Remafedi described a sample of 29 male homosexual and bisexual (white, Christian, and middle class) adolescents, ages 15-19 years.1 Whereas the reader may object to the small sample size, there is some detailed information on the participants available and care was taken to obtain a diverse sample. The participants were recruited from a wide variety of settings, maximizing the diversity of respondents. No participants were solicited from mental health settings. The demographic characteristics of the participants closely resembled that of the general population in the community from which they were sampled, as would be expected in a random sample of homosexual individuals. Therefore, the sample is a good approximation of a probability sample, and it is unlikely that selection bias skewed the sample toward dysfunctional adolescents.

Table 1 lists some of the problems faced by the participants.

Table 1: Some Problems of 23 Homosexual and 6 Bisexual Men
Type of Problem Number Age < 18 Age > 18
Worsening school performance 12* 7 5
Mental health problems requiring consultation 21 15 6
Substance abuse 17 12 5**
Running away 14 10 4
Conflict with law 14 12 2
STDs 13 6 7
Truancy 7 2 5
Suicide attempts 10 7 3
Psychiatric hospitalization 9 8 1**
High school drop out 8 8 0**
Chemical dependency treatment 5 5 0
Prostitution 5 4 1
Notes: *only 15 were in school, **statistically significant difference

Table 2 lists drugs used by the participants. 58% met DSM- III criteria for substance abuse.

Table 2 : Drug Use by 23 Homosexual and 6 Bisexual Men
Drug Current use Daily use > 3 Times/Wk 1-2 Times/Wk 1-3 Times/Mo < 1 Times/Mo
Ethanol 23 2 5 8 7 1
Marijuana 22 3 4 2 3 10
Tobacco 14 14        
Nitrate 13 0 2 1 3 7
Amphetamines 9 1 0 3 0 5
Hashish 7 0 0 0 2 5
Cocaine 6 0 0 0 0 6
LSD 5 0 0 1 0 4
Valium 3 0 1 0 0 2
Barbiturates 2 0 0 0 0 2
PCP 1 0 0 0 0 1

45% reported a history of STDs. One-third had a steady male partner at the time of the interview. 4 had a steady relationship of less than a month duration. Only one had a steady partner for over 1 year. The mean age of partner(s) was 25 years. Of 19 participants not involved in intimate relationships, 11 had been in one in the past. All but 2 participants hoped for a steady partner in the future.

Each participant was asked how he met his past 3 partners. 69% of the meetings were in gay bars or public places such as parks, beaches, and on the streets. In one-third of the cases, participants indicated that they did not know each other before initiating sex. 23% of the couples had spent an evening or a day together. In only 28% of the cases did the participants report that they had maintained contact with their partners for more than a week. After initial relations, there were no subsequent encounters in 30% of the cases. There were less than 5 additional dates for 63% of the couples.

3 participants reported no homosexual experience in the previous year, one had more than 200 partners; the mean number of homosexual partners for the remaining was 7 in the previous year. 15 had had some heterosexual experience during the previous year, with a mean of 5.6 partners; the number of female partners ranged from 1 to 25. Note the variability of sexual behavior.

Let us consider some factors that may explain the behaviors of the participants:

  • Of the 21 who had consulted a psychologist or psychiatrist on at least one occasion for emotional problems, in 12 cases, the problems were related to personal or interpersonal conflict regarding sexual identity. 9 had been hospitalized for mental health issues including treatment for drug abuse; 5 of these cases followed a suicide attempt.
  • 28 had contemplated suicide at one or the other point of their lives; 10 had attempted suicide, and 2 had made multiple attempts. Of the 19 who had previously not made suicide attempts, 4 considered attempting suicide in the future. Of the 10 who had attempted suicide, 5 directly related it to issues regarding conflict about sexual identity, 3 mentioned factors other than sexuality as the precipitating event, the remaining 2 refused to discuss precipitants, and 8 out of the 10 attempts chronologically followed the individual’s self-identification as homosexual. One subject who had made multiple suicide attempts described his attempts as follows, “[I have made] a total of 13 or 14 attempts-and they’re good attempts. I am no fool who doesn’t know how to do it right. I crashed my mother’s car at 150 mph into a guardrail. I tried to OD on codeine, heroin, and alcohol. I gassed myself. I tried to slit my wrists. Somehow, each time I survived. And each time I’d be hospitalized, I’d stay in the hospital a few days, and then just disappear.”
  • 14 had run away from home at least once; among them, 6 had done so repeatedly. 10 participants resided with their parents; of the remaining 19, 8 had moved away from their parents due to sexuality issues, 3 for other family conflicts, 2 for personal freedom, 5 for employment or education, and 1 for miscellaneous concerns.
  • 2 participants believed that they had been victims of sexual assault. Another 3 reported that they had, on occasion, acquiesced to sexual encounters with peers, although they had felt uncomfortable in doing so. One subject reported sexual exploration at age 10 years with his 14-year-old brother. Another had multiple sexual experiences between age 4 and 10 years with his stepfather and 8 different uncles. Neither believed that they had been sexually abused.
  • 20 reported school problems; 14 out of 20 reported verbal abuse, 2 out of 20 reported both verbal and physical abuse from peers, and 8 had left high school prior to graduation.

In this sample, how would so-called homophobia explain the sexual behavior and drug use? How would so-called homophobia explain why participants less than age 18 years had more social and mental health problems (higher rates of psychiatric hospitalization, substance abuse, high school drop-out, and conflict with the law), although both the less than 18 group and the older than 18 group did not differ in ethnic background, religion, sexual identity labels, duration of homosexual or bisexual identity, parents’ marital status, and residence?

In another study, Remafedi et al. studied 137 homosexual and bisexual men, ages 14-21 years, from the upper Midwest and Pacific Northwest.2 29.9% reported suicide attempts, and almost half of these individuals reported multiple suicide attempts. 21% of all suicide attempts resulted in medical or psychiatric admissions. Discrimination, violence, loss of friendship (after coming out), or current personal attitudes toward homosexuality could not explain the suicide attempts. Compared with non-attempters, attempters had more feminine sex roles and adopted a bisexual or homosexual identity at younger ages. Additionally, attempters were more likely than peers to report sexual abuse, drug abuse, and arrests for misconduct. Childhood molestation did not predict suicide attempts after controlling for the age of acquisition of sexual orientation identity, illegal drug use history, and presence of feminine behavior.

Remafedi et al. compared 394 homosexual and bisexual adolescents (212 male, 182 female) with 336 sex-matched heterosexual adolescents from a population-based survey of junior and senior public high school students.3 Suicide attempts were reported by 28.1 % of bisexual/homosexual boys, 20.5% of bisexual/homosexual girls, 14.5% of heterosexual girls, and 4.2% of heterosexual boys. Sexual orientation in girls was not associated with suicidal intent. Compared to their heterosexual counterparts, homosexual and bisexual boys were 3.61 times as likely to think about suicide and 7.10 times as likely to attempt suicide. Whereas this study and another paper4 argued that homosexuality on its own does not appear to increase risk of suicide attempts in female adolescents, a representative Norwegian sample showed greater odds of suicide attempts among adolescent Norwegian girls that were not diminished after statistically controlling for multiple variables expected to contribute to suicidal behaviors,5 and increased suicide attempts among adult lesbian/bisexual women have also been documented.6

Garofolo et al. studied 4,159 9th- to 12th-grade students representative of public high schools in Massachusetts.[Garofalo R, Wolf RC, Kessel S, et al. The association between health risk behaviors and sexual orientation among a school-based sample of adolescents. Pediatrics 1998;101(5):895-902.] 2.5% of the students self-identified as homosexual or bisexual (HB). Table 3 compares HB youth with non-HB youth. Can so-called homophobia account for all the differences between HB and non-HB youth in this sample, for instance, a relative overrepresentation of HB youth among those who start smoking before age 13 years?

Table 3: Health-risk Behaviors in a Representative Sample of Adolescents
  Time period % HB % non-HB

Cigarette use

< age 13 47.9 23.4
30 days 59.3 35.2
30 days (at school) 37.4 18.4
Smokeless tobacco use 30 days 33.7 7.7
30 days (at school) 26.8 4.1

Alcohol use

< age 13 59.1 30.4
life 86.8 79.0
30 days 89.4 52.8
30 days (binge drinking) 46.2 33.0
30 days (at school) 25.0 6.2

Marijuana use

< age 13 36.5 8.5
life 68.5 47.4
30 days 53.7 31.4
30 days (at school) 31.6 10.7

Cocaine use

< age 13 17.3 1.2
life 33.0 6.9
30 days 25.3 2.7
Crack (freebase) use life 31.2 3.5
Inhalant use life 47.6 18.5
Anabolic steroid use life 25.0 3.9
Other illegal drug use life 48.5 16.3
Injection drug use life 22.2 2.3
Shared needles life 15.5 1.1
Offered drugs at school 12 months 59.2 38.0

Sexual intercourse

ever 81.7 44.1
< age 13 26.9 7.4
3 or more sexual partners life 55.4 19.2
3 months 37.9 7.5
Alcohol or drug use at last sexual episode   34.7 13.3
Sexual contact against will   32.5 9.1
Weapon carrying (30 days) 30 days 46.3 19.8
30 days (at school) 25.3 8.9
Gun carrying 30 days 24.7 4.9
Missed school because of fear 30 days 25.1 5.1
Threatened with weapon at school 30 days 32.7 7.1
Property damaged at school 12 months 50.5 28.7
Fighting 12 months 68.1 37.6
12 months (at school) 38.1 14.4
Fighting requiring medical treatment 12 months 14.0 4.1
Suicide attempts 12 months 35.3 9.9
Notes: HB = homosexual and bisexual male and female high school students.

Fig. 1 compares risky behaviors between HB and non-HB groups in the Garofalo et al. study. Approximately 50% of HB respondents reported engaging in more than 5 risky behaviors compared with less than 25% of the non-HB respondents.

Nonheterosexual youth manifest elevated risky behaviors.
Fig. 1. Sexual orientation and prevalence of risky behaviors. HB = homosexual and bisexual youth.

Lock and Steiner studied an upper middle class community sample of 1,769 high school students.7 Sample characteristics:

The students were sampled from an unusually well-educated community near a major University in Northern California and close to two major metropolitan areas with significant nonheterosexual communities. 99% response rate; 47.9% were girls; mean age = 15.9 years (SD = 1.16).

6% self-identified as gay, lesbian, or bisexual (GLB) and an additional 13% reported being unsure of their sexual orientation (UNSURE). Heterosexuals were less likely than GLB youth to manifest mental health problems [OR = 0.719, 95% CI = 0.53-0.92.], general health problems [OR = 0.690, 95% CI = 0.47-1.00.], and sexual victimization plus risky sexual practices [OR = 0.537, 95% CI = 0.34-0.85.]. Heterosexuals and GLB youth did not differ with respect to general risk taking and eating problems, which contrasts with the report by Garofalo et al., but note that the sample comes from a highly educated upper middle class background. Heterosexuals were less likely than UNSURE youth to manifest mental health problems [OR = 0.636, 95% CI = 0.57-0.79.] and sexual victimization plus risky sexual practices [OR = 0.725, 95% CI = 0.51-1.00.], but were similar to UNSURE youth on the other measures mentioned above. Both GLB and UNSURE youth were more likely than heterosexuals to be uncomfortable with their sexual orientation. GLB and UNSURE youth more uncomfortable with their sexual orientation manifested more general health problems and tended to manifest more mental health problems; self-identified sexual orientation and comfort with sexual orientation significantly interacted with general health problems but not with mental health problems. Homophiles would blame discomfort with sexual orientation on so-called internalized homophobia, but this so-called internalized homophobia is hardly explaining the worse mental health of the GLB youth in this sample and accounting for only a small portion of the worse general health outcome of GLB youth.


  1. ^ Remafedi G. Adolescent homosexuality: psychosocial and medical implications. Pediatrics 1987;79(3):331-7.
  2. ^ Remafedi G, Farrow JA, Deisher RW. Risk factors for attempted suicide in gay and bisexual youth. Pediatrics 1991;87(6):869-75.
  3. ^ Remafedi G, French S, Story M, et al. The relationship between suicide risk and sexual orientation: results of a population-based study. Am J Public Health 1998;88(1):57-60.
  4. ^ Garofalo R, Wolf RC, Wissow LS, et al. Sexual orientation and risk of suicide attempts among a representative sample of youth. Arch Pediatr Adolesc Med 1999;153(5):487-93.
  5. ^ Wichstrom L, Hegna K. Sexual orientation and suicide attempt: a longitudinal study of the general Norwegian adolescent population. J Abnorm Psychol 2003;112(1):144-51.
  6. ^ Skegg K, Nada-Raja S, Dickson N, et al. Sexual orientation and self-harm in men and women. Am J Psychiatry 2003;160(3):541-6.
  7. ^ Lock J, Steiner H. Gay, lesbian, and bisexual youth risks for emotional, physical, and social problems: results from a community-based survey. J Am Acad Child Adolesc Psychiatry 1999;38(3):297-304.