THE AMERICAN ACADEMY OF CLINICAL SEXOLOGISTS AT MAIMONIDES UNIVERSITY GUIDE FOR MENTAL HEALTH PROFESSIONALS IN THE RECOGNITION OF SUICIDE AND RISKS TO ADOLESCENT HOMOSEXUAL MALES A DISSERTATION SUBMITTED TO THE FACULTY OF THE AMERICAN ACADEMY OF CLINICAL SEXOLOGISTS AT MAIMONIDES UNIVERSITY IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY BY KENDALL FIELDS NORTH MIAMI BEACH, FLORIDA DECEMBER 2005 Copyright © by Kendall L. Fields All rights reserved ii DISSERTATION COMMITTEE William Granzig, Ph.D., MPH, FAACS. Advisor and Committee Chair James O Walker, Ph.D. Committee Member Peggy Lipford McKeal, Ph.D. NCC, LMHC Committee Member Approved by dissertation Committee Maimonides University North Miami Beach, Florida Signature Date _________________________________ William Granzig, Ph.D. James Walker, Ph.D. _ Peggy Lipford McKeal, Ph.D. iii ACKNOWLEDGEMENTS I would like to express my sincere gratitude to those who assisted in the formulation of this dissertation: Dr. William Granzig, professor, advisor, and friend, who without his guidance, leadership, and perseverance this endeavor would not have taken place. To Dr. Walker, thank you for your time, patience, insight and continued support. To Dr. McKeal, thanks for you inspiration and guidance. You kept me grounded and on track during times when my motivation was waning. To Dr. Bernie Sue Newman, Temple University, School of Social Administration, Department of Social Work and in memory of Peter Muzzonigro for allowing me to reprint portions of their book. To those professionals who gave of their time to complete and return the survey questionnaires. To my darling wife, Irene Susan Fields, who provided support and faith in me. iv ABSTRACT This qualitative research study reviews the literature associated with the high risk of suicide among adolescent homosexual males. It has been reported that gay youth are two to three times more likely to attempt suicide and may comprise up to 30 percent of completed youth suicides annually. Suicide is not only distressing to clinicians caring for youth at risk, but it is also a significant liability risk to the clinician. Assessment of suicide is one of the most important functions exercised by mental health professionals. This study and review looks at these risks, liabilities, experience and training of clinicians and suggests ways of limiting suicidal behavior in homosexual adolescent males. Despite progress in defining the predictive factors associated with suicide, knowledge on which to base sound clinical and public policies regarding suicide prevention and treatment remains remarkably limited for this group. This study focuses on what counselors do know and what they need to know in order to work effectively with sexual minority adolescents. Several approaches have been suggested in the past according to research. One recommended approach suggested diversity training, which begins with awareness of the counselors’ own attitudes and beliefs, moves into the acquisition of knowledge, and then toward the final stage of skill acquisition. It is this writer’s opinion that effective counseling with homosexually oriented youth, or those questioning their sexual identity, cannot happen if the provider has not first come to terms with his or her own feelings and attitudes about homosexuality Currently, no known empirical data exists that encompasses or addresses the question of what mental health professionals should be aware of, or know, concerning homosexual adolescent male’s risk of suicide. There is no data addressing the number of v homosexual males seen in therapy who have active or passive thoughts of suicide directly related to their homosexual identity. This review of literature summarizes some of the current knowledge regarding the risk to adolescent homosexual males. A list of topics by chapter provides an overview of covered areas: Introduction to the Problem, A Brief History of Suicide, Mental Health/Higher Level of Pathology, Substance Abuse, Social Support/Relationships, Social Stigma Coming Out, Homophobia and Suicide. Information and later a guide to assist mental health professionals in the assessment, treatment, and understanding of the intricate problems associated with this special population are addressed by the author. vi TABLE OF CONTENTS Pages TITLE PAGE------------------------------------------------------------------------------------ APPROVAL----------------------------------------------------------------------------------- iii ACKNOWLEDGEMENTS------------------------------------------------------------------ iv ABSTRACT------------------------------------------------------------------------------------- v Table of Contents------------------------------------------------------------------------------- 1 Chapter 1 – Introduction----------------------------------------------------------------------- 2 Chapter 2 – Brief History of Homosexuality------------------------------------------------- 6 Chapter 3 – Suicide ---------------------------------------------------------------------------- 16 Chapter 4 – Substance Abuse----------------------------------------------------------------- 22 Chapter 5 – Social Support/Relationships--------------------------------------------------- 32 Chapter 6 – Social Stigma coming out-------------------------------------------------------40 Chapter 7 – Mental Health/Higher Level of Pathology------------------------------------46 Chapter 8 – Homophobia --------------------------------------------------------------------- 58 Chapter 9 – Conclusions----------------------------------------------------------------------- 78 APPENDIX A. SURVEY INSTRUMENT------------------------------------------------- 88 APPENDIX B. RESULTS-------------------------------------------------------------------- 92 APPENDIX C. DEFINITIONS---------------------------------------------------------------99 REFERENCES ------------------------------------------------------------------------------- 166 1 CHAPTER ONE INTRODUCTION A tiny blade will sever the sutures of the neck, and when that joint, which binds together head and neck, is cut, the body’s mighty mass crumbles in a heap. No deep retreat conceals the soul, you need no knife at all to root it out, no deeply driven wound to find the vital parts; death lies near at hand…. Whether the throat is strangled by a knot, or water stops the breathing, or the hard surface, or flame inhaled cuts off the course of respiration---be it what it may; the end is swift. (Seneca, 1935) Death, as Seneca states, has always lain close at hand: yet it is a mystery why the first person to kill him/herself did. Was it a sudden impulse, or prolonged disease? An inner voice commanding death? Perhaps shame or the threat of capture by an enemy tribe? Seneca (1935), a Roman statesman and philosopher, was forced to take his own life after having been accused of conspiracy by Nero, emperor of Rome. Three years later Nero, too, was forced to commit suicide. There is no written data reflecting an account of when or where the first suicide took place, or the method formulated to consummate it. What is known is that suicide can be extremely contagious and final (Jamison 1999). The assessment of suicide is among the most important functions exercised by mental health professionals. This qualitative research study reviews the literature associated with the high risk of suicide among adolescent homosexual males. It has been reported recently that gay youth are two to three times more likely to attempt suicide than others and that they may comprise up to 30 percent of completed youth suicides annually (Gibson 1989). It is also recognized, based on the best research data available (Bagley and Tremblay 1996; Bell and Weinberg 1978), which a major suicide problem has existed in the gay and bisexual male youth 2 population for at least 50 years. Available information suggests that the problem has existed for at least 100 years. Statistics on behaviors that may precede completed suicides also indicate the seriousness of the problem. A study using a large, nationally representative sample found that 31 percent of eighth graders and 36 percent of tenth graders reported having thought at some point in their lives about committing suicide, while 13 percent of eighth graders and 15 percent of tenth graders reported having attempted suicide (Windle, Miller-Tutzauer, and Domenico 1992). Even these striking estimates, based on World Health Organization (WHO) and government surveys, almost certainly underestimate suicide rates by at least one third and possibly by half, due to underreporting (American Association of Suicide 1998; Jamison 1999). Currently, no known empirical data exists that encompasses or addresses the question of what mental health professionals should be aware of, or know, concerning homosexual adolescent male risk of suicide. As such, this review of the literature represents an attempt to provide information and, later a guide to assist mental health professionals in the assessment, treatment and understanding of the intricate problems associated with this special population. Areas of specific concern are • history of homosexuality • mental health problems / higher level of pathology • social support • social stigma coming out process • homophobia (sexual prejudice) • substance abuse 3 • suicide In a culture already uncomfortable about adult sex and worried about adolescent sexual behavior, the idea of homosexual sex generates hostile and almost reflexive contempt.