Lily Koblenz MD
Regional Medical Consultant, Region 6
Fostering Well-Being Care Coordination Unit, HCS/ ALTSA/ DSHS
September 25, 2019
“About 3 months after I entered the foster care system at age 12, a foster parent uttered words that would stay with me for the rest of my life. ‘Gay people are sinners who have no direction in life,’ she told me. That comment still lives with me today, deeply ingrained into my self-esteem more than 15 years later. As a well-educated gay man, I am able to recognize it has no bearing on who I am today as a person. But youth in the child welfare system still hear statements like these as they grow up in care.”
“My quality of life within the child welfare system would have been drastically more positive had there been individuals whom I could turn to during times of need. To feel support, rather than ridicule and judgment would have made all the difference in my development as a teenager.”
Terry Scraggins, “For LGBTQ Youth in Foster Care, Finding a home is Hard”, Chronicle for Social Change, November 26, 2018, https://chronicleofsocialchange.org/analysis/for-lgbtq-youth-in-foster-care-finding-home-is-hard/32813
In this article I would like to discuss why it is essential that all members of the child welfare community (social workers, foster parents, adoptive parents, medical providers, mental health providers):
- become knowledgeable about LGBTQ+ children and youth and the challenges they may experience,
- learn the importance that accepting and supportive adults have in promoting physical, behavioral, and mental well-being for LGBTQ+ children and youth,
- receive the necessary screening and training to ensure that they are able and willing to be supportive and accepting,
- learn about the many, many excellent resources available to help further inform, train, and support adults living and working with LGBTQ+ children and youth.
This article is not meant to be a comprehensive document about LGBTQ+ youth. Please use the references at the end of this document to become more familiar LGBTQ+ terminology, statistics, and other details. However, I have included the following definitions for the purpose of clarity:
Sexual Orientation: who someone is attracted to emotionally, mentally, physically, and/or sexually.
Gender Identity: how one identifies themselves (female/girl/woman, male/boy/man, or other such as transgender or non-binary).
Gender Expression: how one presents themselves externally (dress, mannerisms, behavior).
SOGIE: an acronym that will be used to refer to Sexual orientation, Gender Identity, and Gender Expression collectively.
Is identifying as LGBTQ+ or having gender dysphoria a choice?
Gender identity and sexual orientation are not choices. Sexual orientation and gender identity emerge early in childhood. They are the result of complex genetic, biological, and environmental factors. Individuals decide about how to embrace their gender identity and sexual orientation at various points in their life but their underlying identity is not a lifestyle choice.
At what age do children become aware of their gender identity or gender dysphoria?
A child develops recognition of their gender identity slowly, over time. In some individuals gender identity may shift depending on context. According to an AAP policy statement on transgender and gender-diverse children: “Children report being aware of gender incongruence at young ages. Children who later identify as TGD report first having recognized their gender as “different” at an average age of 8.5 years, however, they did not disclose such feelings until an average of 10 years later.” For some children gender identity begins to form as early as ages 2 to 4.
At what age do children begin to understand their sexual orientation?
According to the studies done by the Family Acceptance Project ( San Francisco State University) people report first being attracted to another person on average around 10 years of age and identifying as straight, gay, bi/pansexual at an average age of 13.
Can SOGIE be effectively changed by conversion therapy, reparative therapy, or sexual orientation change efforts?
There is broad agreement in the medical and psychological community that an individual’s sexual orientation, gender identity, or gender expression cannot be changed and efforts to attempt such change are harmful.
Reparative and Conversion therapies are not effective and can do damage to LGBTQ+ youth. According to the American Psychological Association “The longstanding consensus of the behavioral and social sciences and the health and mental health professions is that homosexuality per se is a normal and positive variation of human sexual orientation….. APA is concerned about ongoing efforts to mischaracterize homosexuality and promote the notion that sexual orientation can be changed and about the resurgence of sexual orientation change efforts (SOCE)”.
The APA resolved in 2009: “the APA advises parents, guardians, young people, and their families to avoid sexual orientation change efforts that portray homosexuality as a mental illness or developmental disorder and to seek psychotherapy, social support, and educational services that provide accurate information on sexual orientation and sexuality, increase family and school support, and reduce rejection of sexual minority youth.”
The Substance Abuse and Mental Health Services Administration (SAMHSA) has deemed as inappropriate any mental health therapy that attempts to change a child’s gender identity or expression.
Are LGBTQ+ children and youth overrepresented in the foster care population?
LGBTQ+ children and youth are definitely overrepresented in the child welfare system. According to “Supporting Your LGBTQ Youth: A Guide for Foster Parents” (Child Welfare Information Gateway): “While approximately 5-10 percent of the general population is estimated to be gay, a study conducted in three Midwestern States found that a greater percentage of those aging out of the child welfare system reported a sexual orientation other than heterosexual (24% of females and 10% of males). These numbers are likely to be underreported because youth who come out often risk harassment and abuse.”
Many of these youth enter the child welfare system for typical reasons: abuse, neglect, family chaos, drug/ alcohol abuse, mental illness, parental incarceration etc… However, some of these children enter the system because of rejection by their biological family when the children reveal their LGBTQ+ identity. Some children are adopted as infants or toddlers and then face rejection by their adoptive family when their gender identity, gender expression, or sexual orientation (SOGIE) becomes evident.
What has been the experience of some LGBTQ+ children and youth in foster care?
“Unfortunately, a high percentage of LGBTQ youth in foster care experience further verbal harassment or even physical violence after they are placed in out of home care. As a result, many of these youth experience multiple disrupted placements, compounding the trauma associated with leaving their families of origin. In one study, as many as 56 percent of LGBTQ youth in care spent some time homeless because they felt safer on the streets than in their group or foster home“ - from “Supporting Your LGBTQ Youth: A Guide for Foster Parents” (Child Welfare Information Gateway).
Do LGBTQ children and youth have higher rates of mental health needs when compared with other youth?
Yes, teens and adults who identify as LGBTQ+ have higher rates of many mental illnesses including: depression, anxiety, suicide, self-harm, and eating disorders. LGBTQ+ youth are 4 times more likely to attempt suicide, have suicidal thoughts, or self-harm, as compared to youth who are “straight”. Suicidal ideation is especially high in transgender youth. LGBTQ+ youth also have higher rates of drug and alcohol abuse.
There is no evidence that LGBTQ+ identity inherently causes mental health problems. The etiology of mental health problems in LGBTQ+ youth is multifactorial and includes:
- stigma and rejection,
- lack of familial, social, and community acceptance and support,
- discrimination in school and workplace,
- internal conflict between personal identity and personal appearance,
- lack of availability of experienced mental health counsellors,
- lack of supportive health care providers.
- increased rate of bullying, harassment, and victimization.
The American Psychological Association made the following statement in 2012:
“Being transgender or gender variant implies no impairment in judgement, stability, reliability, or general social or vocational capabilities; however, these individuals often experience discrimination due to a lack of civil rights protections for their gender identity or expression… (Such) discrimination and lack of equal civil rights is damaging to the mental health of transgender and gender variant individuals. “
How important is a supportive family for children and youth who identify as LGBTQ?
The degree to which a family accepts versus rejects a child’s sexual orientation, gender identity, or gender expression (SOGIE) has a profound effect on the physical, emotional, and mental well-being of the child. Children and youth who face parental rejection because of their SOGIE may attempt to suppress their identity and/or may face other consequences:
- lowered self-esteem,
- increased mental illness and suicidality,
- increased substance abuse,
- increased risk of running away from home which increases the risk of victimization, sexual exploitation and trafficking, homicide etc…
- increased risk of family disruption and child welfare involvement.
On the other hand, according to the AAP, “adolescents who identify as transgender and endorse at least 1 supportive person in their life report significantly less distress than those who only experience rejection”.
LGBTQ+ children and youth who can freely express their identity and have their identity accepted and embraced by family, friends, and community are much more likely to be successful, healthy, and happy.
According to the AAP, what are the messages that should be conveyed in the “Gender Affirmative Care Model”?
- “Transgender identities and diverse gender expressions do NOT constitute a mental disorder.”
- “Variations in gender identity and expression are normal aspects of human diversity, and binary definitions of gender do not always reflect emerging gender identities. “
- “Gender identity evolves as an interplay of biology, development, socialization, and culture.”
- “If mental health issue exists, it most often stems from stigma and negative experiences rather than being intrinsic to the child.”
How can we move forward to improve the experience of LGBTQ+ children and youth in foster and adoptive care?
We need to embark on a campaign of screening, informing, training, and supporting future foster and or adoptive parents. All potential foster and adoptive parents should be involved in this process. When an infant or toddler is placed in foster care, there is no way to predict what their sexual orientation, gender identity, or gender expression (SOGIE) will be later in childhood or adolescence. We need to be sure that each child and youth in foster care is placed with caregivers who will accept and support them for who they are, not for who the parent prefers or wishes they were.
“For LGBTQ young people who endure trauma when they’re removed from the only home they’ve ever known, having foster families who are prepared to understand their needs is the least we can do to create a better system for all children.”
Terry Scraggins, “For LGBTQ Youth in Foster Care, Finding a home is Hard”, Chronicle for Social Change, November 26, 2018, https://chronicleofsocialchange.org/analysis/for-lgbtq-youth-in-foster-care-finding-home-is-hard/32813
Acknowledgements:
Thank you to Dae Shogren (DYCF- Statewide Program Manager for LGBTQ+/ Disproportionality/ Commercially Sexually Exploited Children) for her careful review and editing of this document.
Thank you to Nicole Gorman (DCYF- DLR Region 6) for bringing up the topic and encouraging me to write about it.
Thank you to Amber Salzer (DCYR- LGBTQ+ Lead for Licensing Division) for providing additional support.
References:
“CW Policy 6900: Supporting LGBTQ+ Identified Children and Youth”, WA State Child Welfare Policy, July 1, 2018.
https://www.dcyf.wa.gov/6000-operations/6900-supporting-lgbtq-identified-children-and-youth
“Supporting Your LGBTQ Youth: A Guide for Foster Parents”. Child Welfare Information Gateway, May 2013.
https://www.childwelfare.gov/pubPDFs/LGBTQyouth.pdf
“Caring for LGBTQ Children and Youth: A Guide for Child Welfare Providers”, Human Rights Campaign Foundation: all children all families- Achieving Safety, Permanency and Well- Being by Improving Practice with LGBT Youth and Families.
https://www.hrc.org/resources/all-children-all-families-caring-for-lgbtq-children-youth
“A Guide for Understanding, Supporting, and Affirming LGBTQI2-S Children, Youth, and Families”,
This guide was developed by members of the National Workgroup to Address the Needs of Children and Youth Who Are L G B T Q I 2 – S and Their Families, supported by the Child, Adolescent and Family Branch of the Center for Mental Health Services (CMHS)) at the Substance Abuse and Mental Health Services Administration (SAMHSA).
https://www.air.org/sites/default/files/A_Guide_for_Understanding_Supporting_and_Affirming_LGBTQI2-S_Children_Youth_and_Families.pdf
“Appropriate Affirmative Responses to Sexual Orientation Distress and Change Efforts; minutes of the annual meeting of the council of representatives and minutes of the board of directors”, American Psychologist, Volume 65, 385-475, August 5, 2009.
https://www.apa.org/about/policy/sexual-orientation
“Ensuring Comprehensive Care and Support of Transgender and gender-diverse Children and Adolescents”, Pediatrics, Volume 142, Number 4, October 2018:e20182162.
http://pediatrics.aappublications.org/content/142/4/e20182162
“Considerations for LGBTQ Children and Youth in Foster Care; Exploring Normalcy as It Relates to PL 113-183”.
Capacity Building Center for States- Children’s Bureau, September 29, 2014.
https://library.childwelfare.gov/cwig/ws/library/docs/capacity/Blob/105738.pdf?r=1&rpp=10&upp=0&w=+NATIVE(%27recno=105738%27)&m=1
“For LGBTQ Youth in Foster Care, Finding a Home is Hard”, Terry Scraggins, Chronicle for Social Change, November 26, 2018.
https://chronicleofsocialchange.org/analysis/for-lgbtq-youth-in-foster-care-finding-home-is-hard/32813
“Using Chosen Names Reduces Odds of Depression and Suicide in Transgender Youth”, University of Texas at Austin: News, March 30, 2018.
https://news.utexas.edu/2018/03/30/name-use-matters-for-transgender-youths-mental-health/
https://familyproject.sfsu.edu/
The Family Acceptance Project® is a research, intervention, education and policy initiative that works to prevent health and mental health risks for lesbian, gay, bisexual and transgender (LGBT) children and youth, including suicide, homelessness and HIV – in the context of their families, cultures and faith communities. We use a research-based, culturally grounded approach to help ethnically, socially and religiously diverse families to support their LGBT children. Our team has been putting research into practice by developing an evidence-based family model of wellness, prevention and care to strengthen families and promote positive development and healthy futures for LGBT children and youth. We provide training and consultation on our family-based prevention and intervention approach across the United States and in other countries.
