Integrating Gay Issues Into Mainstream Psych

Selected Bibliography D'Zurilla, T. J., & Goldfried, M. R. (1971). Problem solving and behavior modification. Journal of Abnormal Psychology, 78, 107-126. Goldfried, M. R. (1971). Systematic desensitization as training in self-control. Journal of Consulting and Clinical Psychology, 37, 228-234. Goldfried, M. R. (1980a). Psychotherapy as coping skills training. In M. J. Mahoney (Ed.), Psychotherapy process: Current issues and future directions (pp. 89-119). New York: Plenum. Goldfried, M. R. (1980b). Toward the delineation of therapeutic change principles. American Psychologist, 35, 991-999. Goldfried, M. R. (Ed.). (1982). Converging themes in psychotherapy: Trends in psychodynamic, humanistic, and behavioral practice. New York: Springer. Goldfried, M. R. (1995). From cognitive-behavior therapy to psychotherapy integration: An evolving view. New York: Springer. Goldfried, M. R. (1999). Reflections of a scientist-practitioner. In S. Soldz & L. McCullough (Eds.), Reconciling empirical knowledge and clinical experience: The art and science of psychotherapy (pp. 17-32). Washington, DC: American Psychological Association. Goldfried, M. R. (2000). Consensus in psychotherapy research and practice: Where have all the findings gone? Psychotherapy Research, 10, 1-16. Goldfried, M. R. (Ed.). (2001). How therapists change: Personal and professional reflections. Washington, DC; American Psychological Association. Goldfried, M. R., Castonguay, L. G., Hayes, A. H., Drozd, j . F., & Shapiro, D. A. (1997). A comparative analysis of the therapeutic focus in cognitive-behavioral and psychodynamic-interpersonal sessions. Journal of Consulting and Clinical Psychology, 65, 740-748. Goldfried, M. R., & Davison, G. C. (1976). Clinical behavior therapy. New York: Holt, Rinehart & Winston. Goldfried. M. R., & Davison, G. C. (1994). Clinical behavior therapy (expanded ed.). New York: Wiley-Interscience. Novemfaer 2001 • American Psychologist

Goldfried, M. R., & D'Zurilla, T. J. (1969). A behavioralanalytic model for assessing competence. In C. D. Spielberger (Ed.), Current topics in clinical and community psychology (Vol. 1, pp. 151-196). New York: Academic Press. Goldfried, M. R, & Goldfried, A. P. (2001). The importance of parental support in the lives of gay, lesbian, and bisexual individuals. Journal of Clinical Psychology/In Session: Psychotherapy in Practice, 57, 681-693. Goldfried, M. R., Raue, P. J., & Castonguay, L. G. (1998). The therapeutic focus in significant sessions of master therapists: A comparison of cognitive-behavioral and psychodynamic-interpersonal interventions. Journal of Consulting and Clinical Psychology, 66, 803-810. Goldfried, M. R., & Wolfe, B. E. (1996). Psychotherapy practice and research: Repairing a strained alliance. American Psychologist, 51, 1007-1016. Goldfried, M. R, & Wolfe, B. E. (1998). Toward a more clinically valid approach to therapy research. Journal of Consulting and Clinical Psychology, 66, 143-150. Norcross, J. C , & Goldfried, M. R. (Eds.). (1992). Handbook of psychotherapy integration. New York: Basic Books. Samoilov, A., & Goldfried, M. R. (2000). Role of emotion in cognitive-behavior therapy. Clinical Psychology: Science and Practice, 7, 373-385. Wolfe, B. E., & Goldfried, M. R. (1988). Research on psychotherapy integration: Recommendations and conclusions from an NIMH workshop. Journal of Consulting and Clinical Psychology, 56, 448-451.

Integrating Gay, Lesbian, and Bisexual Issues Into Mainstream Psychology Marvin R. Goldfried Stale University of New York at Stony Brook

Despite the growing clinical and research literature dealing with gay, lesbian, and bisexual (GLB) issues, mainstream psychology has tended to ignore much of the work that has been done in this area. This article illustrates how clinical and research writings on GLB issues continue to remain invisible to mainstream psy977

chology in such areas as life span development and aging, teenage suicide, substance abuse, victimization and abuse, and family and couple relationships. It also deals with some of the determinants of well-being among GLB individuals, such as family support, and notes the benefits accruing to mainstream psychology from studying GLB issues. A network of family members within psychology having GLB relatives has been formed—AFFIRM: Psychologist Affirming Their Gay, Lesbian, and Bisexual Family—and is dedicated to supporting its own family members, encouraging other family members to do likewise, supporting research and clinical work on GLB issues, and closing the gap between GLB clinical and research work and mainstream psychology. For most of my career, my primary clinical and research interests have centered around clinical assessment and psychotherapy, particularly in the areas of behavior therapy and psychotherapy integration. However, this is about to change. After many years of silence, I have decided it is time for me to come out professionally—not as a gay man but as the father of a gay son. As a result, I am beginning to devote more of my professional energies to research and clinical work on gay, lesbian, and bisexual (GLB) issues. There have been two experiences that have led me to this decision. The first involved my participation in a gay pride parade several years ago, and the second occurred at a symposium at an Association for the Advancement of Behavior Therapy (AABT) conference. In attending the gay pride parade, my wife and I decided to march with the Parents, Family, and Friends of Lesbians and Gays (PFLAG) contingent. In doing so, we had the opportunity to witness the profound loss of family support that many gay men, lesbians, and bisexuals have suffered. The onlookers had very definite emotional reactions as we passed by with our banners reading "We love our gay and lesbian children" and "You will always have a home in PFLAG." They responded with shouts of "We love you, too" and "We wish our parents would march." The verbal responses and facial expressions of the younger

Editor's Note Marvin R. Goldfried received the Award for Distinguished Professional Contributions to Knowledge. Award winners are invited to deliver an award address at APA 's annual convention. This award address was delivered at the 109th annual meeting, held August 24-28, 2001, in San Francisco. Articles based on award addresses are not peer reviewed, as they are the expression of the winners' reflections on the occasion of receiving an award.

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onlookers communicated happiness and longing; the older women and men were silent, looking sad and regretful, perhaps reflecting a never-to-be-fulfilled longing. This experience provided me with the profound realization of how important family support—or lack thereof—is in the lives of GLB individuals. The second experience was at a very crowded AABT symposium dealing with the appropriateness of altering a GLB person's sexual behavior and orientation. One of the panelists was a colleague with whose opinion I disagreed somewhat. However, I knew that my view was likely to be controversial and might be perceived by some as being antigay. I felt the need to raise my point from the audience but was concerned about a possible negative reaction on the part of others in the room. Consequently, I prefaced my comment by stating that one of my two favorite sons was gay and that I was a dues-paying member of PFLAG. When the meeting was over, the colleague approached me and indicated that it was brave of me to say what I had said. At first, I thought he was referring to my contrary opinion, but he quickly indicated that he was referring to my self-disclosure—noting that I had come out. I would like to begin by commenting on the importance of family support in the lives of GLB individuals. I then offer an overview of how the mental health professions have conceptualized homosexuality over the years. Next, I document how the mainstream professional literature has ignored GLB issues, with the unfortunate consequences that have resulted from this. Some of the determinants of psychological well-being among GLB individuals are considered, as well as the benefits accruing to mainstream psychology from studying GLB issues. I conclude by describing the formation of a network of mainstream psychologists who represent family of GLB individuals and how it can help to close this gap between the mainstream and GLB literature. The Importance of Family Support There is no question but that the status of GLB individuals has improved dramatically in very recent years. Nonetheless, they continue to represent a stigmatized segment of society both inside and outside the home, where they continue to experience both verbal and physical abuse. The reactions of family members to their GLB relatives can serve to either exacerbate or alleviate distress. In a study of victimized youth, Hershberger and D'Augelli (1995) found that symptomatology was significantly reduced as a function of parental support. It was also found by Savin-Williams (1989) that self-esteem among lesbians was positively correlated with a satisfactory relationship with their mothers and that self-esteem in gay men was related to a positive relationship with both mother and father. November 2001 • American Psychologist

When GLB individuals fear they cannot be open about their sexual identity within the predominant heterosexual social system, their only recourse is to hide (Martin, 1982). Indeed, this theme of hiding has traditionally characterized the lives of many GLB individuals. It has only been in very recent years that there has existed greater support for GLB youth to come out earlier in life, resulting in the development of a more positive, self-accepting identity (Savin-Williams, 1998, 2001b). This change in societal attitudes clearly underscores the cultural relativity associated with the acceptability of being gay. As is well known, there was a far more accepting view of male same-sex behavior in ancient Greek and Roman societies. In some Native American cultures, there is a positive quality associated with so-called "two-spirited people." And, some years ago, it was Woody Allen who pointed out that one of the advantages of being bisexual is that it doubles your chances of getting a date on New Year's Eve! Of course, not everybody sees it that way. When parents learn that their daughter or son is gay, the initial reactions are often negative. The adjustment on the part of some parents, as well as perhaps their eventual acceptance of this reality, has been likened to a grieving process. Dealing with this reality is very much a process and, as such, takes time and corrective experiences. Many of these experiences can be facilitated by having contact with other supportive parents, often through PFLAG. PFLAG is an organization that is designed to support family members who have learned that their son, daughter, or other family member is GLB. Its mission is also to educate the public and to advocate for equal rights for lesbian, gay, bisexual, and transgendered individuals. Although there are no data to support this, I believe that PFLAG, rather than individual or family therapy, is the intervention of choice to help facilitate parental acceptance of GLB children. Not too long ago, I attended a local PFLAG support group at which a very angry and distressed mother reported that her son had just come out to her. Even at the coffee hour before the actual group began, she had difficulty in containing herself. She indeed was in the midst of a crisis. She began the group discussion by tearfully expressing her anger on hearing the news that her son was gay, questioning, "How could he do this to me?" and "Doesn't he know he's ruining my life?" Approximately halfway into the meeting, after she had the opportunity to describe what had happened and how she felt, a young woman in her early twenties described her own current dilemma. Although she had come out to some of her friends, she had not done so to her mother and father. With great anguish, she described her fears associated with her parents learning that she was a lesbian. She was struggling with the choice of openly being who she was but fearful of the possibility of being disowned by her parents, whom she loved dearly. As she spoke to the others in the room and received support from November 2001 • American Psychologist

the group—consisting mostly of parents—I watched the expression on the face of the mother who had spoken earlier. She appeared stunned in hearing what it was like from the child's point of view, and her face softened to reveal the sadness and sympathy she felt for this young woman. This experience, as well as others I have witnessed, is what leads me to conclude that referral to PFLAG should be the intervention of choice in fostering parental acceptance. The Conception of Homosexuality Within Mental Health Professions Over the years, the mental health professions have evolved considerably in how they deal with the topic of homosexuality. For example, the 1955 Group for the Advancement of Psychiatry report on the sexual orientation reflected the prevailing theme of the time, identifying homosexuality as a form of sexual perversion . . . psychological in origin [with] no valid evidence that homosexuality is inherited. Homosexuality is an arrest at, or a regression to, an immature level of psychosexual development. While the treatment of homosexuality is difficult and time-consuming, success has been reported. Psychotherapy offers the best chance of success, particularly in the turbulent transition period from adolescence to maturity wherein sexual goals have not been finally established. (Group for the Advancement of Psychiatry, 1955, p. 6)

During that time period, there were also, in such places as psychoanalytic institutes, discriminatory policies that maintained that gay and lesbian candidates were unfit for training. It should come as little surprise that therapists who themselves were homosexual remained closeted. The evolution of this antigay bias within the field is reflected in the changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM) over the years. In the first edition appearing in 1952 (American Psychiatric Association, 1952), homosexuality was categorized as a "sociopathic personality disorder." In the 1968 revision (American Psychiatric Association, 1968), it was reclassified as a "sexual deviation." The version of DSM appearing in 1980 (American Psychiatric Association, 1980)—DSMIII—limited the category only to individuals who were distressed about their homosexuality, creating the classification of "ego-dystonic homosexuality." The version that appeared seven years later as DSM-III-R (American Psychiatric Association, 1987) removed homosexuality as a diagnostic category altogether. In his presidential address delivered at the 1974 AABT meeting, Davison (1976) strongly condemned the practice of conversion/reparative therapy, urging his fellow behavior therapists to question the moral and ethical implications of attempting to alter an individual's sexual behavior and orientation. Within psychoanalytic circles, it was not until the 1990s that gay and lesbian therapists began to openly criticize the existing conceptual models of homosexuality. 979

Much like what had happened when women entered the profession and began to challenge gender biases in the field, GLB analysts began to question existing conceptualizations of homosexuality. The difference is that GLB analysts had always been there but were only now able to speak out—at the risk of stigmatization. It may be argued that this antihomosexual bias is rooted in psychoanalytic theory. To some extent, it is. However, one cannot totally blame theory for psychologists' antigay bias. In a survey of behavior therapists by Davison and Wilson (1973), it was found that although the respondents indicated that they would not attempt to change the sexual orientation of homosexual clients who did not wish to change and that they did not view homosexuality as being pathological, they nonetheless had conceptions of it as being less good, less masculine, and less rational than heterosexuality. In 1975, the American Psychological Association (APA) adopted a clear position against homosexual bias, and psychologists were encouraged to work toward removing this long-standing stigma. Five years later, APA instituted the standing Committee on Lesbian and Gay Concerns. In 1991, the committee reported the results of a survey of what psychologists knew about the experiences of lesbians and gay men with psychotherapy. It found that 84% of the respondents knew of cases in which lesbians or gay men were adversely affected by their therapeutic experiences (Garnets, Hancock, Cochran, Goodchilds, & Peplau, 1991). Analogue psychotherapy research by Gelso and his colleagues (Gelso, Fassinger, Gomez, & Latts, 1995; Hayes & Gelso, 1993) involving videotaped clients demonstrated that both male and female therapists were less cognitively attuned to lesbian clients than to heterosexual female clients and that male therapists' homophobia was associated with less effective therapeutic interactions. Still another example of bias within the field may be seen in a more recent survey that revealed that practicing psychologists were less likely to recommend adoption for a gay or lesbian couple than they were for a heterosexual couple, and that the belief that homosexuality was a matter of choice was a significant variable associated with this decision (Crawford, McLeod, Zamboni, & Jordon, 1999). In an excellent chapter appearing in Perez, DeBord, and Bieschke's (2000) Handbook of Counseling and Psychotherapy With Lesbian, Gay, and Bisexual Clients, Bieschke, McClanahan, Tozer, Grzegorek, and Park's (2000) review of the literature indicated that gay men and lesbians are far more likely to make use of individual psychotherapy than are heterosexuals. This is also true of lesbian and gay couples in that approximately one half of lesbian couples and close to one third of same-gender male couples indicate that they have sought professional help for relationship issues (R.-J. Green, 2000b). A survey of members of the American Association for Marriage and Family 980

Therapy confirmed this, finding that the vast majority of respondents (72%) reported that 1 out of 10 couples they saw clinically involved same-gender relationships (S. K. Green & Bobele, 1994). Unfortunately, in a separate survey of therapists within the same organization, it was found that almost half indicated that they did not feel clinically competent in working with gay men and lesbians (Doherty & Simmons, 1996). The more frequent use of therapy by GLB individuals may be explained by the fact that they not only have to deal with the kind of issues that confront heterosexual clients but also need to cope with stigmatization, family rejection, oppression, sexual identity issues, and internalized societal homophobia (Bepko & Johnson, 2000; Liddle, 1997). In reporting on the results of the National Lesbian Health Care Survey carried out in the mid-1980s, Bradford, Ryan, and Rothblum (1994) described some of the distressing life issues confronted by the participants. They found that 37% had been physically abused and 32% had been raped or sexually attacked. Close to one out of five experienced incestuous relationships when growing up. One in five at times thought about committing suicide, and close to that number had actually made the attempt. More than half reported that anxiety interfered with their functioning, and over a third had been depressed. What is particularly distressing about the findings is that the survey was based primarily on well-educated professional women, describing what the authors indicated as being the best scenario for lesbians in the United States. Although mental health professions no longer consider homosexuality a disorder, there nonetheless has been a movement to "cure" GLB individuals (Haldeman, 1999). Alternately called conversion or reparative therapy, these attempts seem to be religiously and politically motivated and serve to reinforce the concept of homosexuality as a mental illness. The effectiveness of these interventions is controversial (Spitzer, 2001), and clinical contact with individuals who have gone through conversion or reparative therapy suggests that some individuals are harmed by this experience (Haldeman, 1999). Several publications that provide useful information for therapists who work clinically with GLB individuals have recently been published (see, e.g., Campos & Goldfried, 2001; Greene & Croom, 2000; Perez et al., 2000). In February 2000, the APA Council of Representatives adopted Guidelines for Psychotherapy With Lesbian, Gay, and Bisexual Clients, which were developed by a joint task force comprised of members of Division 44 and the Committee on Lesbian, Gay, and Bisexual Concerns. This document, which was published later that year (Division 44/Committee on Lesbian, Gay, and Bisexual Concerns Joint Task Force on Guidelines for Psychotherapy With Lesbian, Gay, and Bisexual Clients, 2000), is designed to guide both graduate students in training and practicing therapists in November 2001 • American Psychologist

their clinical work with GLB clients. The guidelines review a number of the issues associated with GLB individuals (e.g., the risks that exist for adolescents, life challenges, stigmatization, family issues), the implicit biases that may exist among practicing therapists, and the need for psychologists to become better aware of these issues if they are to work with GLB individuals—which they are clearly likely to do. The Gap Between Mainstream and GLB Literature As indicated earlier, a long-standing theme in the lives of GLB individuals has been the need to be in hiding—to be invisible. This has also characterized the mental health professions over the years, in that GLB professionals have remained closeted. Not surprisingly, the mainstream literature has had a history of having little of a positive nature to say about GLB issues. It was as if the implicit guideline between GLB and mainstream professionals was "Don't tell/don't ask." Since the Stonewall rebellion over 30 years ago, which marked the beginning of a very dramatic gay rights movement, GLB individuals have been able to be more open about who they are. This trend has also been seen within the mental health professions, in that there has been a marked increase in professional writings about GLB issues, typically by people who have decided to come out professionally. Although the mental health professions have shown support for GLB concerns, the GLB literature continues to remain invisible to those outside the area and has not been incorporated into the mainstream body of knowledge. It appears that GLB professionals are now telling, but the rest of psychology has not been listening. I would hasten to add that I am as guilty of this as anyone. Even though I strongly suspected that my son was gay over 20 years ago and have known for certain for more than 10 years now, I typically ignored the GLB literature. One may speculate about the various reasons why this may have occurred for myself and for others, including the fact that there has always been—and still is—a stigma associated with writing about GLB issues (Rothblum, 1995). Of course, it is possible to argue that much of what is written about in this area is not relevant to one's research and clinical interests. I would like to illustrate, however, how this is not at all the case. There are many issues in the GLB literature that, although having a direct bearing on issues currently receiving attention within mainstream psychology, continue to remain invisible. I comment on just a few of these, including life span development and aging, teenage suicide, substance abuse, victimization and abuse, and family and couple relationships.

life Span Development and Aging There is an extensive literature dealing with the developmental milestones of GLB individuals (see, e.g., Cohen & November 2001 • American Psychologist

Savin-Williams, 1996; Hershberger & D'Augelli, 2000; Savin-Williams, 1998). For example, much has been written about the developmental task of forming one's identity during adolescence, where many of the same issues that exist with heterosexual teenagers are relevant, along with those uniquely associated with one's homosexual identity. It is well known that negative self-concept is associated with a host of psychological difficulties, including depression, anxiety, and level of functioning. This is very much the case with GLB individuals, as demonstrated by a dramatic -.87 correlation that has been found between personal self-acceptance on the part of gay youth and the existence of psychological problems (Hershberger & D'Augelli, 1995). However, there is a long history within the gay community of having individuals describe themselves with the term self-loathing, clearly reflecting the messages gay youth are exposed to very early in life. Even before they develop their own sexual identity, many boys and girls have traditionally assimilated the view that there is something very wrong with homosexuality. The openly gay comic and author David Sedaris (1997), in providing a poignant side to an otherwise funny story about his school experiences, put it this way: We had long ago identified one another and understood that because of everything we had in common, we could never be friends. To socialize would have drawn too much attention to ourselves. We were members of a secret society founded on self-loathing. When a teacher or classmate made fun of a real homosexual, I made certain my laugh was louder than anybody else's, (p. 85) This internalization of the societal stigma comes at a crucial developmental phase in the lives of GLB youth. As observed by Cohen and Savin-Williams (1996), "At a time when most youths are gradually building self-esteem and establishing an identity, some sexual minority adolescents are learning from peers and adults that they are amongst the most hated in society" (p. 124). The complex and difficult developmental task for GLB youth is to form a positive identity for themselves when many of the societal messages are negative. There is clearly a cohort effect here, as GLB teenagers are now growing up in a very different environment than those who came to maturity a mere 10 to 20 years earlier (Savin-Williams, 1998, 2001b). Although GLB adolescents feel freer about coming out, many nonetheless continue to face formidable stressors in doing so, such as being rejected or even thrown out of the home by their parents. Despite the available literature on developmental issues among GLB youth, this is often ignored within mainstream psychology. For example, nowhere in the fourth edition of Sebald's (1992) text on adolescent development is there any mention of GLB youth. Although a variety of ethnic, racial, socioeconomic, and cultural factors are considered

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in McLoyd and Steinberg's (1998) volume on minority adolescents, nothing is said about sexual minorities. And in an edited volume dealing with the impact of social change on adolescent development (Crockett & Silbereisen, 2000), none of the contributors make any reference to GLB issues. Another invisible aspect of GLB life span development that has relevance to mainstream literature is the topic of aging. With the graying of the U.S. population in general, aging has been an area that has been receiving an increasing amount of attention within psychology. Here, too, GLB individuals not only need to deal with many of those same issues confronting heterosexual individuals but also have unique challenges. Much has been written about these challenges, dealing with such topics as the decline in physical attractiveness, the relative absence of supportive family members, health care concerns, the untimely death of partners and friends, employment discrimination, and both legal and financial limitations associated with same-sex partnerships (Baron & Cramer, 2000; Grossman, D'Augelli, & O'Connell, in press). These challenges, together with the emotional stress they bring, are clearly described in the GLB literature but absent within mainstream psychology.

neously indicated that "There is no one, typical adolescent suicide." As one researcher (Tremblay, 1995) questioned at thie Sixth Annual Conference of the Canadian Association for Suicide Prevention,

Teenage Suicide

Substance Abuse

Gay and lesbian youth are far more likely to attempt suicide then are their heterosexual peers; estimates have been made that approximately one out of three GLB youth has attempted suicide (D'Augelli, Hershberger, & Pilkington, in press; Hershberger & D'Augelli, 2000; Remafedi, Farrow, & Deisher, 1991; Safren & Heimberg, 1999). In a study by Safren and Heimberg (1999), GLB and heterosexual youth were compared on the basis of suicidality and other psychosocial variables. Consistent with past research, Safren and Heimberg found that approximately one third of the GLB participants reported having made a past suicide attempt, in comparison with only 13% of their heterosexual counterparts. However, after taking into account other relevant variables—depression, hopelessness, substance abuse, social support, stress, and coping—sexual orientation no longer differentiated the two groups on suicidality. Thus, it is not being GLB per se that puts an adolescent at greater risk for suicide but rather other variables associated with psychological distress. For example, it has been estimated that close to one out of every five homeless youth in Los Angeles, California, is GLB (Unger, Kipke, Simon, Montgomery, & Johnson, 1997) and that the attempted suicide rate among these gay-identified street youth exceeds 50% (Kruks, 1991).

It has been found that GLB adolescents and adults have higher frequencies of substance abuse (see, e.g., Hershberger & D'Augelli, 2000). It is also generally known that individuals are at a higher risk for suicide if they abuse alcohol and drugs—in the population at large and also within the GLB community. Compared with those GLB individuals who do not attempt suicide, four times as many young gay and bisexual individuals who make suicide attempts have a past history of treatment for chemical dependency (Hershberger & D'Augelli, 2000). Within the mainstream literature, much has been written about adolescent substance abuse. For example, in an article entitled "A Comprehensive and Comparative Review of Adolescent Substance Abuse Treatment Outcome," appearing in a recent issue of Clinical Psychology: Science and Practice, Williams and Chang (2000) reviewed the results of 53 studies carried out on this topic. The client characteristics reported in these studies include race/ethnicity, gender, socioeconomic status, past arrests, suicide attempts, school problems, and family conflict. Nowhere is sexual orientation mentioned, which is obviously not the fault of the authors but rather a reflection of the nature of mainstream research carried out on this topic (see Herek, Kimmel, Amaro, & Melton, 1991; Rothblum, 1994). Another study appearing that year (Kilpatrick et al., 2000), entitled "Risk Factors for Adolescent Substance Abuse and Dependence: Data From a National Sample," reported on the findings of a national survey of over 4,000 adolescents between the ages of 12 and 17. In this report,

A reality that is also distressing is that the mainstream literature on suicide all too often fails to mention the findings obtained with GLB youth. For example, a brochure published by the Association for the Advancement of Behavior Therapy (1992) on the topic of teenage suicide erro-

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Why have most studies of youth suicide problems not been concerned with identifying sexual orientation, and child sexual abuse in their research? Is this how truly scientific work should be done? . . . Has it been ethical, given the facts of the case, for suicidologists to have ignored GLB issues? Why did this happen? In attending a conference on adolescent suicide two years later, Mallon (1997) was similarly shocked to learn that none of the experts who presented their work made any mention of GLB adolescent suicide. One presenter, during the course of her talk, raised the question, "What secret could be so terrible that you would rather kill yourself then tell?" As neither the presenter nor any member of the audience provided an answer, Mallon approached her afterwards and asked why she had not mentioned the higher risk of suicide among lesbian and gay adolescents. Her response was, "Oh, I never even thought about them." (Mallon, 1997, p. 25).

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the authors indicated that they controlled for those demographic factors that were believed to increase the risk of substance abuse, including age, race, gender, and parental substance use. One of the findings that resulted from those surveyed was that adolescents who had been physically or sexually abused had an increased risk for substance abuse and dependence. Nowhere in this report is there in any mention of sexual orientation. Victimization and Abuse It is estimated that 1 out of every 3 gay youth is verbally abused by family members, 1 out of 10 is physically assaulted by a family member, and 1 out of 4 has experienced physical abuse at school (Hershberger & D'Augelli, 2000). It has also been found within a GLB population that there is a positive association between early abuse and current depression, suicidality, and risky sexual behavior. Reporting on the results of the National Lesbian Health Care Survey, Descamps, Rothblum, Bradford, and Ryan (in press) indicated that lesbians who had a history of early sexual abuse and more recent partner violence reported higher levels of stress, depression, and alcohol abuse. Moreover, lesbians who were victims of physical hate crimes had significantly more stress and drug abuse than those whose physical assault was not associated with a hate crime. Although Descamps et al. found that early abuse was no more prevalent among lesbians than heterosexual women, Brown (1995) has pointed out that because they are made up of two women, lesbian couples are more likely to include at least one person who was the victim of early physical or sexual abuse. Partner abuse is common in same-gender male and female relationships, with some estimates being close to 50% (West, 1998). However, because most people typically think of partner abuse as involving male violence against women, same-gender abuse is often ignored in mainstream circles (Renzetti, 1994; Renzetti & Miley, 1996). Samegender abuse is also likely to be less visible in that there is often a reluctance to let others know about it, either because one or both members of the couple may not be fully out or because of a very real fear of discrimination by the police. The mainstream literature on physical and sexual abuse in children, victimization, and posttraumatic stress disorder has dealt with numerous issues associated with assessment and intervention. To my knowledge, little if anything has been said in this literature about these related issues within a GLB population. Family and Couple Relationships Despite accusations within some quarters that GLB individuals are antifamily, the reality is that families play a most important role in their lives. A frequently asked question within GLB circles is, "Have you come out to your November 2001 • American Psychologist

family?" If answered in the affirmative, the next question usually is, "How did they take it?" As indicated earlier, parents and other family members often react negatively on hearing the news (D'Augelli, Hershberger, & Pilkington, 1998). Having a GLB family member clearly changes the nature of the family dynamics, and GLB individuals often find themselves needing to create new "families" out of their friends to substitute for their family of origin. The discussion of such issues is virtually invisible in the mainstream family literature (Crosbie-Burnett, Foster, Murray, & Bowen, 1996). In a review of 718 articles submitted for publication in the Journal of Marital & Family Therapy between the years 1990 to 1995, only 7 dealt with GLB issues (R.-J. Green, 2000b). An even more comprehensive survey of 17 journals during the 20 years from 1975 to 1995 revealed that only a little more than half of one percent focused on family issues associated with GLB individuals (Clark & Serovich, 1997). There are instances where the failure to acknowledge relevant GLB issues within the mainstream family literature can be harmful. R.-J. Green (2000a) pointed to this in a critique of an article that recommended the importance of coming out to one's parents as a psychologically healthy move in differentiating oneself from one's family. What that article failed to note was the finding that some GLB individuals can suffer negative consequences in doing so. As R.-J. Green argued, to draw conclusions about what constitutes healthy psychological development on the basis of a heterosexual population and to make suggestions for intervention derived from this reflects a highly limited, ethnocentric, and potentially harmful view of psychological maturity. In Halford and Markman's (1997) Clinical Handbook of Marriage and Couples Interventions, one of the chapters deals with issues associated with GLB couples (Julien, Arellano, & Turgeon, 1997). Checking the index to this volume of over 700 pages reveals that this indeed is the only chapter in the entire book that makes any comments about GLB couples. Yet one may readily recognize the relevance of the other, "mainstream" chapters, which deal with such issues as cognitive and affective processes in marriage, sex and relationships, violence and partner abuse, the developmental course of couples' relationships, children, restructuring marriages after infidelity, aging, couples intervention and alcohol abuse, individual pathology and distress, and physical health and relationships. Determinants of Mental Health One of the dangers of calling attention to the literature on GLB issues is that one may reach the erroneous conclusion that being gay, lesbian, or bisexual is intrinsically associated with psychopathology. GLB individuals are at greater risk for suicide, are more likely to abuse substances, and have a greater need for therapeutic services. Although 983

these findings do exist, there are also data indicating that there are wide individual differences and that many GLB individuals do not have such problems (McDaniel, Purcell, & D'Augelli, 2001; Savin-Williams, 2001a, 2001b). Indeed, there is a growing recognition within the GLB literature that research and clinical work in this general area needs to attend to determinants of resiliency as well as pathology. As noted earlier, although GLB adolescents are more likely to attempt suicide than their demographically comparable heterosexual peers, the differences disappear when one controls for such variables as substance abuse, depression, stress, and social support (Safren & Heimberg, 1999). A study by Remafedi et al. (1991) of gay adolescents having made suicide attempts revealed that their suicidality was the result of family problems associated with their sexual orientation, a finding that has more recently been replicated by D'Augelli et al. (in press). In a survey of older GLB individuals, it was found that individuals with a history of having been physically attacked because of their sexual orientation were more likely to have had suicidal thoughts and actions than those who were not victimized or those who had experienced only verbal abuse (D'Augelli & Grossman, in press). It was also found that a history of such physical abuse was associated with reports of lower self-esteem, greater loneliness, and poorer psychological adjustment. When compared with victimization that is unrelated to sexual orientation, hate crimes have been found to result in more stress and drug abuse among lesbians (Descamps et al., in press) and more stress, anxiety, depression, and anger among both lesbians and gay men (Herek, Gillis, & Cogan, 1999). A study of what can buffer the negative impact of victimization among GLB youths revealed that family support is related to higher levels of self-acceptance, which in turn is positively correlated with psychological well-being (Hershberger & D'Augelli, 1995). Taken together with the findings noted above about the association between suicide attempts and family conflict over one's sexual orientation, one may safely conclude that parental acceptance and family support play a significant role in the lives of GLB individuals (see Goldfried & Goldfried, 2001). This consideration of mediators and moderators of mental health among GLB individuals is obviously incomplete. What little is offered is merely to illustrate that there is nothing intrinsic to being lesbian, gay, or bisexual that results in psychological disturbance. There are clearly problems about being gay, lesbian, or bisexual, but the vast majority of these stem from those of us who are heterosexual.

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What Can Mainstream Psychology Learn by Studying GLB Issues? Research and clinical work on GLB issues can have important implications not only for understanding factors that influence the lives of sexual minorities but also for shedding light on human behavior in general. In many respects, one may think of research with both GLB and heterosexual individuals as providing a natural laboratory for learning more about the relative importance of gender and sexual orientation in understanding human behavior (Rothblum, 1994; Stacey & Biblarz, 2001). For example, a common pattern of interaction seen in marital conflict is the situation where wives pursue their partners to discuss difficulties but husbands withdraw from such discussions (Mien et al., 1997). This demand-withdrawal pattern is related to the development of marital distress and is believed to be a function of gender differences (e.g., men react with greater physiological arousal). However, such an interpretation needs to be reconsidered in light of the findings that demand and withdrawal are also seen in distressed same-gender partnerships, where the demand-withdrawal pattern is unrelated to gender (Julien et al., 1997). Another example is seen in the research that has been carried out on domestic violence. Koss et al.'s (1994) feminist interpretation of partner abuse cannot easily be applied to instances of abuse that occur within the context of samesex relationships. Although gender-based views of domestic violence may nonetheless continue to have merit, multiple pathways to abuse in intimate relationships must be considered (M. P. Koss, personal communication, October 19, 2000). A final example may be taken from the work that has been done on eating disorders. Given the fact that society places a greater emphasis on the physical attractiveness of women than of men, it comes as little surprise that, in comparison to men, women are more likely to have concerns about their weight and are more likely to manifest eating disorders. However, this emphasis on appearance also exists within the gay community, and a study by Siever (1994) found gay men have greater concerns about their weight and are more likely to report eating disorders than heterosexual men. By attempting to understand human behavior on the basis of a limited sample, we as psychologists face the danger of drawing biased conclusions. This is very much like the point recently made by Taylor et al. (2000), who suggested that the well-accepted fight-or-flight response to stress is biased in that it has been based on research carried out primarily with male rats. When findings using female subjects are considered, Taylor et al. argued, a more protective "tend-and-befriend" response may be seen as another way of reacting to stress. By learning more about November 2001 • American Psychologist

GLB issues, it is possible that mainstream psychology can similarly extend its conceptual horizons in better understanding human behavior. Closing the Gap Between Mainstream and GLB Psychology Despite the many advances that GLB individuals have made in society and within the mental health professions, there nonetheless continues to be a stigma associated with doing work in this area. With some notable exceptions (e.g., Davison, 1976; Hooker, 1957), most of the research and clinical writing has been done by individuals who themselves are GLB. Consequently, for them to decide to work on GLB issues professionally involved their coming out, as well as the possibility of putting themselves at risk of being marginalized within the mainstream community. Perhaps these factors contribute to the lack of incorporation of GLB issues into mainstream psychotherapy practice and research. My own long-standing professional interests have involved issues of integration. This has included the attempt to create links among different theoretical approaches to therapy (Goldfried, 1980) and also an interest in closing the gap between clinical practice and research (Goldfried & Wolfe, 1996). At this point in my career, I have decided to focus on a third aspect of integration—the integration of mainstream and GLB issues, particularly the goal of having relevant GLB clinical and research issues incorporated into mainstream psychology. As noted earlier, family support plays an important role in the lives of GLB individuals. With this in mind, a network of family members within psychology who have GLB relatives has been established—AFFIRM: Psychologist Affirming Their Gay, Lesbian, and Bisexual Family. Not only does AFFIRM serve to provide open support for its own family members but it also facilitates an indirect contact with or exposure that others will have to GLB individuals. By having family members come out in this way, it will increase the number of individuals who are able to say they know someone who is GLB, which has been found to decrease negative bias (Herek & Glunt, 1993). Moreover, this network is dedicated to supporting clinical and research work on GLB issues and to closing the gap between GLB clinical and research work and mainstream psychology. Work is currently underway to generate bibliographies of those topics within the GLB literature having relevance to mainstream psychology, including such areas as adolescent development, teenage suicide, substance abuse, family and couples issues, parenting, partner abuse, aging, and psychotherapy. Once available, the bibliographies will be posted on the AFFIRM Web site (http://www. sunysb.edu/affirm) to be used by mainstream professionals in their teaching, research, and clinical work. November 2001 • American Psychologist

Thanks to the Internet and e-mail, well over 200 psychologists having GLB family members have joined AFFIRM. What is dramatically evident from my e-mail contacts with these family members is their enthusiasm for the establishment of this network; their responses reflect far more emotional support than I had expected. What is disappointing, however, is the large number of family members from whom AFFIRM has not yet heard. Given that there are over 80,000 members of APA, one would think that thousands of family members would qualify—mothers, fathers, sisters, brothers, grandparents, aunts, uncles, cousins, sons, and daughters. Although originally concerned that more people did not respond to AFFIRM's announcements, I came to realize that this, in fact, is symptomatic of the gap between the mainstream and GLB professional communities and thus illustrates the very need to close it. AFFIRM hopes that it will be able to increase its numbers several-fold in the near future, enrolling motivated psychologists having interest and expertise in many of those areas in which relevant GLB issues continue to remain invisible to the mainstream profession. Once having done so, the real work of AFFIRM will begin, namely, actually closing the gap. Author's Note / thank Anthony R. D'Augelli, Gerald C. Davison, Ritch Savin-Williams, and Philip G. Zimbardo for their comments on an earlier version of this address. Correspondence concerning this address should be sent to Marvin R. Goldfried, Department of Psychology, State University of New York at Stony Brook, Stony Brook, New York, 11794-2500. Electronic mail may be sent to marvin. goldfried© sunysb. edu. References American Psychiatric Association. (1952). Diagnostic and statistical manual of mental disorders (1st ed.). Washington, DC: Author. American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (2nd ed.). Washington, DC: Author. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. Association for the Advancement of Behavior Therapy. (1992). Adolescent suicide. New York: Author.

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Baron, A., & Cramer, D. W. (2000). Potential counseling concerns of aging lesbian, gay and bisexual patients. In R. M. Perez, K. A. DeBord, & K. J. Bieschke (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients (pp. 309-335). Washington, DC: American Psychological Association. Bepko, C , & Johnson, T. (2000). Gay and lesbian couples in therapy: Perspectives for the contemporary family therapist. Journal of Marital and Family Therapy, 26, 409-419. Bieschke, K. J., McClanahan, M., Tozer, E., Grzegorek, J. L., & Park, J. (2000). Programmatic research on the treatment of lesbian, gay, and bisexual clients: The past, the present, and the course of the future. In R. M. Perez, K. A. DeBord, & K. J. Bieschke (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients (pp. 207-223). Washington, DC: American Psychological Association. Bradford, J., Ryan, C , & Rothblum, E. D. (1994). National Lesbian Health Care Survey: Implications for mental health care. Journal of Consulting and Clinical Psychology, 62, 228-242. Brown, L. (1995). Therapy with same-sex couples: An introduction. In N. S. Jacobson & A. S. Gurman (Eds.), Clinical handbook of couple therapy (pp. 274-291). New York: Guilford Press. Campos, P. E., & Goldfried, M. R. (Eds.). (2001). Working with gay, lesbian, and bisexual clients. Journal of Clinical Psychology/In Session: Psychotherapy in Practice, 57(5).

Crosbie-Burnett, M., Foster, R. L., Murray, C. I., & Bowen, G. L. (1996). Gays' and lesbians' families-of-origin: A social-cognitive-behavioral model of adjustment. Family Relations, 45, 397-403. D'Augelli, A. R., & Grossman, A. H. (in press). Disclosure of sexual orientation, victimization and mental health among lesbian, gay, and bisexual older adults. Journal of Interpersonal Violence. D'Augelli, A. R., Hershberger, S. L., & Pilkington, N. W. (1998). Lesbian, gay, and bisexual youth and their families: Disclosure of sexual orientation and its consequences. American Journal of Orthopsychiatry, 68, 361-371. D'Augelli, A. R., Hershberger, S. L., & Pilkington, N. W. (in press). Suicidal patterns and sexual orientation-related factors among lesbian, gay, and bisexual youths. Suicide and Life-Threatening Behavior. Davison, G. C. (1976). Homosexuality: The ethical challenge. Journal of Consulting and Clinical Psychology, 44, 157-162. Davison, G. C , & Wilson, G. T. (1973). Attitudes of behavior therapists toward homosexuality. Behavior

Therapy, 4, 686-696. Descamps, M. J., Rothblum, E., Bradford, J., & Ryan, C. (in press). Mental health impact of child sexual abuse, rape, intimate partner violence and hate crimes in the National Lesbian Health Care Survey. Journal of Gay and Lesbian Social Services.

Clark, W. M., & Serovich, J. M. (1997). Twenty years and still in the dark? Content analysis of articles pertaining to gay, lesbian, and bisexual issues in marriage and family therapy journals. Journal of Marital & Family Therapy, 23, 239-253.

Division 44/Committee on Lesbian, Gay, and Bisexual Concerns Joint Task Force on Guidelines for Psychotherapy With Lesbian, Gay, and Bisexual Clients. (2000). Guidelines for psychotherapy with lesbian, gay, and bisexual clients. American Psychologist, 55, 1440-1451. Retrieved November 14, 2001, from http:// www.apa.org/pi/lgbc/guidelines.html

Cohen, K., & Savin-Williams, R. (1996). Developmental perspectives on coming out to self and others. In R. SavinWilliams & K. Cohen (Eds.), The lives of lesbians, gays, and bisexuals: Children to adults (pp. 113-151). Fort Worth, TX: Harcourt Brace.

Doherty, W. J., & Simmons, D. S. (1996). Clinical practice patterns of marriage and family therapists: A national survey of therapists and their clients. Journal of Marital and Family Therapy, 22, 9-25.

Crawford, I., McLeod, A., Zamboni, B. D., & Jordon, M. G. (1999). Psychologists' attitudes toward gay and lesbian parenting. Professional Psychology: Research and Practice, 30, 394-401.

Garnets, L., Hancock, K. A., Cochran, S. D., Goodchilds, J., & Peplau, L. A. (1991). Issues in psychotherapy with lesbians and gay men: A survey of psychologists. American Psychologist, 46, 964-972.

Crockett, L. J., & Silbereisen, R. K. (Eds.). (2000). Negotiating adolescence in times of social change. Cambridge, England: Cambridge University Press.

Gelso, C. J., Fassinger, R., Gomez, M. J., & Latts, M. G. (1995). Countertransference reactions to lesbian clients: The role of homophobia, counselor gender, and

986

November 2001 • American Psychologist

countertransference management. Journal of Counseling Psychology, 42, 356-364. Goldfried, M. R. (1980). Toward the delineation of therapeutic change principles. American Psychologist, 35, 991-999. Goldfried, M. R., & Goldfried, A. P. (2001). The importance of parental support in the lives of gay, lesbian, and bisexual individuals. Journal of Clinical Psychology/In Session: Psychotherapy in Practice, 57, 681-693. Goldfried, M. R., & Wolfe, B. E. (1996). Psychotherapy practice and research: Repairing a strained alliance. American Psychologist, 51, 1007-1016. Green, R.-J. (2000a). "Lesbians, gay men, and their parents": A critique of LaSala and the prevailing clinical "wisdom." Family Process, 39, 257-266. Green, R.-J. (2000b). Lesbians, gays, and family psychology: Resources for teaching and practice. In B. Greene & G. L. Croom (Eds.), Education, research, and practice in lesbian, gay, bisexual, and transgendered psychology: A resource manual (pp. 207-225). Thousand Oaks, CA: Sage. Green, S. K., & Bobele, M. (1994). Family therapists' response to AIDS: An examination of attitudes, knowledge, and contact. Journal of Marital & Family Therapy, 20, 349-367. Greene, B., & Croom, G. L. (Eds.). (2000). Education, research, and practice in lesbian, gay, bisexual, and transgendered psychology: A resource manual. Thousand Oaks, CA: Sage. Grossman, A. H., D'Augelli, A. R., & O'Connell, T. S. (in press). Asking and telling: Findings from a study on the lives of older gay, lesbian, and bisexual adults. Journal of Gay and Lesbian Social Services. Group for the Advancement of Psychiatry. (1955). Homosexuality with particular emphasis on this problem in governmental agencies (Report No. 30). Topeka, KS: Author. Haldeman, D. C. (1999). The pseudo-science of sexual orientation conversion therapy. Angles: The policy journal of the Institute for Gay and Lesbian Strategic Studies, 4, 1-4. Halford, W. K., & Markman, H. I. (Eds.). (1997). Clinical handbook of marriage and couples interventions. New York: Wiley. Hayes, J. A., & Gelso, C. J. (1993). Male counselors' discomfort with gay and HIV-infected clients. Journal of Counseling Psychology, 40, 86-93. November 2001 • American Psychologist

Herek, G. M., Gillis, J. R., & Cogan, J. C. (1999). Psychological sequelae of hate-crime victimization among lesbian, gay, and bisexual adults. Journal of Consulting and Clinical Psychology, 67, 945-951. Herek, G. M., & Glunt, E. K. (1993). Interpersonal contact and heterosexual's attitudes toward gay men: Results from a national survey. Journal of Sex Research, 30, 239-244. Herek, G. M. , Kimmel, D. C , Amaro, H., & Melton, G. B. (1991). Avoiding heterosexist bias in psychological research. American Psychologist, 46, 957-963. Hershsberger, S. L., & D'Augelli, A. R. (1995). The impact of victimization on the mental health and suicidality of lesbian, gay, and bisexual youth. Developmental Psychology, 31, 65-74. Hershsberger, S. L., & D'Augelli, A. R. (2000). Issues in counseling lesbian, gay, and bisexual adolescents. In R. M. Perez, K. A. DeBord, & K. J. Bieschke (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients (pp. 225-247). Washington, DC: American Psychological Association. Hooker, E. (1957). The adjustment of the male overt homosexual. Journal of Projective Techniques, 21, 18-31. Julien, D., Arellano, G, & Turgeon, L. (1997). Gender issues in heterosexual, gay and lesbian couples, hi W. K. Halford & H. I. Markman (Eds.), Clinical handbook of marriage and couples interventions (pp. 107-127). New York: Wiley. Kilpatrick, D. G., Acierno, R., Saunders, B., Resnick, H. S., Best, C. L., & Schnurr, P. P. (2000). Risk factors for adolescent substance abuse and dependence: Data from a national sample. Journal of Consulting and Clinical Psychology, 68, 19-30. Koss, M. P., Goodman, L. A., Browne, A., Fitzgerald, L. F., Keita, G. P., & Russo, N. P. (1994). No safe haven: Male violence against women at home, at work, and in the community. Washington, DC: American Psychological Association. Kruks, G. (1991). Gay and lesbian homeless street youth: Special issues and concerns. Journal of Adolescent Health, 12, 515-518. Liddle, B. J. (1997). Gay and lesbian clients' selection of therapists and utilization of therapy. Psychotherapy, 34, 11-18. Mallon, G. (1997). Obstacles to queer research. In the Family, 2, 4, 25.

987

Martin, A. D. (1982). Learning to hide: The socialization of the gay adolescent. In S. C. Feinstein, J. G. Looney, A. Schartzberg, & A. Sorosky (Eds.), Adolescent psychiatry: Developmental and clinical studies (Vol. 10; pp. 52-65). Chicago: University of Chicago Press. McDaniel, J. S., Purcell, D. W., & D'Augelli, A. R. (2001). The relationships between sexual orientation and risk for suicide: Research findings and future directions for research and prevention. Suicide and Life-Threatening Behavior, 31, 84-105. McLoyd, V. C , & Steinberg, L. (Eds.). (1998). Studying minority adolescents. Mahwah, NJ: Erlbaum. Perez, R. M., DeBord, K. A., & Bieschke, K. J. (Eds.). (2000). Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients. Washington, DC: American Psychological Association. Remafedi, G., Farrow, J. A., & Deisher, R. W. (1991). Risk factors for attempted suicide in gay and bisexual youth. Pediatrics, 87, 869-875. Renzetti, C. R. (1994). On dancing with a bear: Reflections on some of the current debates among domestic violence theorists. Violence and Victims, 9, 195-200. Renzetti, C. R., & Miley, C. H. (Eds.). (1996). Violence in gay and lesbian partnerships. New York: Harrington Park. Rothblum, E. D. (1994). "I only read about myself on bathroom walls": The need for research on the mental health of lesbians and gay men. Journal of Consulting and Clinical Psychology, 62, 213-220. Rothblum, E. D. (1995). Lesbians in academia. National Women's Studies Association Journal, 7, 123-130. Safren, S. A., & Heimberg, R. G. (1999). Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents. Journal of Consulting and Clinical Psychology, 67. 859-866. Savin-Williams, R. C. (1989). Coming out to parents and self-esteem among gay and lesbian youths. Journal of Homosexuality, 18, 1-35.

Savin-Williams, R. C. (1998). " ...And

then I became

gay": Young men's stories. New York: Routledge.

Savin-Williams, R. C. (2001b). Mom, dad. I'm gay: How families negotiate coming out. Washington, DC: American Psychological Association. Sebald, H. (1992). Adolescence: A social psychological analysis (4th ed.). Englewood Cliffs, NJ: Prentice Hall. Sedaris, D. (1997). Naked. Boston: Little, Brown. Siever, M. D. (1994). Sexual orientation and gender as factors in socioculturally acquired vulnerability to body dissatisfaction and eating disorders. Journal of Consulting and Clinical Psychology, 62, 252-260. Spitzer R. L. ( 2001, May). 200 subjects who claim to have changed their sexual orientation from homosexual to heterosexual. Paper presented at the meeting of the American Psychiatric Association, New Orleans, LA. Stacey, J., & Biblarz, T. J. (2001). (How) does the sexual orientation of parents matter? American Sociological Review, 66, 159-183. Taylor, S. R, Klein, L. C, Lewis, B. P, Gruenewald, T. L., Gurung, R. A. R., & Updegraff, J. A. (2000). Biobehavioral responses to stress in females: Tend-and-befriend, not flightor-flight. Psychological Review, 107, 411-429. Tremblay, P. J. (1995, October). The homosexual factor in the youth suicide problem. Paper presented at the Sixth Annual Conference of the Canadian Association for Suicide Prevention, Banff, Alberta, Canada. Unger, J. B., Kipke, M. D., Simon, T. R., Montgomery, S. B., & Johnson, C. J. (1997). Homeless youth and young adults in Los Angeles: Prevalence of mental health problems and the relationship between mental health and substance abuse disorders. American Journal of Community Psychology, 25. 371-394. West, C. M. (1998). Leaving a second closet: Outing partner violence in same-sex couples. In J. L. Jasinski & L. M. Williams (Eds.), Partner violence: A comprehensive review of 20 years of research (pp. 163-183). Thousand Oaks, CA: Sage. Williams, R. J., & Chang, S. Y. (2000). A comprehensive and comparative review of adolescent substance abuse treatment outcome. Clinical Psychology: Science and Practice, 7, 138-166.

Savin-Williams, R. C. (2001a). A critique of research on sexual-minority youths. Journal of Adolescence, 24, 5-13.

988

November 2001 • American Psychologist