In addressing this topic, one is immediately confronted with the difficulty of defining homosexuality.
Some investigators have used the term in a limited sense to mean overt sexual relations exclusively between persons of the same sex, while others, such as Kinsey and his associates,1'2 have considered homosexuality, bisex uality and heterosexuality on a spectrum ranging from exclusive homosexuality to exclusive heterosexuality. Still others, of a more sociological bent, have used the term to include all the social activities of homosexual subcultures, where people of similar sexual preference seek one another out to indulge in a wide variety of activities (which may be intellectual, athletic, recreational, charitable, or mutually supportive, as well as erotic).
To consider homosexuality in early adolescence, it may be useful to use the more limited definition of the term as a condition in which the individual, exclusively or preferentially, repeatedly seeks sexual gratification with a member of the same sex, for it is this desire which becomes apparent to the pubertal boy or girl who is destined to become homosexual, and may cause them the most intense anguish and embarrassment, not only because they become progressively more aware of the deviance of these feelings, but also because they are aware of the highly critical attitude of their peers toward homosexuals, so that the prospect of discovery brings anticipation of rejection and isolation at the very stage of development when peer acceptance and support is all-important.
At this point, it is essential to differentiate homosexualify from homosexual experience, which simply connotes any sexual activity between members of the same sex, regardless of age, sex, achieving orgasm, or many other variables.
It is this homosexually stimulating experience which has been the subject of many reports in the literature, the most important of which remain those of Kinsey and his coworkers.1'2 They found that 33% of girls had had at least one such experience by age 15, and 60% of boys reported some homosexual experience by the same age.
In both sexes, during preadolescence and early adolescence, homosexual experience appears to be more common than heterosexual experience, a fact which the practitioner should remember.
However, data on emerging homosexuality in adolescence is, at present, conspicuous by its absence. This is hardly surprising, since such a study would involve a detailed prospective analysis over many years of a large number of adolescents.
The increasing tendency in recent years for homosexual adolescents to "come out," despite the consequences, instead of hiding their feelings, as in the past, may lead to an impression that homosexuality is more common now among adolescents than it used to be, an impression that is probably not correct.
Sexual curiosity about their own bodies and those of the opposite sex, as well as sexual activity, is considerable in prepubertà! boys and girls. Many masturbate and achieve orgasm; a few attempt coitus. Such activity may occur in a group setting, being experienced by the children as a kind of play, relatively free from guilt.
The advent of puberty reinforces the curiosity and activity, adds great variability to bodily development, and self-consciousness to relations with the opposite sex. Thus experimentation with same-sex peers and exploration of their bodies and reactions may be more familiar and therefore less threatening in early adolescence. The frequency and normality of this passing phase of homosexual interest must be appreciated by the practitioner, who may be called upon to educate and calm an alarmed family. Group activities (such as exhibition and /or mutual masturbation) among boys, and kissing and mutual masturbation between girls, are the usual forms of activity, and mostly need cause no anxiety that they are the harbingers of lifelong homosexuality.
The more frequently the homosexual activity occurs; whether it persists into later adolescence; whether it is actively sought out; whether it is preferred to heterosexual gratification when the opportunity for this occurs; and whether any particular psychological or emotional gratification is derived from the homosexual relationship are all questions of great prognostic importance. Early adolescent homosexual experience is typically selfcentered. If, on the other hand, there is a feeling of being "in love" with the person of the same sex, a homosexual preference should be strongly suspected. (This phenomenon is more likely to occur between girls than boys.)
Finally, a previous history of sex-inappropriate behavior (cross-sex behavior, such as tomboyishness in girls, sissiness in boys, cross-dressing and preferring the toys, games and company of the opposite sex, with whom they identify and feel comfortable) is prognostic of homosexuality. Probably only a minority of adult homosexuals have shown these behaviors, so that their absence does not imply a healthy heterosexuality, but their presence should certainly be taken seriously.
SOME PROBLEMS OF HOMOSEXUAL ADOLESCENTS
As mentioned earlier, the discovery by an adolescent that he or she is being sexually attracted to members of the same sex, at a time in development when, as far as the boy or girl knows, all his or her friends are becoming attracted to members of the opposite sex, may be a very disturbing experience.
The first reaction may well be the primitive defense of denial, not only to himself or herself, but to any friends, if there should be any questions or comments about such feelings. Refuge may be taken in humor, both telling and laughing at anti-homosexual jokes, or in teasing others suspected of similar tendencies, to point the finger of suspicion in another direction.
An attempt may be made to suppress homosexual feelings by ostensibly becoming involved with one or several members of the opposite sex, in the hope that heterosexual experience will dispel the homosexual leanings.
As time passes and the realization comes that the homosexual drive is not being dispelled, but is becoming stronger, an identity crisis may occur which may be handled in a variety of ways, and therefore may be associated with varied new symptoms. The most obvious one is depression, which may be manifested by withdrawal, lack of interest in school work, lack of interest in activities which involve associating with peers, irritability and moodiness. Loss of peer relationships naturally produces a sense of isolation, which heightens the fear of abandonment already present and increases depression.
Escape from the situation may be sought through the use of alcohol or drugs, which, though they may allow transient escape, may also make matters worse by lessening self-control while under their influence and increasing the depression after their effect has worn off.
Another alternative, particularly in recent years since so much publicity has been given in the media to homosexuality and the various homophile organizations and resources which have been developed in many communities, is for the homosexual adolescent to decide to "come out," either to one or two close friends, or to the family, or both, or to become quite blatant about it with everyone, parading his or her homosexuality in a caricature of the effeminate male or "butch" lesbian, with some such slogan as "I'm gay and I'm proud." This may lead to the formation of some homosexual friendships, but it will also lead to notoriety and increased rejection.
Still other homosexual adolescents may handle their problems by promiscuity, and boys may get involved in hustling, a more extreme form of acting-out behavior.
The majority of homosexual adolescents probably do not choose any of the courses just described, but keep their real inclinations suppressed, or at least concealed, until they are old enough to be out of the family household and out of high school. Going away to college may be a time of considerable homosexual activity (both erotic and social) and of self-discovery. Support may be obtained under these circumstances from the Gay People's Organizations which are now present on most college campuses.
Adolescents make considerable use of role models, and although women's liberation and such sports as tennis and golf have recently provided a number of well-known women who may be acceptable role models for lesbian adolescents, there is still an almost complete absence of masculine homosexual role models for homosexual adolescent boys. The stereotype of ballet dancer or hairdresser as the likely profession for a homosexual boy to end up in dies hard - few professional ball players have admitted their homosexuality! Yet homosexual adolescents need to know that there are homosexual men and women in all the professions, as well as the arts, and that many of them are leaders in their field.
To conclude discussion of this category of problems, the choice between having a family or sticking to their true sexuality, which means childlessness, is a difficult one for many homosexual adolescents. As Kinsey pointed out, homosexuality is not an all-or-none phenomenon, and many homosexuals achieve a compromise, with marriage and children on the one hand, and periodic homosexual encounters on the other.
ORGANIC PROBLEMS - SEXUALLY TRANSMITTED DISEASES
Male homosexuals, on the whole, are considerably more promiscuous than lesbians, and the adolescent homosexual who signals his emergence into "the gay world" by a continuing round of sexual encounters will be likely to contract a number of sexually transmitted diseases.
Gonorrhea is the most common of these, and it should be remembered that in this population, the patient may present with gonococcal pharyngitis, ranging in appearance from a purulent, exudative lesion with much swelling and toxemia to a normal-looking throat. Likewise, gonococcal proctitis may show a wide range of presentations, or be asymptomatic. The important thing is for the physician to think of the possibility in a homosexual male and plate out throat and anal canal cultures on Thayer Martin medium.
Syphilis may present with a primary chancre in the genital area, around the mouth, at the anus, or in the rectum, or the patient may show the rash and diffuse shotty lymphadenopathy of secondary syphilis.
Infectious hepatitis of varied etiology is prevalent in male homosexuals, many of whom have had both type A and type B1 and must be considered a sexually transmitted disease in this group, by oral-anal contact, fellatio, or rectal intercourse.3
A variety of colonie and rectal diseases occur in male homosexuals, including amebiasis, shigellosis, chlamydial infection, gonorrhea, syphilis, nonspecific proctocolitides and anal warts, and may present problems in diagnosis and treatment.4
Finally, there recently have been a number of reports of Kaposi's sarcoma and opportunistic infections in homosexual men,5"10 as a result of which the Centers for Disease Control have formed a task force to undertake surveillance for these disorders and conduct epidemiologie and laboratory investigations.11
In an article of this length, only a few points in management may be emphasized for guidance in handling what may be a very complex and continuing problem.
Listen to the parents together, not only to get their side of the story, but to study their roles and interaction, and assess the importance of these on their child's behavior.
Listen to the patient alone and observe his or her mood, affect, mannerisms, masculinity, femininity and interests.
Educate the parents and the adolescent about the difference between a homosexual experience and homosexuality. Educate them about what homosexuality is not (e.g., that homosexuals are violent, that they prey on young children, that they'll become heterosexual if the right person of the opposite sex comes along, that they are maladjusted, sick, unhappy people).12
Exaggerated concerns about homosexuality in a child, or the demand that a child conform to a sexual pattern which the parent happens to find personally rewarding, should be replaced by an interest in promoting a sexual way of life which is entirely congruent with the young person's deepest needs and interests. Sensitive, intelligent parents do not insist that their children become carbon copies of themselves, sexually or otherwise. And it is such parents who are most apt to enjoy a relationship of mutual love and respect with their children long after their offspring have reached adulthood.12
Promote the Use of Support Systems
If, as a result of analyzing the various factors discussed earlier in homosexual behavior and prognostic pointers, the conclusion is reached that one is dealing with a homosexual adolescent, it will be important to see what support systems are available to him or her.
The first of these, one would hope, will be the parents. If, at least initially, they cannot play this role, support, education and opportunity for discussion must be arranged for them.
The second support system should be the physician - he may be the only person in whom the boy or girl can really confide without fear of ridicule or rejection.
The third support system will consist of whatever ageappropriate resources the community has to offer the patient - for instance, there has been, in the Boston area, a discussion group for gay teenagers which has met regularly to share problems and solutions, while most colleges and even some high schools have homosexual discussion groups which provide mutual support, peer group interaction and education by invited speakers.
1. Kinsey AC. el al: Se xual Behavior in the Human Mate. Philadelphia. WB Saunders Co. 1948.
2. Kinsey AC. el al; Sexual Behavior in the Human Female. Philadelphia. WB Saunders Co. 1953.
3. Kawa? KA. Mat !off DS: Viral hepatitis in homosexual men, uamroentertilugy /9Sl; SJ;5J7-53S.
4. Sohn N. Robilotti JG Jr: The gay bowel syndrome. Am J Gamrtienirrol 1977; 67:478-484.
5. Pneumocystis pneumonia - Los Angeles. MMWR 1981; 30:250-252.
6. Kaposi's Sarcoma and pneumocystis pneumonia among homosexual men - New York Ciiy and California. MMWR 1981; .10:305-308.
7. Du rack UT: Opportunistic infections and Kaposi's Sarcoma in homosexual men. .V KnKl J MnI 1981; 305:1465-1467.
8. Cioiilieb MS. Schroff R. Schanker HM. et a!: Pneumocystis carinii pneumonia and muco sa I candidiasis in previously healthy homosexual men: Evidence of a new acquired cellular immunodeficiency. ? Engl J Meü 19KI; 305:1425-1431.
9. Masur H. Micheli* MA. Greene JB, et al: An outbreak of communityacquired pneumocyslis carinii pneumonia: Initial manifestation of cellular immune dysfunction. .V Engt J MfJ 198 1: 305:1431-1438.
10. Siegal KP. Lope/ C, Hammer US. et al; Severe acqui red immunodeficiency in male homosexuals, manifested bv chronic pena nal ulcerative herpes simplex lesions. N Engl J Med 1981; 305:1439-1444.
11. Epidemiologie aspects of the current outbreak of Kaposi's Sarcoma and opportunistic inleclions, special repon. Eng J Med 1982; 306:248-252.
12. Homosexuality, in Slitti? (iuitl? Vu. .' (Revixed). Sex Information and Mutation Council of the US, 1973. pp 8-13.