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Adolescent homosexuality: we need to learn more about causes and consequences

K Berg-Kelly

Institute for the Health of Women and Children, Medical Faculty, Go¨ teborg University, The Queen Silvia Children’s Hospital, Go¨ teborg, Sweden

Berg-Kelly K. Adolescent homosexuality: we need to learn more about causes and consequences. Acta Pædiatr 2003; 92: 141–144. Stockholm. ISSN 0803-5253

In this issue a descriptive study of various aspects of homosexual orientation among adolescents is presented. In agreement with previous American studies, the authors identify three separate domains of homosexuality: attraction, fantasy and self-identification. This knowledge is important in understanding an adolescent struggling with homosexual thoughts.

Conclusion: The development of an homosexual identity is a process connected with serious health hazards related to both physical and mental health. Most adolescents are not given adequate support because heterosexuality is considered the norm in most cultures.

Key words: Adolescence, homosexuality

The world history of homosexuality has still to be written, but in the meantime we can study what the Berkeley-based sociologist Manuel Castells has to say (1). According to him, patriarchy, which is the dominant organizational structure in the world, requires compul- sory heterosexuality. Civilization is based on taboos and sexual repression. The regulation of desire underlies social institutions. This coherent system of domination, however, has one weak link: the assumptions of heterosexuality. If this assumption is challenged, the whole system of patriarchy crumbles. While historical accounts show permissiveness for male homosexuality in some cultures, particularly in ancient Greece, lesbianism was severely suppressed throughout most of human experience. Male homosexuality was gen- erally confined in time and space by knowingly ignoring adolescent impulses or hidden expressions in specific contexts. Because men kept their gender, class and race privileges, repression was, and still is, highly socially selective. Yet, the fundamental norm of patriarchy was, and is, organized around the heterosexual family, occasionally allowing for same-sex desire in men, as long as it could be kept hidden from society. This pattern still dominates in most parts of the world. Homosexuality is not generally an acceptable form of sexual expression or lifestyle. Acceptance is often dependent on the status and context of those practising it, and homosexuality usually remains out of sight. This pattern was first challenged in the USA around 1970. It started as a strong movement defending the sexual rights of gay and lesbian populations, involving

2003 Taylor & Francis. ISSN 0803-5253

groups that are outspoken opponents of the patriarchal society. They are often linked to feminist and queer movements, and as such have met much resistance. The development and the pace in different parts of the world differ. As is often the case with taboo-breaking move- ments and radical solutions, the academic, the urban and the young sections of populations have been the first to change traditions. According to several reports, accep- tance and visibility seem to have increased to a great extent in the past decade. Homosexuality was declared a disease in the Diag- nostic and Statistical Manual of Mental Disorders III (DSM III). It was removed from the manual in the USA in 1973. However, the homosexual lifestyle is generally difficult and requires considerable personal stamina. Many interesting and illuminating witnesses of the difficulties of homosexuality can be found within the cultural sphere that is obviously a free zone where homosexuality is acceptable. With the exceptions of Frederik II of Prussia, Sapfo from Lesbos in ancient Greece and Selma Lagerlo¨f from Sweden, few wit- nesses are available from the political and business worlds, or from lesbian women. Publicly known gay artists include Leonardo da Vinci, and in modern times Andy Warhol, Robert Rauchenburg, Keith Haring and Jean-Michel Basquiat. Early examples of authors are Oscar Wilde and Selma Lagerlo¨f. Gertrude Stein in Paris is another famous person with much influence on the publishing of modern literature. Performing artists include the film actor Rock Hudson, the film maker Rainer Werner Fassbinder and the ballet dancer Rudolf Nurejev. The fashion world contributes names such as


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ACTA PÆDIATR 92 (2003)

Giorgio Armani and Yves St Laurent. In Sweden, two

popular lesbian singers have recently engaged in a legal

partnership, and so have two gay actors, and this has

sent an important message to Swedish society.

Authors, poets, film directors and other artists have

always been able to use sensitive material to discuss

problems for both everyday and high-brow audiences.

Fiction provides interesting insights. James Ellroy is an

American crime author who specializes in the violent

days of Los Angeles in the early 1950s. In The big

nowhere, the main police detective commits suicide

about two-thirds of the way through the novel, when he

finally accepts that he is gay at the age of 27. This gives

the rest of the novel a rather strange twist, with the hero

already dead. Two recent movies both use the word

“cry” in the titles, thereby indicating the sadness of the

stories. One is The crying game, about a black homo-

sexual soldier, and the other is Boys don’t cry, about a

lesbian girl who leaves her conservative family and

town dressed as a boy, makes love to girls in this

disguise and eventually is killed when her story is


One of the greatest film successes in recent years in

Sweden is a film dealing with the discovery of homo-

sexual feelings during adolescence. Lukas Moodysson’s

film Fucking A ˚ ma˚ l tells the story of two 16-y-old girls

who start a lesbian relationship in the small rural town

of A ˚ ma˚ l. The film is funny, serious and sad. It could

easily be used to facilitate discussions among adoles-

cents, parents and others concerned. The neutral English

title is interesting in this connection: Show me love.

The majority of adolescents will continue to grow up

in societies where homosexuality is a shameful,

invisible infliction suitable only for the alleys and

backstage of society.

There are serious problems facing an adolescent who

identifies homosexual feelings. The risks for negative

health outcomes are found in several domains.

The classical Kinsey Reports state that 2% of adult

women and 4% of adult men reported being exclusively

homosexual (2, 3). However, as also originally

described by the Kinsey group, being exclusively

homosexual is just one aspect of homosexuality. The

proportion of adult males who have had at least one

homosexual experience is reported to be 37% (2). There

is a whole spectrum of sexual behaviour from exclu-

sively heterosexual to exclusively homosexual. The

development of the homosexual identity presumably

starts in childhood and is fairly settled by early

adolescence (4, 5). Bisexual experimentation is prob-

ably the most common activity.

In our own studies of adolescent health and health

behaviour, we ask one question on homosexuality:

“Have you had thoughts about being homosexual?” The

respondent has five options, the first two being: “I know

I am homosexual” and “I think I might be”. In the 1994

study, 2% of 1740 15.7-y-olds and of 890 18.0-y-olds

answered yes to these two options (6). There were no

significant gender or age differences. The trend was

similar in surveys from 1990 onwards. In 1998, how-

ever, the proportion acknowledging these two options

had doubled, and more so for girls than for boys

(unpublished data). In a recent Swedish study from a

multicultural suburb, 14% of 17-y-olds reported homo-

sexual or bisexual experiences, a substantial increase on

studies conducted by the same group in 1992 with the

same questions (7). A similar trend towards many more

people reporting homosexual orientation and behaviour,

and in particular bisexual activities, is evident in other

recent Swedish studies of all age groups.

There exist numerous other papers, particularly of

American origin, with epidemiological data on adoles-

cent homosexuality. In this issue of Acta Paediatrica

Narring et al. make an important contribution to the

studies in this field in Europe, exemplified by Switzer-

land (8). This study is descriptive and of great interest

because it not only gives the percentage of people who

identify themselves as homosexuals, but also describes

the various aspects of being or becoming homosexual,

inspired by American theories in this field. Therefore, it

adds to our knowledge of what adolescence is and how

young people handle homosexual feelings. Similarly to

several American studies, Swiss youth belonged to three

different homosexual domains. The domains are

described as homosexual self-identification, fantasies

and attractions, not necessarily overlapping. The study

shows that sexual behaviour or self-identification alone

is a poor measure. The increasing trend towards bi-

sexual contacts seen in Swedish studies is not evident in

the Swiss population.

It is not easy for adolescents to adopt a sexual identity

that means marginalization in most societies. They face

several threats to their health. For this reason, every

physician who comes in contact with troubled young

people must be sensitive to this problem, and be able to

introduce discussions when appropriate, offering con-

fidentiality and support in these interactions. Growing

up recognizing homosexual feelings is a threat to both

the physical and psychosocial health of the individual.

One threat concerns psychosocial health. Adoles-

cence is a transitional stage characterized by becoming,

not by being. One of the key areas is to become a sexual

person. Identity work is performed in context with

peers, parents and other important people. This im-

portant self-definition is seriously hampered when a

young person discovers personal feelings that differ

from those of mainstream society. He or she quickly

realizes that such desires are not valued by the society at

large, and will commonly feel alienated. His or her

feelings should be concealed and not discussed with

peers. It is not easy to find a support group in most

societies. Most youngsters realize that this disclosure

will be hard for parents to accept. Even youngsters who

have loving relationships with their parents are afraid to

tell them. Depression, suicide and suicidal attempts are

overrepresented among homosexual youth (for refer-

ACTA PÆDIATR 92 (2003)

Adolescent homosexuality


ences see ref. 4). A recent study found that victimization

at school appears to be the mediating factor for negative

outcomes regarding psychosocial health (9). This is an

example of the importance of peer acceptance as a

health-promoting factor for adolescents.

Victimization at school, and in the streets and parks

can be both physical and mental. Being subjected to

violence is a reality. Murders of homosexual youths are

extreme examples, often perpetrated by extreme right

radical groups.

Physical health also concerns the risk of contracting

the human immunodeficiency virus (HIV), which is a

well-known complication of homosexuality. Other

sexually transmitted diseases (STDs) are common.

The HIV epidemic has made it necessary to break

cultural taboos regarding adolescent sexual behaviour.

However, in many parts of the world discussing even

mainstream sexual behaviour of adolescents is unac-

ceptable. Sexually liberal countries such as Sweden still

publish local surveys without including questions on

homosexual orientation.

Another threat to health is social marginalization.

Self-medication with drugs is one resource for troubled

young people. Dropping out is a common negative

reaction to being bullied in school. Looking elsewhere,

outside familiar circles, poses threats. The back alleys

of society are never safe, and becoming involved with

drugs is a real danger.

So what has happened over the years regarding the

provision of support to adolescents with homosexual

inclinations? Not much, despite solid data on health

problems reported from the USA, where the acceptance

of homosexuality has probably been the highest, with

most western European cultures following suit some

decades later.

It is beyond the scope of this commentary to survey

support options in this area. Any person concerned with

the problem should investigate their local services.

Information and discussions around homosexuality

should be part of health promotion in school, but is

this happening? Sweden has a long tradition of excellent

health promotion in schools, but is falling behind

according to personal and governmental reports. Not

all students even receive a basic education in this area.

Homosexual themes may be handled in some schools as

theme days, with invited representatives from gay and

lesbian organizations. Adolescent clinics including

special services for boys and young men report seeing

those who have already come out and are at ease with

their sexuality but want STD screening. Many health

workers feel that the internet and various web sites are

the main source of information for young people

reflecting on their problems. Several gay and lesbian

organizations offer chat sites for young people, but the

quality of support and advice in some of these web sites

is often questionable.

Furthermore, if a paediatrician who is eager to learn,

where can the relevant skills be acquired? The easily

accessible material varies widely in both quantity and


Over the years American paediatric textbooks have

improved their coverage of adolescent homosexuality,

but there are still examples of American textbooks from

the 1990s that omit this subject. A European example is

the Nordic textbook in pediatrics, the latest edition of

which was published in 1993 and does not cover this

area at all. The latest Swedish paediatric textbook,

published in 1999, contains no information on the

subject. Both of them cover HIV and AIDS, but only as

a maternal problem regarding newborn infants.

Textbooks on adolescent medicine are more adequate

in this area; however, my co-worker in the Swedish

textbook on adolescent medicine covers the subject on

less than one page. My favourite textbook on adolescent

medicine by McAnarney et al., published in 1992, is

now old but nevertheless has several informative

chapters and discussions on the subject (10). Neinstein’s

practical guide to Adolescent health care, latest edition

published in 2000 (11), is to the point, with 15 pages on

adolescent homosexuality (compared with 12 pages on

adolescent sex, 20 on adolescent pregnancy and 72 on

contraceptive methods). The general impression after

reading about homosexuality in textbooks is that the

risks and negative outcomes are overwhelming. For

those eager to learn more, papers of general interest

have been published by several authors, including G

Remafedi, ST Russell, RC Savin-Williams, J Hunter

and M Rosario. There is even a moving personal report

of the difficulties faced by a gay paediatrician (12).

Now it is time for physicians in any speciality who

deal with adolescents to make themselves familiar with

homosexuality. We have learned long ago to look for

sexual abuse, including incest, as a possible background

cause in adolescent depression, suicidal ideation, eating

disorders, drug abuse, school dropout and related

serious health problems. Unresolved homosexual iden-

tity problems and outright victimization of adolescents

who have come out need to be added to that list of

suspicion when meeting adolescents with poor mental

health. Skills to learn include diagnostic interviewing,

outcome and the necessary support for the young

person. Support for his or her family is equally

important. If the physician is not comfortable with the

issue, he or she must identify capable community

groups. Interviewing should be performed in a sensitive,

non-judgemental and supportive way, for example by

phrasing questions in such a way that heterosexuality is

not presumed.

Maybe it is still too early to pay attention to the

positive aspects of homosexuality. Many of our greatest

authors, artists and other great personalities have been

homosexual, maybe because of the creative environ-

ment around some homosexual groups. Identification of

locally or internationally successful gay and lesbian

personalities may help young people who are struggling

with their sexual identity. Pride festivals carried out


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ACTA PÆDIATR 92 (2003)

once a year in major cities are not enough. Maybe,

hopefully, times will change and homosexuality may

not be such a difficult and risky identity to accept in the



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Received Sept. 16, 2002; accepted Sept. 19, 2002

K Berg-Kelly, Drottning Silvias barn- och ungdomssjukhus, SE-416

85 Go¨ teborg, Sweden (Tel. 46 31 343 4668, 343 4662, fax. 46 31 843 010, e-mail. or kristina@bob-