That it doesn't matter, she still loves me no matter what and that I’m still her child.” In some cases, family support seems to have evolved over time. “My dad, he gave me a hard time at first, for like a week. After about a week or so he got over it and now is O.K. with it.” A couple of adolescents emphasized how critical their family support is in terms of buffering them from outside negative forces or from other family members who are less accepting. “My mom accepts me for who I am … my family ‘has my back’ (i.e., will defend me). It was a relief when my mom reacted so understandably … My dad said that if anybody hurts me, he would kill them.” Along the same lines, another adolescent reported that her aunt and grandmother told her, “whatever makes you happy” and were instrumental in protecting her from her mother's criticism and sarcasm.

Five of the adolescents also reported significant, meaningful extrafamilial support. One of the participants who had experienced discrimination upon trying out for the school football team reported that her school's athletic director had told her, “From now on, I’ll be on your side because I see you really want this.” This same adolescent also reported having an advocate from the local LGBT youth organization who had met with school officials on her behalf. Other adolescents pointed to their peer/friend network as being instrumental. “I have my friends and that's like my family, I have a whole bunch of friends who are like my family.” Others found strength in romantic partners: “I have my girlfriend … she is my main supporter.”

The narratives from five of the adolescents revealed remarkable stories of resilience. When talking about her experience of trying out for the boys’ football team, this adolescent recounted how “they told me I couldn't do it but I didn't care and I made the team … they put me at the end of the field and made me practice by myself but I came to every practice.” Another adolescent recalled how she persevered in helping her father go through the acceptance process. “I gave him books and got him more educated, statistics and everything. I answered any questions he had.” Another adolescent, after speaking about the negative life events he had experienced, stated proudly, “I never look at myself as a victim … it's always a learning experience.”

Less frequent were explicit statements regarding self-acceptance. “There is nothing wrong with me! Being gay is part of who I am.” Another adolescent took it one step further: from acceptance to affirmation. “Being gay is the happiest thing in my life … Having access to that community! … I swear, I feel bad for straight people sometimes because when you are queer … there are so many things that are put out there today for queer, gay, lesbian, bisexual and trans youth. If you’re not queer, it's like you’re missing out on so much … That's why I love fags so much. It just reminds me about the good things about being gay.” Another adolescent proclaimed, “People love me … It's not hard for me to make friends—I’m funny, people like hanging around me, and I give good advice.”

Another strength evident in four of the narratives was adolescents’ ability to reflect empathically or “mentalize” regarding their parents’ experience and behavior. For example, one adolescent described, “At first, my father felt disappointment in himself as a parent … that having a kid was gay indicated that he had messed up … I realized that everyone goes through their own struggles and when you come out, other people come out too. The first step is to realize that you are not the only one going through something.” Another adolescent exhibited understanding and empathy regarding her parents’ off-handed, sarcastic comments. “I don't think they mean to intentionally make me feel bad by joking, it's just their way of dealing with it.” Yet another adolescent made the connection between his mother's own upbringing and the way she approached him. “I think my mom went through a lot a as a child that made her close down. She is not very strong.”

Desire for Change

One of the more consistent themes running across the interviews was adolescents’ wish or longing for greater closeness and acceptance in their family relationships. As one adolescent said, “I wish my mother could accept me … could understand me more.” Yet another adolescent said with sadness, “I wish my Mother and I were closer … I wish I could tell her my secret and that we could start over … That she would accept me. I can't now because I don't feel safe.” Yet another adolescent lamented, “I shouldn't be able to talk to my friend's mom more than I can talk to my own mom. … I think my life would have been much better if I had had my family.”

Alongside this longing for greater closeness and acceptance, we found that three of the adolescents also expressed hopelessness regarding the possibility of change. One adolescent said, “My parents are negative. It's not going to change. I don't think it will ever change.” Another adolescent conveyed the process he had gone through—from hope to hopelessness. “At one point I wished my dad would become more accepting but, now, I really don't care anymore.”

Experience of and Attitudes Toward Counseling

Nine of the participants had had some experience with counseling/therapy. Eight of the adolescents reported positive past or current experiences. One participant reported that she currently goes to therapy and that “it relieves my stress … makes me feel like I’m opening up more and not holding things in.” Perhaps the most enthusiastic endorsement of counseling came from this adolescent, who stated, “I have been in both individual and family therapy … I love it. We talk about everything and it helps me to get deeper. The counselor is really helpful!” Another adolescent explained that the counseling “made me feel better … realize that I was not the only one like this (i.e., lesbian). I could finally sit down and talk with somebody who would actually listen.”

Two adolescents reported having had negative past or current experiences in counseling. One adolescent reported that he went “but it didn't help. We talked about ‘dumb’ stuff.’” Another participant angrily recounted, “The LGBT issue never came up. I was around 13 when I was coming out and that was part of my acting out. … I didn't think it was worth bringing up because he [the therapist] didn't understand me or what I was going through. He tried to tell me I had the same problems as everybody else does … Once, when I tried to bring it up, he changed the topic.”

Five of the adolescents commented about specific characteristics of the therapist. All expressed an interest that their therapist be “gay or LGBT sensitive.” One adolescent reported feeling comfortable after finding out that her therapist's daughter was also lesbian.

Because of our expressed interest in family based treatment models, we specifically asked adolescents if they had participated in family therapy or would be interested in participating in family therapy. Seven of the ten adolescents expressed an interest in family therapy and thought that it could have been, or could be in the future, productive/important for them. “I would have wanted to have had family therapy to work on our family relationships … we really haven't had a chance to get our bond back … It's hard, even today, to tell my mother stuff. I am afraid that if I tell her stuff, she will look at me differently.” In the words of another adolescent, “If we (i.e., my mother and me) could use the therapy to work out our relationship, then that would be the most important thing in the world to me.” Another participant said, “I would be willing to participate in family therapy with my mother … She is the seed of all of my problems, her not accepting my lesbianism … I don't trust her.”

Two adolescents, however, expressed a lack of interest in family therapy, or at least some reservations. One of these adolescents reported that she was not sure she would have gone to family therapy. “My mother doesn't react well when she feels criticized on attacked. She would be afraid of being criticized.” The other adolescent simply stated, “I would not have considered family therapy.”

DISCUSSION

Whereas numerous cross sectional studies have documented that LGB adolescents are at heightened risk for depressive symptoms and suicidal ideation, to our knowledge this is the first study to examine how LGB adolescents themselves understand what causes their depressive and suicidal symptoms. Adolescents reported three main categories of causes: family rejection of sexual orientation, extra-familial LGB related victimization, and non-LGB related negative family life events. All three of these categories were identified by at least half of the sample. The fact that family rejection of sexual orientation was mentioned as a catalyst of depressive or suicidal symptoms in most of the cases was not surprising. Past cross-sectional studies have shown that family rejection and abuse are prominent risk factors for depression and suicidal ideation among adolescents in general (Wagner et al., 2003) and that family rejection and abuse related to sexual orientation have been associated with depression and suicidality among LGB adolescents (D’Augelli et al., 2005; Remafadi, 1991; Ryan et al., 2009).

Interestingly, in this study, family rejection of sexual orientation took on a number of forms. In some cases, adolescents’ spoke about blatant and harsh rejection, including instances in which parents used derogatory language or cut-off relations with the adolescent altogether. In other cases, rejection was more subtle and communicated in a non-verbal manner, as reflected in one adolescent's account of the “sadness and disappointment” she saw “cross her mother's face.” Parents’ subtle perhaps unconscious rejection of their children's minority sexual orientation has been mentioned in literature (Maurer, 2007), and has direct clinical implications when working with LGB adolescents and their parents. For example, identifying and making family members aware of what may be fleeting, unintentional yet significant interactions conveying disappointment, disapproval or rejection may be an important step in transforming the nature of family relationships.

It is worth noting that in half of the cases, adolescents attributed their families’ rejection, at least in part, to religious beliefs. This finding is consistent with literature linking certain religious doctrine, institutions and figures to anti-gay, homophobic messages (Halstead & Lewika, 1998; Kubicek et al., 2009; Ward, 2005). In our clinical work, we have found anti-gay religious beliefs to be one of the most intransigent obstacles to family acceptance. Helping parents and other family members reconcile their religious beliefs with their love, concern for and acceptance of their child is an enormous clinical challenge.

Our finding that LGB related victimization outside of the home was typically cited as a cause of depressive or suicidal symptoms was expected. As noted in the introduction above, sexual minority adolescents experience more frequent and more violent victimization than heterosexual adolescents and there is evidence that discrimination and victimization play an important role in depressive symptoms and suicidality. The experiences of discrimination and victimization described by the adolescents in this study ranged from invalidation to public humiliation to being terrorized and even fearing for one's life.

Our findings also remind us that, for these youths, it is not all about their sexual orientation. Many reported that non-LGB related negative events, including poverty and the incarceration or death of a family member, were related to their depressive and suicidal symptoms. These findings echo findings from previous research suggesting that negative life events, particularly in conjunction with low self-esteem (Auerbach, Abela, Ho, McWhinnie, & Caizowska, 2010) or low problem solving capabilities (Adams & Adams, 1996), are related to depression and suicidal ideation among adolescents. It is worth noting, however, that the impact of negative life events seemingly unrelated to minority sexual orientation may, in fact, interact with LGB related variables, such as internalized homophobia or rejection. For example, one adolescent in this study reported that the primary cause of his suicidal ideation was his biological mother's death years earlier. However, later in the interview, this same youth reported that he was sure that if his mother was alive today, she would accept him totally despite the fact that he was gay, suggesting that there may be a link between his current experience of LGB related rejection and the impact of his mother's death.

Alongside reports of family rejection and negative life events, eight of the ten adolescents described experiencing at least some positive, supportive family reactions to their sexual orientation. In some cases, such family support existed from the moment of disclosure. In other instances, it seemed to evolve over time. Regardless, reports of support are encouraging in light of the literature illustrating that family support can moderate or buffer against the negative effects of gay-related victimization (D’Augelli, 2003; Evans, Hawton, & Rodham, 2004). One reason may be that parental support translates into protection and advocacy. As one adolescent put it, “My family has my back [i.e., will defend me] if anybody ever gives me a hard time.” Another reason may be that parental support leads to increased self-esteem and a greater sense of competency which, in turn, increases resilience (Anderson, 1998). More importantly, almost all of the adolescents who reported suffering from family rejection also reported experiences of family support, suggesting that these are not two opposite poles of a single dimension but rather two different and somewhat independent variables. This finding has implications for future research on family processes.

Half of the adolescents reported feeling supported by people outside of their family. In some cases the support came from school personnel, in other instances from peers and in yet other instances from romantic partners. Research suggests that such extra-familial support is critical. In a study of sexual minority high school students, the combined social support of mothers and peers was found to almost completely mediate the relation between sexual orientation status and both depressive and externalizing symptoms (Williams, Connolly, Pepler, & Craig, 2005). Along the same lines, research on Gay-Straight Alliances (GSAs) in high schools suggests that the presence of a GSA predicts lower rates of victimization and suicidal behavior among LGB youth, as does the belief that there is a school staff person one could talk to if there was a problem (Goodenow, Szalahka, & Westheimer, 2006), although the exact mechanisms by which GSAs work have yet to be identified (Walls, Kane, & Wisneski, 2010).

The results of our study also suggest that suicidal and depressed LGB adolescents may be more resourceful and hardy than first meets the eye. Our participants described overcoming heterosexism, discrimination and even victimization, sometimes through pure determination and persistence. Along the same lines, there were expressions of self-acceptance and pride about being gay. These findings echo the findings from studies on nonclinical LGB youth who, on the whole, perceived themselves to be “strong competent individuals who felt good about themselves and had control over their lives … They viewed being gay as a source of strength and reframed their sexual orientation in a positive way” (Anderson, 1998, p. 65).

The finding with perhaps the most important clinical implications was that most of the adolescents reported wishing that their relationships with their parents were closer and more accepting. This finding is consistent with anecdotal reports in the literature illustrating adolescents’ desire for parental acceptance and love, even in the face of extreme parental rejection and neglect (Savin-Williams & Ream, 2003). Not only did adolescents express a desire for increased closeness with their parents but they evidenced an empathic and sometimes complex understanding of the distress their parents were experiencing, and how such distress was related to their parents’ own childhood history. Such findings are not unique. In a sample of nonclinical LGB youth, Floyd et al. (1999) found that between 5% and 8% of the sample expressed empathy for their parents’ struggle to cope with their minority sexual orientation.

In recognition of the difficulties most parents experience upon learning of their child's same sex orientation, and the importance of parental acceptance in relation to the adolescent's welfare, some have suggested that family therapy may be the vehicle of choice for helping parents and adolescents navigate the coming out process and subsequent tensions (Saltzburg, 1996). Whereas two of the participants indicated that they would not be interested in family therapy, seven of the ten adolescents in our study indicated that they would be interested in participating in family therapy in order to improve their relationships with their parents. As one participant stated, “If we (i.e., my mother and me) could use the therapy to work out our relationship, then that would be the most important thing in the world to me.”

The methodological strengths of this study increase our confidence in the validity of our findings. For example, the inclusion criteria were well defined (i.e., self-identified LGB and clinical levels of depressive and/or suicidal symptoms). While such criteria made recruitment more difficult, it contributed to the internal validity of the study or the degree to which the specific phenomenon of interest was captured. Also, the emphases on consensus and monitoring during the data analytic process contributed to the trustworthiness or convergent validity (or reliability) of the findings.

Alongside these methodological strengths, however, were some methodological limitations. First and foremost was the size of the sample. While some coders felt as if they had reached saturation by the fifth transcript, and a sample of 10 is considered reasonable in the context of such labor intensive work (Hill, Thompson, & Williams, 1997), additional participants would have increased our confidence in the stability of the findings and afforded us the opportunity to examine potential moderating variables, such as gender or type of sexual orientation. For example, only one participant was both gay and transgender. The lack of representation of transgender people precluded our ability to examine unique themes relevant to this population. Another limitation involved the sampling procedure. It may be that adolescents presenting at a department of adolescent medicine differ from those recruited from LGB centers. Unfortunately, the sample size was too small to explore whether referral source was related to reported causes of distress. Finally, while all of the participants suffered from clinical levels of depressive symptoms, only 7 of the 10 exhibited clinical levels of suicidal ideation. It is not clear if the experiences of these three “nonsuicidal” adolescents were qualitatively different from those of the other seven participants and whether such differences may have influenced the results. Perhaps those with current suicidal ideation were suffering from current environmental stresses, such as family conflict, but research using larger samples would be required to examine such hypotheses empirically.

Despite these limitations, this study provides the first qualitative data on how LGB adolescents understand the causes of their depressive and suicidal ideation. Findings strongly implicate the role of family rejection and victimization. The adolescents in this study clearly stated a desire for improved relationships with their parents as well as a willingness to participate in family therapy designed to improve adolescent-parent relationships and increase acceptance. These findings have important clinical implications and emphasize the importance of initiatives to develop effective family-based programs (Ryan et al., 2009) and treatments (Diamond, Diamond, Levy, Closs, & Lapido, under review; Stone-Fish & Harvey, 2005).

Acknowledgments

This study was supported, in part, by a grant from the American Foundation for Suicide Prevention.