Treating families as allies, not enemies

When families reject their LGB adolescents by telling them the way they act is shameful, excluding them from family activities, or similar behaviors, the young people are more likely to have health and mental health problems in early adulthood. This may seem obvious, especially to the LGBT community, but a paper published this month in the journal Pediatrics quantifies the impact in a way that could have a dramatic effect on how parents and healthcare providers relate to and support LGBT youth. Dr. Caitlin Ryan and her team at the César E. Chávez Institute of San Francisco State University have found that LGB young adults who reported higher levels of family rejection during adolescence were: * 8.4 times more likely to report having attempted suicide; * 5.9 times more likely to report high levels of depression; * 3.4 times more likely to use illegal drugs; * and 3.4 times more likely to report having engaged in unprotected sexual intercourse, compared with peers who reported no or low levels of family rejection. The study was based on a survey of white and Latino young adults, ages 21-25, recruited from diverse venues in and around San Francisco. Carolyn Laub, executive director of California's Gay-Straight Alliance Network, explained why Ryan's research breaks new ground. "For too long, we've served LGBT youth without involving their parents, often because we have feared the parents would reject their child. But to insure that LGBT youth develop into healthy adults, we need to involve parents, teaching them how their acceptance of their child impacts their health outcomes," she said. She added, "Caitlin Ryan's research changes the paradigm for how we think about serving LGBT youth in the context of their families, and will have a profound impact on the safety and health of LGBT youth. These findings need to be shared with everyone who works with youth and their families." Laub said the GSA Network will be exploring how parental involvement can support their own work of empowering students. The paper forms part of Ryan's ongoing Family Acceptance Project (FAP), a research, intervention, and education initiative she developed with colleague Rafael Déaz in 2001. From the start, Ryan and her team designed the FAP with the involvement of LGBT youth and family members, as well as healthcare providers, educators, and organizations like the Gay-Straight Alliance Network and the Bay Area's Adolescent Health Working Group. Ryan said this participatory approach helped ensure a more representative and culturally sensitive program. The initial phase of the FAP was a series of in-depth, qualitative interviews with white and Latino LGBT adolescents and their families across California, in both English and Spanish. The families covered a mix of all socio-economic classes, including immigrant families and urban, suburban, and rural households. Based on the two- to four-hour interviews, Ryan and her team identified 106 different behaviors that parents and caregivers use to express rejection or acceptance of their LGBT adolescents, for example, excluding them from family activities or looking for positive LGBT adult role models. They then developed measurement scales for each of these actions. To test their framework, they recruited a sample of LGBT young adults, and surveyed this second group about their families' reactions to their sexual orientation and gender identity/expression during their teen years. This formed the basis of the Pediatrics paper. Ryan is now planning several more research papers based on the FAP, on the impact of reparative therapy, school victimization, and the role of religion, among other topics. Ryan has made a point to look across the entire LGBT spectrum. For the Pediatrics paper, however, she was asked by the reviewers to focus on sexual orientation. About 10 percent of the youth in both phases identified as transgender, though, and Ryan collected much data related to children's gender expression and their families' expectations, perception, and response to it. Most of her future papers will include the entire spectrum, although some will focus on either sexual orientation or gender expression and identity. Ryan and her team are now working to turn their findings into interventions. She realized early on that the very process of being interviewed was therapeutic for the families, very few of whom had ever talked about having LGBT children before. Even parents who were rejecting of their LGBT children and reluctant to participate would end up talking for hours. After completing the research, she also went back to the families that had participated in the qualitative study, as well as families from other ethnic groups, to share the findings. "We were having a dramatic impact on their behavior," Ryan observed. "For the very first time, they could see how their specific words, actions, and behaviors were affecting their LGBT child." The problem was, there were few places they could send parents for information on how to support their LGBT children. While information existed for LGBT youth outside the context of their family, and for families whose children came out as adults, there was little for parents of LGBT children and adolescents. Ryan is therefore developing tools and educational materials to help families assess their interactions with their LGBT children, change their misconceptions, and see the impact of their behaviors, all in culturally appropriate ways. Although her first paper addresses rejecting behaviors, she said that one of the distinguishing features of the FAP is that it also identifies positive ways parents can support their LGBT children. This is a departure from previous work that focused almost exclusively on the risks faced by LGBT youth, not on what can be done to help them develop into happy LGBT adults. The educational materials will be created in English, Spanish, and Chinese (Cantonese). Most will be available on the FAP Web site, and through offline channels, later in 2009. Another important component of the project is the development of social support networks for families of diverse ethnicities. In particular, families of color with LGBT children tend to be isolated from one another, Ryan said. Language barriers can also make it difficult for them to access resources, so Ryan is working with award-winning filmmaker Vivian Kleiman to produce a series of videos in different languages, showing the journeys of an ethnically diverse group of families with LGBT children. Throughout her work, Ryan is adamant about treating families as allies, not enemies. "What we need to do is to engage them and provide a nonjudgmental environment for them to understand the consequences," she maintains. "There are few people so unconnected to their children that they wouldn't want to try to help them." For example, Ryan's research has shown that blocking access to the child's LGBT peers and resources has the same level of risk for negative health outcomes as physical and verbal abuse. Many of the families who blocked access thought they were helping their children get along better in a homophobic world. When family members realized the actual effects of such behavior, Ryan said, many became eager to change. For healthcare providers, Ryan's team is also creating a risk-assessment tool so they can quickly gauge the level of family rejection and evaluate an LGBT child or adolescent's risk for depression, suicide, substance abuse, HIV infection, or sexually transmitted diseases. They will also develop a "cookbook" of care strategies to employ, and make this material available throughout the U.S., in 14 Spanish-speaking countries, and China, where groups are eager to start demonstration projects. Ryan sees wide application for the FAP in improving wellness, strengthening families, and helping keep young people in their homes and in school. "What our work has done," Ryan said, "is to establish that family rejection has a serious impact on an LGBT young person's health and mental health, and also family acceptance both protects against risk and promotes well being." Mitchell Gold, founder of furniture company Mitchell Gold + Bob William as well as Faith in America, an organization dedicated to ending religion-based bigotry, also sees a great need for Ryan's work. Gold himself has just published Crisis, a collection of stories by 40 well-known gay and lesbian Americans describing their own experiences growing up in fear and isolation. He said, "Hopefully Dr. Ryan's report will serve as the tipping point to bringing an end to the harm parents cause to their LGB children. The information contained can be particularly helpful to well meaning parents. Hopefully and most importantly, it will be a wake-up call to those parents steeped in misguided and ill informed religious beliefs. The spiritual and emotional violence to these kids must stop." Gold noted, too, that Ryan's work itself should send a cautionary message to the major state and national LGBT advocacy groups. "We must focus on the harm caused to LGB teens and not only on the civil rights adults are denied," he said. "We need to take this information to create a climate change in America of how gay teens are treated." Ryan's faces a big hurdle, however, in finding funds for the FAP. The California Endowment, a major health foundation, provided much of the $2.6 million needed for the first six years. Developing the interventions will cost another $2 million. The California Endowment and a matching grant from the Robert Wood Johnson Foundation are supporting the creation of family educational materials, but she is looking for further funds, and said she would need millions more if she was ever to consider expanding the study to other regions or ethnic groups. Ryan is, however, encouraged by the response to the FAP so far. "The one thing that has come out first and foremost . . . is a real feeling of great hope for the future. What is so exciting is that we've seen remarkable reactions and remarkable growth in families from all walks of life, from all class backgrounds, across socioeconomic and ethnic groups. We've seen some beautiful stories of strength and development and change."